Inside Rehab: The Surprising Truth About Addiction Treatment--and How to Get Help That Works

by Anne M. Fletcher

An essential guide to finding the right recovery program from the New York Times–bestselling author of Sober for Good
Drawing on extensive research, including visits to fifteen addiction treatment programs and interviews with more than two hundred clients and professionals in the field, trusted health and medical writer Anne M. Fletcher offers indispensable advice for people seeking quality care for themselves or a loved one. She reveals the ways in which our addiction treatment industry is broken, highlights what is working, and shares insights about how the experience could be more effective. Fletcher sheds light on the science-based practices that should form the basis of treatment, spotlights programs and professionals using those practices, and provides a much-needed guide to different types of treatment and finding quality care when it’s needed.

Genres: Nonfiction, Addiction, Psychology, Health, Audiobook, Self Help, Medical

448 pages, Paperback

First published February 7, 2013

Reviews

[Caroline · Rating 4 out of 5]

I read this book because I had been following the blog of someone who is in rehab. He was intensely critical of the attitudes and practises he found there. I became curious as to how much of his anger was justified, and how much might just be due to his own rather unorthodox views. Having now read this book, I think his criticisms (& there were many of them), are probably valid.

My heart goes out to anyone who feels they need rehab, or is in position of trying to help a friend, relative or spouse who they feel needs rehab. The whole process is most depressing. It's expensive, and positive outcomes are far from being guaranteed.

I thought this book was well researched. Besides visiting 15 addiction programmes and talking to staff and clients, the author also interviews a variety of specialists in the field, and a good reference section is given at the end. One feels she has done her homework.

I end with notes that I have taken from the book

Cost

If you are poor Medicaid will cover your costs, or if you are rich you may be able to afford the astronomical costs of rehab. It's the middle classes who really struggle to pay. Addiction is also a chronic disease, and there may well be relapses. Often people end up going to rehab several/many times.

Genetic factors

Genetic factors account for 40-60% of a person's vulnerability to addictions.

Mental health issues

More than half the people with addictions also suffer with one other mental disorder, like depression, anxiety or bipolar disorder, and these need to be treated as well as the addiction, or treatment will likely fail.

12 step programmes

Most rehabs follow the AA model, and many don't follow the latest research about best practises for addicts. Also in many instances clients who don't like the principles of AA are not catered for. Often no alternatives are provided.

AA also has a culture that tends to be dismissive of medication. This can be an issue if someone has a mental health problem, and could benefit from something like anti-depressants. Also a lot of research has shown that methodone and Suboxone can be a lifeline for people coming off heroin and pain-killing medications - ideally they should be taken as a long-term support, or the prospect of relapse is very high. But AA is often critical of this.

Inpatient rehab versus outpatient rehab

Outpatient rehab generally has just as good results as inpatient rehab. The latter may be needed though for people at the more severe end of the spectrum.

81% of addiction treatment is for outpatients (intensive outpatient programmes)
10% is for inpatients, within a non-hospital setting
6% is for inpatients, within a hospital setting.

Young people

Adolescents do best with family-based treatment, not the 12-step programmes.

Supporting an addict in your family

The two most famous approaches can be found in Al-Anon (AA's approach of tough love) and CRAFT (which tends to be more gentle, and has shown to be a far better way of getting people into treatment than classic 'interventions'. )

Success rates

AA versus programmes with evidence-based treatments (like cognitive behavioural therapy) ........ Surprisingly research has shown that both have pretty well the same success/failure rates.

How long should someone be in rehab?

The National Institute on Drug Abuses says that research indicates that most addicted individuals need at least three months in treatment, and that the best outcomes occur with longer durations of treatment. "The longer people stay with something, the better the outcome. That's true of residential treatment, outpatient treatment, therapeutic communities, medication, AA and even placebo pills". It has been pointed out though that people who are more motivated tend to stay in treatment longer. Plus for many people with addiction problems, the thought of a longer treatment period would be highly unattractive.

