Tag Archives: drug rehab

What To Look For In Drug Rehab


If you go to a 12-step meeting one of the slogans you’re likely to hear is “keep coming back”. It’s meant to welcome you, and be encouraging. And it is. But with respect to rehab, you don’t want to “keep coming back”. As a therapist of 20 years, I can’t tell you how many times I’ve heard something like the phrase “I’ve been going to rehabs for years,” from weary drug addicts who are still suffering, wanting to get clean. They are not so much unmotivated as stuck with something that is more than an attitude, and something closer to an embedded way of being: I want to feel better, not get better.

            Find a program that does not collude with this misguided goal. Here are a few tips and explanations:

1.)    First of all, size matters: the size (as in number of beds, # of patients participating in activities); the size of a case manager/therapist caseload. If a program has more than six beds, or offers groups with more than 8 participants, the tendency is for treatment to become unwieldy, possibly unsafe. If a therapist has more than half dozen patients on their caseload, it is unlikely they will have sufficient time to devote to one individual or family. I’ve observed these phenomena over many years, and depict numerous examples in Working Through Rehab.

2.)    Secondly, ask questions about the influence of patients’ rights groups, community licensing bodies. Some programs are more answerable to external regulators than others, which isn’t necessarily a good thing. In my book, I chronicle several instances wherein outside agencies influenced program procedures, often based upon societal norms, and not for the better. Often, accommodations served to enable problem-behaviors of substance abusers, not protect individual’s rights. This is a similar view to that offered in Dr. Drew Pinsky’s 2004 book, Cracked: Life on the Edge in a Rehab Clinic.

3.)    Thirdly, observe the proscription of depth therapy in rehab settings. Note the tendency of programs to sell short-term models that address behavior and cognition, but not underlying feeling states, maladaptive patterns of relating to others—attachment difficulties, and trauma. For example, anger management skills and mindfulness training are well and good, but they don’t address pervasive distortions of self and others. Furthermore, dovetailing with item #1, if a therapist is too preoccupied with multiple staff meetings, producing rote documentation, communicating with collaborators on largely pragmatic matters, in-depth focus with any one individual or family is more or less squeezed out.

4.)    Finally, hear with some distrust the phrase “fun in recovery”. This language is pitched to teens in order to get a buy-in, but while teen programs should include recreational activities, make no mistake: recovery, or meaningful change, is not fun. If you are a parent looking to place your child in rehab, I suggest the requirement of “fun” has not worked, and reinforcing this idea may have you or your child coming back, again and again.




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The Mirror Defense


Within the branch of psychotherapy that is self psychology, which is derived from Object Relations Theory, which in turn is derived from classical Psychoanalysis, Heinz Kohut was pioneering. He was the first to emphasize the clinical manifestations of a grandiose self and an omnipotent object representations of a narcissist personality disorder. He also suggested the existence of a ‘healthy’ narcissism, and posited psychotherapy as a restorative exercise in which afflicted patients receive “correctional emotional experiences” through what Kohut termed transmuting internalizations.

He prescribed the technique of mirroring, in which a therapist repeats back what a patient has said, then amplifies its importance to the individual. The therapist doesn’t necessarily elucidate the defensive purpose, which was a problem in places like Thunder Road, the adolescent drug rehab in which I worked for fifteen years, and which I depict in my book, Working Through Rehab.

At Thunder Road, the first order of business was the containment of acting out behaviors, especially destructive behaviors like drug abuse and violence. Mirroring alone wasn’t sufficient to contain this acting out: it failed to acknowledge reality, both of the consequences of destructive behaviors, and also the reality–meaning, the thoughts and feelings– of other individuals, including that of helping professionals. I mean that therapists aren’t fantasy parents. They reject, disappoint, criticize, as anyone does. Sometimes they love, but they don’t really correct. The Kohutian therapist focuses on the inner experience of the patient, more or less ignoring the possibility that what is “needed” may be a distortion, a need with a defensive purpose, such as an expression of helplessness, which may in turn justify apathy. If the therapist doesn’t confront this response (which might be a behavior as well as an internal event) the defensive purpose may be reinforced and treatment may reach an impasse. As a therapist in a residential milieu, it is easy to become overwhelmed, consumed with the day-to-day lives of patients, the hand-wringing, fretful concerns as to whether these individuals will “make it”. This plus the volume of work is the reason that many burn-out, or so management assumes. In my opinion, it’s not. The reason there is high turnover among staff in drug rehabs is the sense of objectification and futility: the experience of being used by patients, and by management, for the mirroring of their insatiable needs. It is the sense that problems never stop, that business never stops, and finally, that some interventions are iatrogenic–not only unhelpful, but also counterproductive. The whole process seems a reenactment of an insidious, circular pattern begun long before treatment started. For the concerned and astute helper this is demoralizing. In actuality, it’s this that leads to burn out.

