One Size Does Not Fit All
What is Treatment?
You can get it for $90,000 per month at a Malibu rehab or for free at 12-step meetings in a church basement.
Addiction and mental illness are chronic brain diseases that never go away. Similar to other chronic illnesses such as diabetes, asthma and hypertension, they are always with you. There is no cure, but treatment enables people to counteract their disruptive effects on their brain and behavior to regain control over their lives. Treatment gives you the tools to manage them so they don’t manage you.
And like a chronic illness, relapse is frequently part of the journey, not the failure of SUD and/or mental health treatment. I’ve seen families lament, “Well, there goes that money down the drain . . . what good did that rehab do when she goes back to using drugs?” It’s a hard and expensive lesson, but one to learn, nonetheless. More than 60% of those treated for SUD relapse within the first year of discharge from treatment — similar to relapse rates of other chronic illnesses.
Does each plan always follow the script? When you have human beings and a relentless disease involved, don’t count on it. Will there be changes along the way? Of course — name one chronic disease where treatment goes exactly as initially planned. Relapse frequently indicates a need to change some components of the aftercare plan or even a completely different approach. Nonetheless, even after a year or two of remission achieved through treatment, it can take three to five more years before the risk of relapse drops below 15 percent, the level of risk that people in the general population have of developing an SUD in their lifetime.¹
Key Components
As already established in an earlier column (Diagnosis: The Key to Finding the Right Rehab), in order to treat SUD and/or a mental disorder, it is necessary to know exactly what needs to be treated. A professional diagnosis normally is one of the following:
- Substance Use Disorder (SUD)
- Mental Health (MH)
- Primary SUD + Secondary MH
- Primary MH + Secondary SUD
The other key component of treatment is evidence-based therapy — i.e. Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), et al. — which is combined with medication and Recovery Support Services (RSS). RSS is intended as a continuum of care after “formal” treatment at a rehab and a lifestyle intended to support long-term recovery. How long does that take? “A lifetime” is what my friends and clients in recovery tell me.
Outpatient versus Inpatient (Residential)
An assessment by a licensed therapist, counselor or physician determines the type of treatment an individual needs. That assessment is required to determine the facilities whose licensure matches the individual’s diagnosis and the optimum therapeutic program for that the individual. Depending upon the intensity of therapeutic care the individual requires and one’s resources, that treatment will be delivered via outpatient, residential or both.
Outpatient treatment provides group and individual counseling in morning or evening sessions accommodating those who maintain a regular work or academic schedule. Typically, two kinds of treatment — intensive outpatient programming (IOP) and outpatient (OP) — are programs at the initial level of care for those with mild to moderate SUDs or continuing care for those recently discharged from a residential program and live at home or in a sober living environment. Occasionally, the same clinics will also offer partial hospitalization programming (PHP), which is the more intensive all-day treatment.
Inpatient is a level of treatment easy to misinterpret. In drug treatment parlance, it refers to medically supervised substance withdrawal delivered in an acute, inpatient hospital or dedicated medical unit — otherwise known as detox. It also is a moniker for residential care — SUD treatment not in a hospital, but in a hospital-like setting that offers 24-hour support, staff, and structure for intensive evidence-based clinical services and therapy. For those who are just out of detox, are prone to relapse, or have a co-occurring illness, residential treatment provides the 24-hour care and support needed at that time.
For our purposes, inpatient detox is referred to as detox and inpatient residential as residential.
The Patient’s Resources and Demographics
Whether one goes to outpatient or residential treatment at a specialty facility — hospitals (inpatient only), rehabilitation facilities (rehabs), mental health centers — two factors will determine which facility will be the chosen one. After matching one’s diagnosis with the licensure of a facility, the patient’s resources (insurance, cash, public assistance, scholarship) and demographics (age, gender, ethnicity, culture, economic status, location and treatment needs) will be the determining factors where the individual gets treatment.
Matching an individual’s demographics with the demographics of the facility’s patients avoids sending a 65 year-old, high-end alcoholic attorney to a facility dominated by 20-something unemployed meth users. First responders do better with fellow first responders. Attorneys, physicians, executives, pilots, veterans, etc. do better with those in the same or similar professions. Examples of an individual’s demographics also include the drug(s) of choice; trauma history; sexual orientation; vocation; and language to name just a few.
Disorders Treated
Drug and alcohol treatment facilities treat addiction to substances that are primarily grouped into four categories: alcohol (beer, wine, liquor); illicit drugs (cocaine, heroin, hallucinogens, etc.); legal drugs used illicitly (opioids, tranquilizers, stimulants, sedatives, over-the-counter drugs); inhalants (amyl nitrate, cleaning fluids, solvents, etc.).
Obsessive behavior not necessarily accompanied by substance use that compels the individual to engage compulsively and repeatedly in conduct detrimental to the individual is process addiction. Obsessive behaviors include: eating disorder; gambling; sex and intimacy; co-dependency; and gaming to name a few.
Mental disorders are stand-alone maladies without substance use or co-occurring with substance use. Mental disorders are generally characterized by changes in mood or thought that range from mild to moderate to severe. Common disorders treated by facilities include but are not limited to depression; anxiety/panic attacks; schizophrenia; PTSD from experiential, emotional, physical or sexual trauma; bipolar disorder.