Therapy

Most rehab centres offer group therapy, but the opportunity to have one-to-one therapy as well has been shown to be far more effective.

Addiction counsellors

They provide most of the treatment at rehabs, and different states have widely varying requirements both in educational level and training for a person to become a drug and alcohol counsellor. Many require just a high school diploma or equivalent. Although there's been a movement to professionalize treatment, much counselling still is provided by minimally trained addiction survivors-turned-counsellors.

Given the complexity of substance use disorders and the fact that more than half of the people with addictions suffer with mental health issues, a college degree or Masters would seem a necessary qualification for addiction counsellors.

Sober living facility with outpatients rehab

As long as the sober living facility is well run, this combined with outpatients rehab can be a better option than residential rehab. They need to be well checked out though, as they are unregulated.

They allow clients to experience everyday life and be part of the community whilst getting treatment, and living in a safe place. As one client says "With residential rehab you can feel institutionalized, and then they boot you out.... Here, you have time to look for a house. You're not kicked out of treatment to go back to only what you knew before."

At a sober living facility you usually get to live there for six months, rather than the twenty-eight days usually found in residential rehab, and for a fraction of the cost.

Coercion

Rehab is usually best when there aren't too many clients who have been coerced into being there, via mandates such as court-ordered rehab, civil commitment , diversion to treatment as an alternative to criminal sanctions, or as a mandate from a professional organization, employee assistance programme or social assistance programme to avoid loss of child custody. One of the directors of a rehab centre says he won't allow more than 20% of his client base to be legally mandated participants. "When a significant portion of patients is there through the criminal justice system, the treatment tends to be less effective. It can ruin it for the others.

Relapse rates from rehab

Amongst those who complete treatment (& drop-out rates are high), one-year relapse rates are 40-60%.

Effective Therapies (these can be googled for further info)

Cognitive-behavioural therapy.(CBT)
Motivational Interviewing (MI)
Twelve-Step Facilitation Therapy (TSF)
Contingency Management
Community Reinforcement Approach (CRA)
Behavioural - Couples and Family Therapies

General procedures that don't work

Educational lectures
Dwelling on the past
Confrontational approaches.

The importance of choice

It's important to give clients the theraputic treatments they prefer. If they are adamantly against something they are unlikely to benefit from it.

Alternatives to AA
SMART (Self-Management and Recovery Training.)
Women for Sobriety (WFS)
SOS (Secular organisations for sobriety)
LifeRing
Moderation Management.
Faces and Voices of Recovery.


----------------------------

An interesting-sounding book on helping people with addictive behaviours (not from "Inside Rehab"...)

https://www.goodreads.com/book/show/2...

[Jordan · Rating 5 out of 5]

I’ve rabbit-eared so many pages in this library book that it would take hours to write a fitting review!!! This book is nothing short of required reading for any beginning therapist looking to understand how substance abuse treatment works well, works poorly and what its future looks like.

Begin by following the money:
Fletcher offers an alternative to 28 inpatient therapy:

28 days at a nice hotel ($150/night), weekly therapy with a psychologist/psychiatrist/addictions counselor ($800), Room service ($100/day), Weekly massage ($100) membership to a nice gym ($100)
28 Day Total:
$10,700 Versus 30,000 + for average 28 day inpatient treatment centers

Inside Rehab does no less than divine the future of substance abuse treatment. Anne Fletcher exhaustively travels to and reviews the good and bad of dozens of treatment centers across the United States. She gives an unbiased recounting and examination of many current treatment practices, costs and whether the results lead to lasting recovery or revolving-door futility.

[Amy Marflak · Rating 4 out of 5]

I wish I would have read this book about 5 years ago. My son was an addict, technically, he will always be battling his addictions. As a mother I thought I was doing the right thing by sending him to a rehab. I had no choice because I was at the mercy of the insurance company unless I wanted a rather large bill. This book was certainly an eye opener for me. Even though I was never the addict, I could relate to so much of the book and the people Anne interviewed. Anne did a wonderful job in uncovering the sad truth about our countries solution to addiction. It obviously is not working. This book will get passed on to someone who may need it. Thank you Anne for such an eye opener.

