Monthly Archives: October 2018

20Oct/18

Profits Before Patients: “We own that client!”

By Andrew Walsh

Edited by Frank L. Greenagel II

Image result for we own you

 

Jessica’s[i] family was extremely concerned about her. Jessica was 24 years old and was abusing alcohol, marijuana, and opiates. Driven by the fear of what would happen to their daughter, Jessica’s parents researched all options for help for their daughter. With the support of her family, Jessica contacted a for-profit partial hospitalization program (PHP) and intensive outpatient program (IOP) in Central New Jersey[ii].

During the course of Jessica’s phone assessment, it became clear to the PHP/IOP that Jessica needed detox first, which was a service that they did not provide. The program made arrangements for her to attend a for-profit detox facility in Northern New Jersey. Upon completion of detox, Jessica would then return to the PHP/IOP she originally contacted.

Over the course of seven days at the detox, it became clear to the treatment team that in addition to substance abuse, Jessica was also suffering from extreme anxiety. The treatment team also learned that Jessica had a significant trauma history stemming from multiple sexual assaults.

The treatment team at the detox found themselves in a quagmire. On the one hand, the program in central New Jersey did not have the appropriate capabilities to treat Jessica’s severe anxiety or her serious trauma history. Jessica needed a program that was licensed to provide dual diagnosis services. Additionally, Jessica would greatly benefit from a program that has extensive trauma programming and experience in treating clients with sexual assault histories. On the other hand, the referring PHP/IOP program owned Jessica. If the detox did not send Jessica back, the PHP/IOP would be upset and would eventually stop referring clients to the detox. In recent months, the treatment team at the detox had been experiencing significant pressure from administration to keep increasing revenue.

The treatment team caved to the pressure from administration and from the referring PHP/IOP. Upon completion of her detox, Jessica returned to the PHP/IOP where she received treatment for her substance abuse. However, the PHP/IOP did nothing to treat her severe anxiety or her history of trauma and sexual assault. Quickly Jessica’s progress stagnated because her anxiety and trauma were not addressed. She ended up developing a relationship with a fellow patient and they left treatment together and relapsed.

Jessica eventually was able to end the unhealthy relationship she developed with her fellow patient and again sought help. She contacted the same PHP/IOP in central New Jersey she had attended previously.

Contacting the same facility had several advantages for Jessica. She was able to speak with the treatment team she worked with before and who knew her case. The team was aware of Jessica’s severe anxiety and history of trauma and sexual assault. Those professionals were also aware that these factors significantly contributed to Jessica’s relapse.

However, there were several negatives that Jessica was not aware of that outweighed the advantages. The treatment team was still unable to treat Jessica’s severe anxiety, trauma, and sexual assault history. Additionally, the treatment team had been experiencing significant pressure from their administrative team to keep increasing revenue by keeping the number of patients in the program as high as possible.

The thought of referring Jessica to a more clinically appropriate program rarely crossed the minds of the treatment team. After all, Jessica belonged to them.

The cover of USA Today on October 3, 2018 reported a similar story. Cody Arbuckle died at an American Addiction Center facility in Nevada last July.

A coroner listed the cause as toxicity from loperamide, an ingredient in the anti-diarrhea drug Imodium A-D.

His mother has filed a lawsuit against AAC in the Clark County District Court. Kathryn Deem, Arbuckle’s mother, is represented by Jeremiah Lowe’s San Diego law firm, Gomez Trial Attorneys. According to Deem’s attorneys, staff at the Solutions Recovery house reported that Arbuckle was under the influence of drugs. But rather than transporting him to a hospital, they say in a lawsuit, they sent him to a “non-medical residential detoxification house” in Las Vegas.

Arbuckle was supposed to be under 24-hour monitoring, the lawyers say in the lawsuit, but he was not checked over 14 hours overnight. He was found dead the following morning. The lawyers say in the lawsuit that AAC kept Arbuckle “in their non-medical program for business reasons, because they did not want to let go of their paying client.”