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Letter to a therapist friend


Hi, sent you a message a few nights ago, haven’t heard back, which isn’t like you. I’m not taking that personally (unless I should be?), but I thought I’d reach out again, imagining you may still be feeling hopeless, as you were last month, mostly because of work. 
I hope this doesn’t sound self-serving, but I think my modest, self-published book about drug rehab and community mental health as a whole does provide hope to those who work in this business. Many like yourself are smothered by the platitudes of directors, administrators, and so on while otherwise feeling technocratic shards of glass pierce into their sides. I felt in your reaching words something(s) unachieved in our world: passion, bravery; risk inflected with humility. I could feel it in your depiction of that unsatisfying exchange with your manager. A “nice” man, you said. It reminded me of something an old SN once said to our group of supervisees in the three-year program: “there’s nothing nice about being nice”–it was in response to a fellow student who was struggling to manage frame issues, and justifying a lack of confrontation by declaring that confrontation was…well, not nice. In my book I am scathing, I think, about rigid adherence to procedure–the tyranny of the HR manual–when not just common sense, but common thoughtfulness, decency, but above all realness, is called for.
There are times when I think that the Masterson model can truly be distilled into these qualities. I reflect on my caseload at any one time and I think, with whom  do I feel spontaneous? who do I really know? what connections feel real to me? More often than not, the best work feels like a jazzy, flowing sense of knowing…something that feels right. That may sound a little soft, and a lot unreliable. It certainly doesn’t sound very “evidence-based” or scientific, or “quantifiable”. But the thing is this: it sounds reliable to me. The reason? I trust myself, whether others do or not. Doesn’t that sound wonderful? Doesn’t it sound like a gift, or a real achievement, if I’m to give myself the credit for doing the work. I’m not saying I’m getting it right with all my patients. I’m saying I can tell who I’m getting it right with, and who I’m not getting it right with.
I agee that being in the quadrants is tantamount to being unsober. I think this was the basis for our original discussions about blending the Masterson model with a 12-step program. I’m working on myself as I flit in and out of defenses; my therapist is fighting me, I think–thinks me defeatist in my self criticism. Among other things, I defend the hard but fair pronouncements that KS made of me last year. I realize that his cool yet cutting approach stirred something vigorous yet frightened in me. It all lingers, the hurt. I was surprised to read that you “identified” (with being seen? or the “bad” experience you referenced), as I specified being seen in a manner that felt menacing, even sadistic. Did I misunderstand you? Were you writing of being scrutinized, and by KS in particular?
You wrote of vulnerability in your last e-mail, “to the toxic foolishness”. I identify with this vulnerability, though I think I have some of the detachment you crave. I’m not entirely free of bad systems. Indeed, there are one or two that are threatening to ensnare me in a fight currently (perhaps more on that in a later e-mail). But TR is nearly two years in my rear view mirror, and completing the book has been, dare I say, cathartic. Anger is draining, despite the sneery, superior tone sometimes evident in the book and especially within this accompanying blog. Whether a handful of people read it (the book), or hundreds more do so, I have cleaned my own internal system of the toxic entity that once dogged me. I have gotten some peace. Like a Schizoid personality, I also have a fantasy, which I’ll share with you: you see, in the future, I imagine achieving a modest, measured (compromised?) fame for my lengthy missive to my peers. I’ll be asked what I think should happen in drug rehabs for adolescents; perhaps what should be happening in all community mental health settings. On the specifics I’ll defer, I think, as I choose to disentangle from Gordion Knots, practice something like a second step, and wait for help from those on the inside. I don’t want to abandon. I don’t want others–least not people like yourself–to give up hope. I just think I need back-up. I need the real selves to present in numbers.

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Dodos In Rehab: What’s Effective Therapy (part one)

Not that long ago I was speaking to a group of practitioners in a community mental health setting, posing a series of challenges designed to tease out what biases exist regarding the above question: what makes for a positive therapeutic outcome, and how do we know who’s doing what kind of therapy?