[victor harris · Rating 5 out of 5]

The most thorough and scholarly analysis of the " treatment" industry I have read. Valuable for parents who may have adolescents who struggle with alcohol or drug abuse issues. Walks you through the questions to ask before committing a young person to treatment. Warns of the possible pitfalls, unethical conduct, and the counterproductive " one size fits all", 12-step form of treatment and recovery many rehabs use.

[Maureen · Rating 3 out of 5]

I have hesitated months writing this review because I learned a lot and recommend that you read it, but I didn't like the book.

I think this book could have been an excellent magazine article. The author's references and checklists are well done and useful. I learned about different addictions and the horrible business of rehab. Unfortunately, I think the book-length gave the author too much latitude with her opinion, and that is the main gripe I have with the book.

The author continually inserts her opinion into the book. This is not useful at all. In fact, it is quite humorous since she criticizes 12-step programs because they are based on opinion and not fact, yet she thinks her opinion is somehow of value.

Her main points (spoiler alert!) are first, and foremost, it is worth finding a rehab that has staff educated in addiction and willing to work with a patient to find a program/the help the patient needs to get sober; That residential rehab and outpatient rehab have the same success rates for folks who graduate BUT residential rehab has a higher completion rate; the 12 steps, and AA in particular, has no higher, or lower, success rate than other programs considered successful; once the addict wants help, the addict may have to try different programs before finding one that works form him/her; opiate addiction is tough to recover from without medicine to combat the changes opiates have made to the addicts' brain.

I enjoyed her stories, but her tone often annoyed me. She implies through tone that she knew what would and wouldn't work. That said, she clearly dislikes 12-step programs yet manages to report honestly about that, albeit about 1/3 of the way through the book.

I recommend reading it for your own information and hope you never have to apply her checklists.

[GONZA · Rating 3 out of 5]

This is a very scaring book, specially if you are a professional and you can imagine how devastating can be the results of some of this "so called treatment". It was also very interesting but still some of the things that were written here, I suppose are really wholly comprehend by people that really know what is it all about.

Questo libro mi ha spaventato, specialmente perchè come professionista posso immaginare facilmente quanto possono essere devastanti i risultati di alcuni di questi "così chiamati" trattamenti. E' stato anche interessant, ma ritengo che alcune delle cose che sono state scritte in questo libro possono essere comprese appieno soltanto da chi ha un'idea piuttosto chiara e precisa del concetto di trattamento e di quello che implica.

THANKS TO NETGALLEY AND PENGUIN GROUP VIKING

[Librarymary · Rating 4 out of 5]

Well, the author did a lot of research and what she found in regard to treatment options outside of the standard 12 step stuff is very valuable. I couldn't help noticing an anti-12 step attitude.
It is a worthwhile, possibly should be mandatory, read for folks in the addiction recovery field. It is full of good info for family and friends of addicted individuals.

[Dervin166 · Rating 5 out of 5]

Exceptional book about the too caught-in-the-past rehab industry. A worthy follow-up to Fletcher's "Sober For Good". With any luck, this book will start a much needed discussion on how rehab services are delivered. If I have one complaint, it's that Fletcher doesn't hit hard enough at the ancient 12-Step mentality found in the industry. Kudos for her chapter on teens in rehab!

[Rosemary · Rating 5 out of 5]

Great! I work in a rehab facility and this author has done all the work I would think of doing to get information about what is presently going on in rehab and what contributes to success. Took a while to read it, only because I devoured every page. An excellent resource for anyone working in the addiction field.