He became the seventh patient who died shortly after entering an AAC facility, the attorneys say in the lawsuit[iii].

These stories highlight a common occurrence in the substance abuse field that is incredibly troubling: treatment providers owning clients. In the past few years, I have been fortunate enough to work with thousands of clients at the Carrier Clinic. I have interacted with the majority of treatment providers in the tri-state area. On a weekly basis I would receive referrals from treatment providers with clients who needed to detox before they could attend the treatment providers’ program (I worked in Carrier’s call center for one year).

These treatment providers would always call me and happily refer their clients to our program. They would go as far as obtaining insurance authorizations and providing transportation to Carrier (no small feat). As a nonprofit, this additional business helps keep the lights on and the program running. However, there was one small stipulation from the referring treatment providers regarding these clients; “Send me back my client when you are done, they are mine.”

The current state of affairs of the substance abuse treatment field is troubling. There are many treatment providers that unintentionally are ill-equipped to provide clinically appropriate services to clients. Often and terribly, there are treatment providers that are consciously aware of the lack of clinical appropriateness and still treat those patients because they put profits before people. One commonality among the majority of treatment providers though is their belief that clients belong to them. This damaging mentality is pervasive throughout the industry and is incredibly destructive.

Jessica’s story highlights a troubling dyad in the substance abuse treatment field:

  1. Detoxes will not refer clients to PHPs/IOPs who do not refer clients to them
  2. PHPs/IOPs will not refer clients to detoxes who do not refer clients to them

Caught in the middle of this dysfunctional relationship between treatment providers are the Jessica’s and their families. Clinical appropriateness is now competing with profits, and the focus on profits outweighs the significance on clinical appropriateness in the decision making process.

Further contributing to the disservice to clients is that the majority of treatment providers are not equipped to provide clinically appropriate services for co-occurring psychiatric disorders or trauma. The majority of treatment providers are licensed to provide substance abuse services. However, they are not licensed, nor have the necessary staff with necessary credentials, to provide psychiatric services.

On a weekly basis marketers would come in to my facility and talk about their program. They would show us glossy brochures and talk about the specialized programs they have for first responders and trauma populations. However, very few of these programs were licensed to provide dual diagnosis services. Whenever I inquired about their ability to take clients who had co-occurring substance abuse and psychiatric disorders, they always assured me that they had the capabilities, as long as the client’s psychiatric disorder was not too acute. Almost every presentation from these marketers ended with some version of the following: “We will definitely send our patients to you for detox and then as soon as they are done you can send them right back to us.”

Having worked with clients with substance misuse disorders, I feel confident in my assertion that occasionally clients change their mind. I firmly believe in my clients’ right to self-determination. When working with clients on their discharge plans, they would occasionally elect to attend a different program instead of returning to the program that referred them. Seeing clients start to take responsibility for their treatment was encouraging because it showed buy-in.

Once the referring facility realized that the client they referred to us was not returning to them they would become upset. Phone calls would pour into our marketing department and clinical team complaining, “Why didn’t you send back the client? That was our client. They are mine.”

The majority of the conversations that I had with these upset treatment providers were with people who did not have the requisite education, experience, or licensure to make clinical determinations. It was not, and is not, uncommon for unqualified marketers to state that the clients they refer to my program are clinically appropriate to return to their program upon completion of their detox.

I would return to the clients I was working with. However, a few days later a message would be passed along to our treatment team that if we didn’t send the patients back to the referring facility in the future, the referring facility would stop sending patients to us. We ended up right where we started: revenue versus clinical appropriateness. The client belongs to the referring facility[iv].

Here are three solutions that clinicians should follow in order to address this problem and put patient care back at the forefront of practice.

