By Andrew Walsh
Edited by Frank L. Greenagel II
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:
- Detoxes will not refer clients to PHPs/IOPs who do not refer clients to them
- 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.
- Adhere to the standards of your profession
- If you are LSW or LCSW, adhere to the Social Work Code of Ethics:
- 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
- If you are a LCADC, adhere to the Ethics for Professional Substance Abuse Counselors:
- 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
- If you are a LPC, adhere to the ACA Code of Ethics:
- 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
- If you are LSW or LCSW, adhere to the Social Work Code of Ethics:
- 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.
- 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.
[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.
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.