[Lynn · Rating 5 out of 5]

Having worked in the chemical field for 12years, always as outsider, I was skeptical, wondering if the author drank the kool aid. Anne M. Fletcher did not! The field desperately needs reforms and Fletcher's book kick starts the public's awareness that the Emperor is wearing no clothes. She lays out exact blueprints for anyone considering treatment and their families. She is just as precise in letting the chemical dependency industry know exactly what is expected for standard of care. A must read if you want your blinders removed and the "magic" removed. No more hocus pouch by untrained or poorly trained personnel.

I thought this book would blow the cover off Mn treatment facilities but the good old boys were successful in squashing and poopooing it. A tragedy as this is a smart well researched book. It deserves to be in classrooms. The old AAers need to leave the field. Young and cutting edge counselors need to read this book.

[Rachelle · Rating 5 out of 5]

If you or someone you care about needs help with alcohol or other drugs, this book will help you understand the treatment options.

Key messages are:

- most treatment is conducted in group therapy or group-based self help, but many people benefit more from one-on-one psychotherapy
- treatments are not sufficiently individualized - everyone gets the same
- not everyone needs residential rehab; outpatient treatment is often more effective
- most rehabs are based on the 12-step (Alcoholics Anonymous) model. Alternatives are available if you know where to look and what to ask
- continuing care is important for long-term success

This is a very worthwhile read. The book is well-researched, blending personal interviews with people who misuse drugs and alcohol, site visits to treatment programs, interviews with rehab personnel and researchers, and reviews of scientific literature. It also provides checklists for those shopping for treatment.

[Pete Dematteo · Rating 3 out of 5]

Fletcher is to be praised in that she clearly exemplifies that 12 Step programs aren't for everyone. In certain instances, they can make the situation worse. Also, rehab is an option for most, as opposed to a necessity. We learn from Fletcher that these places are, at best, to be investigated with complete objectivity, if at all possible, and cautious optimism as best, regardless of their 'prominence' or pricing.

[Linda]

It's interesting how many books there are on addiction and recovery that basically take 300+ pages to say that every person in treatment is different and there are no cookie-cutter solutions to anyone's struggle. I found this book a bit boring, but that's because I've read a zillion like it. The book itself is good.

[Stephanie · Rating 4 out of 5]

An interesting, and at times appalling, look at what drug rehab is actually like. The lack of support for some patients, especially if they don't fit well with a 12 step program, is aggravating, especially given the cost of some programs.

[Keri · Rating 3 out of 5]

Good information, but pretty repetitive. I felt like this information could have been effectively covered in 200 pages instead of 400.

[Monica Willyard Moen · Rating 3 out of 5]

This is a long, fairly discouraging, very detailed description of what it’s like to receive treatment for alcohol or drug addiction in a rehab facility. The author documents types of treatments offered by these centers and interviews a wide range of current and former patients about their experiences. Since the majority of facilities use the 12 step model for treatment of addiction, she spends a fairly large portion of the book discussing its shortcomings and why she does not believe it is a good choice for many people seeking treatment. She does make a point of distinguishing between Alcoholics Anonymous, a group of people who join of their own free will, and the institutional model and its adoption of 12 step principles.