  1. Adhere to the standards of your profession
    1. If you are LSW or LCSW, adhere to the Social Work Code of Ethics:
      1. Section 2.06 (A) Referral for services – social workers should refer clients to other professionals when the other professionals’ specialized knowledge of expertise is needed to serve clients fully
    2. If you are a LCADC, adhere to the Ethics for Professional Substance Abuse Counselors:
      1. Standard 2 – Client Self Determination (8): the addiction professional will refer a client to an appropriate resource when the client’s mental, spiritual, physical, or chemical impairment status is beyond the scope of the addiction professional’s expertise
    3. If you are a LPC, adhere to the ACA Code of Ethics:
      1. Section A.11(a) – Termination and Referral: if counselors lack the competence to be of professional assistance to clients, they avoid entering or continuing counseling relationship

 

  1. For practitioners who feel pressured by their program administrators to make clinically inappropriate decisions for fiscal purposes, report your program to the attorney general’s office at NJ CARES or email Deputy Attorney General Sharon Joyce at Sharon.Joyce@law.njoag.gov.

 

  1. Develop a list of programs that can provide clinically appropriate services to clients (focus on identifying programs that are specific for trauma populations, first responders, LGBTQ, and co-occurring populations).

The substance abuse field has poor reputation because practitioners and programs have been acting horrifically. In a medical practice, if a patient died because a doctor refused to refer the patient to an appropriate level of care for appropriate services, the doctor would be charged and (hopefully) convicted of medical malpractice. A defense of, “This is what everybody does in the field and what my administration wanted me to do,” would not be valid. Medical professionals take an oath to do no harm to the chargers in their care. Practitioners and treatment programs would be better off if they lived by the ethics and values they so highly tout on their websites and brochures.

The for-profit treatment programs (looking at you American Addiction Centers and Recovery Centers of America) are not going to change without significant pressure from advocates and the government (editor’s note: we are working on this). Our immediate hope rests with the clinicians and techs that work in those programs. Tell your bosses that they are acting unethically. Remind the clinical director(s) about the various codes of ethics. If that doesn’t work, report your bosses and your companies. You can contact the NJ Attorney General’s Office (if you are from another state, start with your Attorney General’s Office) or you can email Frank Greenagel. The reckoning is coming.

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[i] Jessica is not her real name. It has been changed to protect her identity.

[ii] The author and this website cannot publish the name of the company unless Jessica and/or staff members went on the record.

[iii] We think that there may be more than that. We are currently investigating American Addiction Centers.

[iv] To be very clear, the Carrier Clinic did not send people back to referring programs that could not address the psychiatric, physical or trauma issues that we discovered. This has made us an outlier in the field.

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Andrew Walsh is a Project Manager and Director of Clinical Trials for Carrier Clinic. Carrier Clinic is one of the largest private non-profit psychiatric facilities in New Jersey. He earned a Master’s Degree in Social Work and a Master’s Degree in Human Resource Management from Rutgers. Prior to working in the behavioral health field, Andrew worked in the Gulf of Mexico oilfield as an internal business consultant focused on innovation and improving the efficiency of people, processes, and procedures. He eventually decided to return to NJ to practice innovation in the behavioral health field. In his free time, Andrew enjoys hiking, cooking, and reading.

He has written previous articles about Addiction Hotlines, Medicaid, Medicare, and A Fix For Addiction Hotlines.

14Oct/18

On Death and Grieving

In early October, a very close friend reached out to me via text to tell me a friend of his had died that day. Just 39 years old, the man had succumbed to his substance misuse disorder after many years of complete sobriety. When my aforementioned friend lost someone very close to him in 2014, I sent an email out about what he (and others) might want to do in both the immediate and long-term aftermath. He asked me for that advice again. I sent him a longer version, which I’m posting here for the public (I’ve edited out the deceased name).

What you should do:

  • Write down everything you can about him/her. Things he said, things you did together, jokes played, things that pissed you off and little gestures. Your mind will be flooded with memories over the next two weeks, and then they will slowly fade. You will never remember him as well as you do right now. Write it down. Also…it will help you grieve. Do this every day, for 30 days, without fail.
  • Keep up your exercise routine. If you don’t exercise, you should start.
  • Consider seeing a therapist who specializes in grief and loss.