One-Year Treatment Plan
Whether one relies upon outpatient treatment or starts with detox then on to residential care, there should be a customized one-year treatment plan for every individual.
Formal treatment at a reputable specialty facility typically incorporates a combination of detox, behavioral therapies, and medications. The facility then structures an aftercare plan — recovery support services (RSS) — when the individual is transitioning into “the real world.” However, no one treatment facility or one single treatment is “the right one” for every individual and disorder.
The good news is that research studies confirm and treatment experts insist that anything less than ninety days of formal treatment, including medications and behavioral therapies, is of limited effectiveness. The bad news is that it costs anywhere between $15K — $40K per month to get an effective 90-day treatment plan at a specialty facility in the U.S.
Does the more money you pay for treatment guarantee long-term sobriety? No. In my experience with clients with unlimited resources, turning addiction treatment into a Club Med experience (minus the alcohol, of course) does not necessarily induce deep introspection and help in answering “Why am I so fucked up?”
Even if health insurance is used during treatment, a hefty amount of cash is still needed upfront to cover the unmet deductible and out-of-pocket costs, then room & board fees when the insurance company stops authorizing residential treatment. When will that be? No telling since the insurance company determines when the patient no longer meets medical necessity for a certain stage of treatment — no matter what the facility says.
Getting 90-days of treatment solely through one’s insurance is a pipedream. It’s not going to happen. Consider yourself lucky if your insurance will cover anywhere from 30-to-45 days of residential & PHP. In rare cases it’s possible to squeeze 60-days maximum out of the insurance carrier, but don’t count on it. More on this in a later column.
For those who live paycheck to paycheck, unless there’s a Robin Hood in your life, ninety days of formal treatment at a rehab is likely not going to happen — even with insurance.
One note here: although it is normal practice for an insurance company to be cruelly parsimonious when it comes to authorizing treatment for adults at any stage of the process, they are generally more lenient when it comes to treatment for adolescents. Sometimes authorized days for adolescents can be double those for adults.
People who really want to get and stay sober make work the tools they can afford. Many individuals in long-term recovery haven’t stepped foot in a residential program — 12-step meetings and/or outpatient therapy works for them. One thing to be clear however, residential treatment’s intensive evidence-based therapy as part of a long-term treatment plan offers more tools and guidance upon which many individuals rely in order to live a life in long-term recovery.
I have worked with drug users and drunks who finally “get it” — from trust-fund babies and self-made, outrageously financially successful people who go through multiple rehabs of the most expensive kind, to those who don’t have two nickels to rub together. What works for one person does not mean it will work for another. When it comes to treatment, one size does not fit all. Although resources play a crucial role, they alone don’t get the victim sober. Ultimately, it’s the individual who decides that.
I have health insurance, but I still can’t afford to use it!
Health insurance has and continues to save lives, no question. But when it comes to behavioral health treatment today, the patient is treated as an orphan. It’s like this: you dutifully pay your premiums every month, then they dare you to use it. In fact, out of the 200 million people in the U.S. who have health insurance, 85 million are underinsured. That means 42% of us have health insurance, but we cannot afford to use it due to ever-rising premiums, deductibles and out-of-pocket maximums. And don’t think that just because you’re one of the 156 M who has insurance through your employer that you are immune to being underinsured — 42 M or 26% of you cannot afford to use it.
The surest way to receive a conventional 90-day treatment regimen is by paying cash for the entire 90-days or using cash to heavily supplement your insurance coverage for as long as you are able. Bottom line: it’s one thing to have health insurance, the question is do you have the cash to use it.
If one has the resources to follow a one-year treatment plan starting with 90-days of formal treatment at a specialty rehab (detox, residential, PHP, IOP), RSS is the 9-month balance of that plan. If your resources cannot allow for 30-days or less of residential care, take advantage of the outpatient programs your resources will allow. Remember, most people who access SUD and/or mental health treatment do not have the resources for residential treatment — outpatient treatment and RSS starting on day 1 are their treatment plan.
Individuals in recovery can live a self-directed, full, active, meaningful, loving, and productive life just like anyone else can on this planet. The point of this and the following columns is to help the uninitiated know the right steps in getting the right treatment for the right individual, without falling prey to the charlatans and grifters infesting the $42 billion per year treatment industry.
Next: How to know a real rehab vs. a rip-off
Walter Wolf is the pen name of a 30-year veteran of the movie and television industry who produced studio and independent films and television throughout the United States, Australia, and South Africa. That all changed in 2010 with one 3 A.M. call that a family member was in crisis due to addiction. Today, he is an interventionist who matches adults and adolescents with the optimum treatment program and facility for their particular diagnosis, demographics, financial and personal needs. In order to demystify and explain in layman terms what treatment is and how to get it, Wolf wrote The Right Rehab which became the only step-by-step guide for vulnerable families navigating the confusing world of addiction and mental disorder treatment, health insurance and recovery.
To know more about interventions and finding the right treatment for you or a loved one, read The Right Rehab or go to www.therightrehab.com or call Walter Wolf at 1–310–210–4334.
Footnotes
[1] Office of the Surgeon General, “Facing Addiction in America,” 5–7.