The reason I say this book is fairly discouraging is that the Author has concluded that the 12 step model has very limited effectiveness in rehab settings. However, there is very little research so far that proves that another model is more successful on a consistent basis. Researching addiction treatment seems difficult by the nature of the people involved and determining single factors that prove treatment is working. Their are several competing methods of treatment for people with addictions, and some of them baby really good. The problem we face right now is that there isn’t enough research to prove that clearly. Most communities have limited budget for addiction treatment, and they want to be certain of results when they build facilities. Unfortunately, it doesn’t look like that’s possible right now. So they go with what we know, what professionals in the field tell them works. To be fair, I’m not sure how a person can be completely objective when comparing treatment, theories of treatments, and outcomes.
On a personal level, one thing that really bothers me about this book is that the author seemed outraged by several cases where people who have been convicted of committing a major crime under the influence and are given a choice of going to rehab or prison. The rehab sentences were always shorter then the prison sentences. She seemed outraged that someone might have his or her beliefs trampled on, calling it a violation of human rights, when they were sent to facilities that use the 12 step model of recovery treatment. She would express her anger at the situation in one paragraph and then mention that most communities don’t have a wide range of rehab facilities to choose from. She seemed more concerned that a person might be exposed to spirituality or religion within a 12 step facility than The fact that they have committed a felony level crime that calls for years of prison time. In one example, the person was found guilty of felony level driving under the influence. But that isn’t as bad as being exposed to the 12 steps! According to her, it was the community and judges responsibility to offer the person a form of rehab that didn’t do anything to violate their human rights by exposing them to an element of spirituality. My question is then what about the right of the community for safety when people are doing things like driving under the influence? Personally, if the outcome of rehab is as poor as she has expounded in this book, I don’t think we should be sending people there instead of prison at all. We are told regularly by people who are supposed to no more than us that R3hab gives people a second chance and can help first time offenders cleaned up their act. We are told that it is merciful to give them another chance. This is something that made sense to me, and it is something I have supported for a very long time. Now I’m beginning to question that.

[Charlie · Rating 3 out of 5]

three real complaints here.
1. repetitive. so repetitive. i could've cut half the book and still got the relevant info.
2. noticed a little sneering at masters-level clinicians, which rubbed me the wrong way (albeit as someone pursuing a master's degree, so i may be biased) as masters-level clinicians are often well trained and not inherently worse than doctoral-level clinicians (and often cheaper).
3. this is very much her opinion and i would absolutely verify many of the claims she makes before taking her at her word. i do happen to agree with her points that 12 steps are ubiquitous but don't work for everyone, and that ongoing care is vital (which is something i've also been taught in psychology classes in the last few years), but i do wish she had been a little more objective in her writing.
if half the practices mentioned in this book are still happening, though, we are absolutely due for an overhaul in addiction treatment. i also would absolutely use the checklists in this book if i ever needed to secure treatment for someone with an addiction, and as someone who's been turned off of the 12 steps i appreciated the information about other options. 3 stars.

[Melissa · Rating 4 out of 5]

This is an insightful investigation into the substance abuse rehab industry that provides a lot of food for thought. It was disheartening to read about the extraordinarily high amounts that rehab facilities charge their desperate patients for relatively little value, especially since they are not paying their treatment counselors well. The author's answer is to get private insurance to pay for more of it, but I wonder if a better solution would be more non-profit care centers. It was also interesting that the industry has operated outside of medical norms and much of the treatment is not evidence-based. The industry is tied to such things as AA and group therapy, although evidence doesn't necessarily support these approaches. Studies tend to show that outpatient treatment is as effective as care at a residential facility. In fact, the studies seemed to demonstrate that there is no one approach that works for everyone, and that any type of counseling, evidence-based or not, can be helpful depending on the person, or may not be.

[seth · Rating 4 out of 5]

this book taught me so much about the rehab industry and the ways it exploits people with addictions/their families. however, lots of her sources were based around a the perspective of one expert and i would have loved to see more of the other side. i have been sober for 3.5 years and i have lots of friends who have been victims to the rehab cycle in exactly the way she describes so it is definitely real and heartbreaking. necessary work and research even if you don't agree with all her points, i know i don't.

[Hallie · Rating 3 out of 5]

Harrowing book inside America's common substance use disorder (SUD) treatment approaches. Anne Fletcher did a nice job reviewing the scientific literature on evidence-based practices for treating SUDs, and contrasting that with the treatments often available in residential treatment settings. As someone with clinical experience in these settings, I appreciated her review and would recommend it for anyone interested in the treatment of SUD, particularly those who will be/are providing SUD treatment.

[Steve · Rating 3 out of 5]

A book full of different views and opinions on treatment experiences and what's best for different people in attempting recovery. Parts were dated, and it is very repetitive in coverage. Also, the tone could be very judgmental of different treatment models and not be as open to exploring the client's possible portion of responsibility in putting their own work into figuring out treatment, relying more on the professional expert to provide the answers. If the repetitiveness is managed, it was valuable to hear different people's experiences and what seemed to work best for them in recovery.