What you should avoid:

  • Avoid isolating after the first 24 hours. Humans (and animals) have a tendency to crawl into a hole when injured or sad and avoid contact. It is a terrible instinct for grieving. Having people around, even if you don’t discuss the death, is helpful. Maybe not 24/7, but certainly daily. I am incredibly grateful for my friends who realized that they should stop by for a meal or watch baseball or just hang around during my various periods of grieving.
  • Do not take in more caffeine or nicotine than usual.
  • Be aware of your eating. Some of you may have no appetite, while others will seek comfort in food. Both options have negative consequences. Try to keep up your regular diet.
  • If you are someone who uses eating, drinking, drugging, sex, gambling or shopping to feel good or self-treat, be very wary over the next three months. If you are in recovery from one or more of these issues, consider talking to friends who are also in recovery or upping your support group attendance.

What you should be aware of:

  • I was angry at Fraser for dying and then I would feel bad about being angry at my dead friend. It was confusing. It took me a while to reconcile all of those feelings.
  • You have the right to talk with who you want about this, and you can also tell people that you are sad and just need some space. I found that I talked about it a lot with a couple of close friends, shared about it at every meeting I went to and discussed it in therapy. But I didn’t have it in me to talk to everyone. Some people just pissed me off or didn’t “get it.”
  • Everyone grieves differently. Everyone. Don’t fight with those close to you because you don’t like the way they grieve.
  • Remember that his/her family’s pain is worse than yours. Writing a letter to them about how much he meant to you, as well as some funny/good stories will be valued more than you can possibly know.

I’ve written a lot about death and grieving over the last four+ years. I have provided some baseline advice in this article, but for more specific situations, you might want to check one or more of the pieces below.

In the spring of 2014, Rutgers published a story about my work and how I was inspired after the death of my childhood friend Fraser Curry. I wrote a follow-up piece about my reaction to his death and what people can do if they have a friend or family member with a drug problem: http://greenagel.com/what-to-do-when-your-friend-or-family-member-has-a-drug-problem/

When my friend Pat died, I wrote this in 2014: http://greenagel.com/our-friend-pat/

This is a (near) copy of a speech I gave at an Overdose Vigil to 350+ parents who lost a child to addiction: http://greenagel.com/to-the-parents-who-have-lost-a-child/

A long-time patient of mine died in December of 2016 and I wrote this for myself and other counseling professionals: http://greenagel.com/on-the-death-of-my-patient/

A cousin of mine lost a baby in 2017 and I wrote this: http://greenagel.com/to-the-parents-who-lost-a-young-child/

I lost one of my closest friends (and my closest co-worker) this past March. I followed almost all of the advice that I’ve laid out (I didn’t work out for three weeks and I over ate). My writing turned into a book and it was released on October 8th on Amazon. It is titled The Book of Eric and it provides an example of how to deal with loss and grief.

06Oct/18

American Addiction Center’s Unauthorized, Unethical and (perhaps) Criminal Behavior

Earlier this week, I googled my name* and discovered that the first link was for a link to drugabuse.com. That is a website that is owned by American Addiction Centers (AAC), which is a for-profit treatment company that has been in the news a lot because of variety of problems at their centers, but most significantly because multiple employees have been indicted for murder of their clients. That’s right: multiple employees from American Addiction Centers have been indicted for the murder of their clients. I have contacted my lawyer and will be pursing a few different legal actions against them.

Question: Why would American Addiction Centers pay for the search engine optimization (SEO) use of the name “Frank Greenagel” and why would they then link the name to drugabuse.com?

Great questions.

1) On June 5, 2017, I wrote an article about how an AAC treatment center in NJ locked out its employees and transferred its patients to other facilities. The article received over 20,000 hits in the first week.