“How many of you consider that you are practicing evidence-based methods?” A dominant percentage in the room raised their hands, uncertainly in some cases. “How many consider yourselves CBT or solution-focused therapists?”, implying a chestnut belief in mental health circles: Cognitive Behavioral Therapy, or models similar to it, are the scientifically-based, empirically supported models of psychotherapeutic care. Roughly the same proportion of practitioners raised their hands after the second question. I then asked the audience to consider factors in outcome studies: time frames for follow up (were outcome measures made within 48 hours of treatment completion? 2 years? five?) What was the method of data collection (clinician assessment? participant self-report?) How did researchers determine what methods were actually being used in psychotherapy sessions? Among the practitioners, there was a smattering of speculations, but none knew definitively how the pronouncement “evidence-base” was being arrived at. I further asked if any in the room made audio tape recordings of their sessions, or made verbatim transcripts of sessions and then submitted them for scrutiny of methods. No one raised their hand. Someone shrugged and called out, “who does that?” I admitted that few did, but then asked one more volley of questions: given that mental health treatment is a confidential undertaking, and the likelihood that few psychotherapists subject their methods to rigorous scrutiny, how is it that researchers know who is doing what kind of therapy? I pointed my finger at my audience: how would they know you are CBT therapists?

The commonplace belief that psychodynamic models of therapy are not effective, or that pronouncements as to its efficacy are not grounded in science, is getting debunked. Meta-analyses of studies are accumulating, presenting effect sizes of close to or above 1.0 (this refers to a standard deviation above a normal distribution, and .8 is considered a large effect). This is the reporting of Jonathan Shedler, whose famous article in the March 2010 edition of American Psychologist is changing minds in professional circles. He is one of many sources quoted in my own non-fiction book, Working Through Rehab: An Inside Look at Adolescent Drug Treatment. I worked in this business for fifteen years, originally under the supervision of professionals who frequently spoke in psychodynamic terms, affording me a rich, comprehensive lens through which I could work with and understand my clients in long-term residential care. Over time this influence was eroded, as shorter term models, with their myopic treatment goals, and sometimes insipid criteria for change (example objective: “reduce instances of tearfulness from 8 out of 10 occasions to 5”), increasingly impinged upon the treatment culture. Imagination, thoughtfulness, even common sense was being squeezed out, in favor of a supposedly utilitarian approach that presented common denominators for care. A reductionist assessment of symptoms, based largely upon Aaron Beck’s depression inventories, prevailed as the means by which treatment progress, and thereafter effective outcomes, were measured. Meanwhile, within the dusty crevices of program operations manuals, there existed old articulations of purpose that aimed for an implicitly internal process, the “core” experiences of the suffering individual in treatment.

In my book I make considerable reference to the work of Fonagy and Bateman (2008) whose mentalization-based treatment model (a psychoanalytically-derived technique) has yielded enormously positive results. At 5 year follow ups, 87% of patients who originally presenting with psychiatric symptoms and measures of social functioning consistent with Borderline Personality Disorder dx. continue to present criteria for the diagnosis, compared to 13% of those patients who received Fonagy and Bateman’s psychodynamic treatment. The centerpiece of Fonagy’s model is this concept of mentalization: the ability to experience another’s mind; to mentalize. Attachment research and decades of clinical observation has revealed the significant problems of those who present for care in community mental health care settings: poor impulse control, low self esteem, lack of empathy, or sensitivity for others’ needs and feelings; the inability to soothe uncomfortable feeling states–the aggregate of deficits that culminate in self destructive, anti-social attitudes and behaviors; drug abuse. Utilizing an index designated as SWAP (Shedler-Westin Assessment Procedure, available at http://www.SWAPassessment.org), Jonathan Shedler coalesces some of the factors that yield positive treatment outcomes from a broader, in-depth perspective: increased capacity for sensitivity; attention to others’ needs and feelings; recognizing others viewpoints, even when feelings run high; healthy use of humor, knowledge of consequences of behavior; linking of feeling states to past experiences; the ability to soothe negative affect (w/out substances). All this constitutes an attempt to operationalize mental health, via clinician report; a means of assessing mental health not just from the absence of symptoms as delineated by past or present versions of the DSM, but by the presence of capacities, strengths and resources that are internal.

* Bateman and Fonagy (2008) An 8-year follow up of patients treated for Borderline Personality Disorder: Mentalization-based treatment versus treatment as usual. American Journal of Psychiatry, 165, 631-638.

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