[Orb Sole]

Everyone has difficulties in life. Sometimes it is just some problems or a series of failures. And sometimes it is something serious, when a person cannot cope without the help of specialists. Especially if we are talking about mental disorders and illnesses. So, orange county rehab will be a good solution even if you just need a quality vacation from the hustle and bustle of the world and your daily life.

[Morgan · Rating 3 out of 5]

3.5 stars

Inside Rehab covers an important topic and contains a lot of interesting information. However, the book is exceedingly slow and repetitive, making it inaccessible for some of its key target audiences. I don't regret reading this book, but I think I could have gotten just as much out of it if it were half the length.

[Ms. Widule · Rating 3 out of 5]

I vacillated between liking and disliking this book. At it's best, it exposes the hearsay and psuedo-science underlying addiction treatment. At it's worst, it reads like a consumer report review about what type of addition treatment program to choose -- missing only the crash test dummies.

[Dana · Rating 5 out of 5]

This book would be perfect for anyone who wants to understand if they should seek residential care, and if so, what they should look for in a rehab for themselves or their loved ones. The book gives excellent suggestions about things you should ask and provides well researched information about what types of treatments and treatment modalities rehabs should have. This book may also be interesting to you if you work in a rehab and want to evaluate it. I saw some comments saying that this book was just common sense, and that may be true to some extent... but if you read this book you would understand that it seems to be the case that a lot of rehabs or people who work at rehabs do not seem to have that common sense. You also might find this book helpful if you are wanting to apply for jobs at rehabs so you can make sure the places you apply to provide effective treatments.

[Zev · Rating 3 out of 5]

I wrote a review on my DreamWidth of this book that I'm still deciding whether or not to put on here. Serious flaws in this book: Fletcher insists that the addiction I have is fake. She also dismisses codependency completely, and quotes doctors who do the same.

[Della Scott · Rating 3 out of 5]

Most of it is not that surprising--just common sense. Mostly a how-to for those contemplating re-hab for themselves or a loved one, but also a lot of information on addiction in general.

[Emily Feldman · Rating 3 out of 5]

3.5
lots of overlap w ED treatments

[Liralen · Rating 3 out of 5]

Moderately interesting but ultimately not-for-me look at rehab in the United States -- what's most common, what works, what doesn't work. The author's clearly done her research, but I think I was hoping for something a little less research-based and more...journalistic, I suppose. It also felt rather as though, past a certain point, new ideas weren't being introduced -- heavy repetition of 'AA doesn't have scientific backing; ask lots of questions; hurray for evidence-based treatment; group therapy is useless; if it doesn't work the first time, why do people keep being given the same treatment?' (Also, a couple of confusing moments -- we learn on page 104 that insurance is more likely to pay for residential treatment than the less expensive outpatient treatment; this is followed, on page 114, with the information that insurance is much more likely to pay for outpatient treatment than for residential...)

With all of that said, I suspect that I would have found this more engaging if it were more applicable to me; I think it's largely a case of (to borrow from Tom & Lorenzo) 'girl, that's not your book'.

[Bryan · Rating 4 out of 5]

I am completely naive in regards to the substance abuse/dependence realm as I'm sure is most of American society. and after reading this book, even those in the substance dependence and addiction field are not as informed as would be desired. the author went into great detail describing the world of addiction treatment. She seemingly leaves no stone unturned with a litany of research and interviews of both helping professionals and participants in the system. The author has a clear position when it comes to using ebp treatments and not an antiquated program which is currently the modality of choice on the field. sadly, this notion of using unsupported scientifically backed treatment is not confined to just the addiction treatment field. Overall, I thought this was a very well researched and written book. at times I thought all of the research was contradictory which said to me we still don't understand how to optimally treat addiction. there are also good resources for both helping professionals and those with addiction problems interspersed in the book.