2) On February 24, 2017, I published a piece by Andrew Walsh about the unethical (and probably illegal) behavior of addiction treatment hotlines. While AAC was never mentioned by name in the article, one of the hotlines that engaged in the horrific and unethical behaviors that Mr. Walsh wrote about is owned by AAC.

3) On February 11, 2018, I wrote an article where I linked to the lock-out piece and also taught my readers to ask three questions of treatment programs. At a conference earlier this year, I spoke to two therapists who work at an AAC facility and both of them emphatically stated that the treatment program they worked at could not answer any of those questions satisfactorily. I encouraged both of them to contact the State Attorney General’s Office and to quit.

I believe that none of those articles caused American Addiction Centers to move against me. I firmly believe that my next two points enraged someone there and then AAC unethically used my name without authorization.

4) On August 28, 2018, I posted this on my Greenagel Counseling Services Facebook page:

American Addictions Center is the company in this story. While they have many sub-sub standard treatment programs and sober homes, they are fairly typical of the field. Because they are such a large player in the market and advertise so much, they are even more to blame. A reckoning will eventually come.

The article is good.

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That price tag of more than $3,300 a day buys recovering addicts group therapy sessions during the day, conducted by interns according to Lapina, not licensed professionals. At night, clients are transported in vans to free 12-step program meetings throughout the valley.

“Mental health counseling, which most of their addiction clients need, would cut into profits, so they rely on Alcoholics Anonymous or Narcotics Anonymous because they are free,” says Lapina, who detailed the daily routine of Solutions’ clients. “They even buy generic cola, not even Coke. Everything is about saving money.”

Lapina has received the green light from the Equal Employment Opportunity Commission to sue Solutions and its parent company, American Addiction Centers. She’s filed a claim in federal court for employment discrimination.

Lapina, who is now a licensed drug and alcohol counselor, says the vast majority of house managers are former clients who have little to no training and are paid just above minimum wage.

“The house managers have traded one drug for another — power. They bully people. I was asked by clients to protect them from house managers,” she says. (and then I linked to this article)

5) On September 10, 2018, I posted this on my Greenagel Counseling Services Facebook page:

Straight up, American Addiction Centers is shit.

SHIT.

They own these websites: recovery.org, rehabs.com, projectknow.com and drugabuse.com. They are set up as community help, but they steer clients towards themselves. And their programs are rife with problems. (and then I linked to this article about their websites)

6) In the post referenced in point #5, I included three more articles:

a) complaints filed against American Addiction Centers through the Better Business Bureau

b) this piece about a dead American Addiction Centers client and how multiple employees have been indicted for murder

c) this lengthy article in the New York Times about the numerous professional, ethical and legal troubles that American Addiction Centers have

I believe that sometime after the September 10th post, American Addiction Centers or one of their subsidiaries or one of their contractors purchased the use of my name (without authorization) to be linked to their website. This behavior should be added to the long list of reasons why you should never, ever send someone to a treatment center owned, staffed or run by American Addiction Centers.

Image result for prison

All too often, America is incarcerating the wrong individuals, particularly when it comes to issues around drugs. Someone who is caught with $200 of heroin goes to jail while no one from a company that knows doctors are overprescribing opioids serves any time. That needs to change. Furthermore, I’m a strong advocate for the incarceration of bad actors within the substance abuse treatment field.

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* update: I checked this on 10/20/2018 and found that the link to drugabuse.com no longer appeared and had been replaced by a link to SAMHSA. This piece was read by over 5,000 people in less than two weeks. Many of the readers are in government or the treatment industry. I have no doubt that AAC decided to remove the link after recognizing they walked into a wolf trap. By removing it and linking it to SAMHSA (their lawyers must have thought it was a good idea), it is tantamount to admitting they did something wrong. I have saved some screen shots to show what it looked like when AAC was engaging in their wildly unethical behavior. Here is one: