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On Suicide, Part Two

I’ve spent a lot of time over the last year reading books and articles on suicide. One book is Stay, which was written by Jennifer Hecht. She chronicles the history of suicide and the philosophical, religious, and civil arguments for and against it (post renaissance philosophers were the only ones that advocated for the right to kill oneself). I won’t rehash them here.

But I do want to summarize her two main arguments against suicide.

  1. “We owe it to society at large, and especially our personal communities, to stay alive.” (6)

The death of a friend or loved one causes great pain. There is the searing emotional agony, as well as growing recognition of permanent absence. Depending upon how present the departed was in another’s life, the more empty time is left. For many, it is a dreadful struggle back to a regular routine. That person’s pain and hardship is passed on to others, even those that didn’t know the deceased. The shockwaves ripple outward.

Ms. Hecht also wrote about the domino effect of suicides. “One of the best predictors of suicide is knowing a suicide.” (x) I would argue that there are proximity and mass domino effects as well: The closer that a completed suicide is to you, the more likely one is to attempt. And the more people you know that completed suicide, the more likely you are to attempt as well.

2. We owe it to our future selves.

Over a decade ago, I read Nick Hornby’s A Long Way Down. It is a novel about four people who meet at the top of a building in London on New Year’s Eve. They all planned to kill themselves, but didn’t because they were in the presence of others (suicide tends to be quite private). Mr. Hornby’s book (which has numerous comic moments) was well researched and took the subject very seriously. A key point was made, which is that most people that contemplate suicide move on if they survive the next 90 days. Many of us know cases where people considered suicide for years, even decades, but they tend to be outliers.

Since 2010, I have been telling friends with children that they should make deals with their kids. “I’ll buy this toy for you now, but you must promise to work five hours every Saturday in the garden at ages 14, 15, and 16” or some deal like that with their seven year old child (and get them to sign a paper and video record it). Kids have little to no sense of the time and long term consequences. Imagine how irritated your 14 year old would be when you produce the contract and the video.

“I can’t be held to what I wanted when I was 7!” they’d probably shout. The same probably goes for a deal made at 19 that is called in at 27, and so on and so on.

Back to suicide. I’ve worked with well over 100 people who were truly suicidal that did not kill themselves. Most of them are long past those thoughts and impulses, and have expressed gratitude that they did not go through with it. I have heard some version of the phrase, “I’m really glad that I didn’t kill myself. Things are so much better these days” then most will probably believe. But hopefully you will believe me.


Ms. Hecht’s book concludes with this:

None of us can truly know what we mean to other people, and none of us can know what our future self will experience. History and philosophy ask us to remember these mysteries, to look around at friends, family, humanity, at the surprises that life brings — the endless possibilities that living offers — and to persevere. There is love and insight to live for, bright moments to cherish, and even the possibility of happiness, and the chance of helping someone else through his or her own troubles. Know that people, through history and today, understand how much courage it takes to stay. Bear witness to the night side of being human and the bravery it entails, and wait for the sun. If we meditate on the record of human wisdom we may find there reason enough to persist and find our way back to happiness. The first step is to consider the arguments and evidence and choose to stay. After that, anything may happen. First, choose to stay.



On Suicide, Part One

I’m finally ready to start writing about suicide.

This year alone, I’ve read a number of books and hundreds of articles about it. My original plan was to write a single piece, but I found that I just have too much to say about that confounding and complex topic. Suicide. It evokes a range of powerful thoughts and emotions.

It is different than other deaths. Accidents, overdoses, and murders are also tragic and painful. In no way am I trying to diminish other ways of dying or rank them in some kind of ridiculous scale.

My mother lost three of the other four members of her nuclear family when I was 2 1/2 years old (she was not yet 40). Her sister, whom she shared a room with when they were growing up in Minneapolis, killed herself by drowning in the Mississippi river. I was immediately told what happened, despite my young age and the inability to really comprehend death at that stage of life. I think my parents did the right thing telling me. They explained that she was sick and took her own life and that my mother was very sad. Mom was a trooper though. She talked about it a lot (I was embarrassed as a child how often it came up in her conversations with others), but she was highly functional. I have no memories of her staying in bed, wailing away or silently brooding while looking out a window. I was a young adult before I really understood how much of an impact her sister’s suicide must have had on her. My mother’s process provided a model for the work I encourage others to do in the face of loss: talk about it, spend time with friends and family, and continue to move forward in life.

Earlier this year, my mom wrote about her sister for my first book. I was startled by something that I had never previously thought about: they shared a room growing up for over a decade (maybe two decades). That type of proximity over such a long period of time suggests a close relationship, or at the very least, a deep knowledge of one another. Late night conversations after the lights go out. Familiarity with early morning routines. Everyday exposure to what they are reading. Intimate understanding of facial expressions and physical gestures.

A couple kids in my high school committed suicide. I knew their names but I didn’t know them. It was a shock. I grew up in a time and place where nothing bad seemed to happen; put better, nothing bad happened to me. There were kids who had private hells that we didn’t know about. The morning in a high school after a suicide is an eerie place. The collective pep and bounce of teenagers has been drained. The day seems long and in slow motion. Laughing and planning feel guilty. The adults stumble with what to say.

There has been a lot of death in my life (that is eventually true for all humans, but usually weighted towards the end of our lives when we have more experience and wisdom to process it). My grandmother when I was 19. Fraser from an overdose when I was 26. Eric suddenly when I was 41. Dozens of students and clients. Soldiers and veterans that I have treated. I also work with the survivors. Hundreds of parents. A few young children of cops.

All of this is prelude to the only point I really want to make today, and one that I may have been able to get to in the third paragraph. I had a close friend complete suicide. I felt a deep sadness, confusion, and a bit of anger. That is almost the universal human response. There is something else though: a feeling of deficiency.

What is wrong with me and my relationship that someone I was so close with sought to kill himself?

It hangs on the edges of our brain and is rarely uttered. This was an invasive thought that popped into my head in the early weeks after my friend’s suicide. It must be far worse for a romantic partner or family member. I suspect that it is unfathomable and unbearable for a young son or daughter. “What is wrong with me?” Perpetually thought but almost never spoken.

It must be said out loud. It must be processed. Because I have an answer. There is nothing deficient about you. Suicide is terrible. Horrible. Do not make it about you, even if every waking instinct tells you to do so. It isn’t. This is why we must talk to other people about it.


Do You Have To Be in Recovery to Help Someone with Addiction? (and other myths)

Do you have to be in recovery to help someone with a drug problem?


That is the unequivocal answer, but I am happy to make my case with another 958 words. There are a few other foolish assertions that should be addressed as well. Over the years, I have heard the following statements out of numerous AA members, paraprofessionals, and licensed therapists:

  • Only you can decide if you are an alcoholic
  • No one shows up to an AA meeting by accident
  • Only an addict can help another addict
  • If you haven’t lived it, you don’t know it
  • People in recovery are better at working with substance abusers and others in recovery

Let’s address these one at a time.

  • Only you can decide if you are an alcoholic

This is a ridiculous assertion. We do not allow individuals to diagnose their own depression, anxiety, diabetes, cancer, HIV, or heart disease. One of the most common defense mechanisms that people with alcohol and/or other substance misuse disorders use is denial. A common form of denial is blaming others (I had a rough childhood, my girlfriend is mean, marijuana should be legalized, the cops were out to get me, school/work cause me a lot of stress). Another major form of denial is minimizing: they will say I’ve never been arrested. If they’ve been arrested, they’ll say I’ve never been to jail. And so on with prison. We can play this game with alcohol, then pills, then heroin, then needles and then sticking needles in the neck. Waiting for a person to admit they have a substance abuse problem is a poor plan, whether you are a family member, friend, member of AA, or professional counselor. Licensed medical professionals are trained in assessing and diagnosing. Some are clearly better at it than others, but they can do an excellent job at getting past denial.

  • No one shows up to an AA meeting by accident

I showed up to a Gambler’s Anonymous meeting by accident once. The GA members welcomed me, asked me 20 questions in the middle of the meeting and then eventually said, a bit disappointedly, “you don’t have a gambling problem.” Over the last 10 years, I have sent hundreds of nursing, pharmacy, communication, social work, and law students to open 12-step meetings to learn more about addiction, recovery and the power of communities. Courts have forced people to attend meetings who made a mistake or committed a crime, but don’t meet diagnostic criteria. There are dozens of young people I’ve met whose parents forced them to attend meetings because they caught their son or daughter smoking pot or were outraged that they came home drunk. People show up to meetings by accident, and they are sometimes sent to one when they don’t have a problem.

  • Only an addict can help another addict

I got clean and sober at 19 (I’m 40 now). When I went to treatment, every counselor and paraprofessional there was in recovery themselves. They talked about their own experiences a lot. Because of their openness, I felt both less alone and less like an outcast. I thought everyone that worked in the field should be in recovery. I had a psychologist who was not in recovery. He helped me with improving relations with family members, discuss college life, navigate job conflicts, point out my faults in romantic relationships and generally become a better version of myself (and better person). After graduating from Rutgers, I took a job in a long term treatment program. Every counselor and paraprofessional was in recovery. Many didn’t attend 12-step meetings outside of work, most had a lot of countertransference issues and there were several with real boundary problems. I remember thinking, “man…people in recovery really shouldn’t be in this field.” I left that job for an outpatient program where less than half of the clinicians were in recovery – I found there were some really good therapists in recovery, really good ones not in recovery, not so good ones in recovery, and not so good ones not in recovery. I am going to belabor my point. We don’t ask suicidal people (or formerly suicidal people) to work with those with current suicidal ideations. Most cardiologists are not in remission from heart disease.

  • If you haven’t lived it, you don’t know it

I figure I’ve used over 2,000 toilets around America and in 21 other countries on four different continents. I can’t fix toilets for @#$%. This is the kind of folk wisdom that you might hear in a 12-step meeting sometime, but I turn it on its head by claiming ignorance in the face of experience rather than expertise from experience. Experience with a problem can be helpful in dealing with an issue or treating someone else, but it isn’t a requirement. I have never had depression, been bullied because I was gay, gotten cancer, overdosed on opiates or lost a child, but I’ve helped people with those problems over the years. And I’ve been very effective at it. I find that people that claim an expertise because of their own recovery most likely don’t have other knowledge, education, training, or skills that they can utilize to help people.

  • People in recovery are better at working with substance abusers and others in recovery

I used to believe in this. Then I worked at that aforementioned program where everyone was in recovery and many of them were terrible at their job. If someone is in recovery, they might be able to use their personal narrative to connect with someone. But there are people who are not in recovery who have stories that can also connect with others and help get them to open up and consider making behavioral changes. I’ve known a number of great clinicians who are not in recovery, and the statement that people in recovery are better than them is not only offensive, it is false.


*I wrote this for Hazelden back in October of 2016. It was recently taken down from their website, so I have republished it here.


A Veterans Day Story

My close friend and colleague Eric Arauz died in March. I wrote about him everyday for one month. Others followed suit. I took a bunch of the stories and made them into a book, which was published last month. Eric served in the Navy during Gulf War I, back in the 1990’s. He described himself as “a poor sailor but a great veteran.” He loved talking to other veterans and he was an excellent advocate for them, especially those with mental health and/or addiction issues.

Near the end of October, I traveled to the Psych Congress annual conference in Orlando. I was invited by the organizers to come down and talk about Eric. They honored him by naming the kickoff keynote after him and also creating an award in his name. Very cool. I read a few sections from the book. Before I closed with my chapter on Eric at Elizabeth High School, I mentioned how I really would have liked to tell him the story about an Army veteran that I met a week earlier in Philadelphia.

Independence Blue Cross of Pennsylvania put on an all day event about the Opioid Epidemic at the Kimmel Center in Philadelphia. There were four panel discussions and a keynote speaker. I was impressed with the event, and every panel had at least one truly impressive person. The keynote took place just after lunch. The speaker was retired U.S. Army Master Sergeant (MSG) Justin Minyard.

MSG Minyard is a big guy (over 6’5″). He wore a suit, no tie (I approved). His hair was short but he had grown a beard. MSG Minyard began his talk with an apology. “I had a traumatic brain injury,” he said, “and there are times that I can’t get my mouth to say what I am thinking. As frustrating it is for you to watch me pause and stumble, it is even more frustrating for me. Please bear with me.” It was a powerful introduction, and my heart went out to him. I think that most of the audience had a similar reaction.

MSG Minyard was stationed near Washington, DC in the late 90’s and early 00’s. He was on details for both President Clinton and President Bush II, and he also had the honorable task of guarding the Tomb of the Unknown Soldier. Within a couple of hours of the attack on the Pentagon on 9/11, MSG Minyard and his unit were at the site trying to rescue people trapped under the rubble. “I was trying to reach a woman who was trapped under three floors of debris and while trying to reach her a load bearing wall collapsed on me and I had spinal damage and had to have several discs removed.” He was 21 years old.

MSG Minyard was a good soldier but a terrible patient. He cut his physical therapy time by more than half and demanded to be returned to the field. He served multiple tours in Iraq and Afghanistan (at least five) and was injured on several occasions. He told a story about how he and a half dozen other special forces operatives were tasked with attacking a bunker in a city. The helicopter was 60 feet above the target. Just as MSG Minyard jumped out of the chopper and went to grab the rope to repel down, they took incoming fire and the helicopter swerved. MSG Minyard was not able to grab the rope and he fell the entire 60 feet. To compound matters, the soldiers that came after him (down the rope) landed on him, exacerbating his back injury.

To deal with the pain and trauma, he was prescribed Oxycodone and Valium. During his speech, MSG Minyard filled a glass with his daily drug cocktail. Then he filled up a glass vase with his monthly dosage. It was a powerful effect and the audience gasped. He lived this way for almost three years. It devastated his wife and his daughter.

“It got to the point that when my four year old daughter asked me to read her a bed time story, I would respond to her with the worst words possible at the highest volume, just inches from her face. Because if I read to her, that was 15 minutes that I could not spare because the CVS would close and I would not be able to get my medication and I’d go into a horrible withdrawal.”

Silence. And then, “I did that. I’m responsible for that. I can never undo what I put my ex-wife and daughter through.”

He talked to therapists and doctors. More than two and half years into his prescribed addiction, someone talked to him about alternative ways to deal with pain. “Why am I just hearing about this now?” he asked.

More silence. And then, “Think about this. I’m just a big dumb Army guy, but I did guard two Presidents and the Tomb of the Unknown Soldier. I was deployed multiple times and worked on highly important missions. I had access to care and support. If this can happen to me, it can happen to anyone around America.”

MSG Minyard was given spinal cord stimulation and got off his pills. The recovery process was difficult. He has been clean and sober for about eight years and now works for Boston Scientific (the company that developed the spinal cord stimulation technology). He said that he still has pain, but it is mostly manageable. He finished by talking about his 11 year old daughter and how she still wants to hang out with him (“at least for another year and a half”). He takes her to “an expensive park in Orlando” and they walk around all day and evening. The all day walking causes him pain, but he does it for his daughter.

He earned a standing ovation, even from me (I rarely do that). I left my seat and forced my way backstage, past staffers and security. MSG Minyard was drinking water and was guarded by two off-duty Philadelphia police officers. I went up to him and introduced myself. We shook hands. I told him what I do and I thanked him for his talk.

And then I asked him if he wore cufflinks. He said yes.

“Do you have a pair of Army cufflinks?” I asked him.


I started to take mine off. He saw what I was doing and said, “Sir, I can’t possibly take those.”

“Sergeant, you’ve earned them. Wear them with gratitude and pride.”

One of the cops turned towards MSG Minyard and said, “You have to take them. He outranks you.” Then the cop turned to me and saluted.

With tears in our eyes, we all shook hands. I gave him my card and told him that I’d like to connect and possible bring him to Rutgers for a talk. As I started to walk away, my first thought was that Arauz would have loved that guy’s speech and my gesture. It was a resurrection story.

A Veterans Day story.



Bearing False Witness: American Addiction Centers’ Client Outcome Studies

Image result for false witness

By Andrew Walsh

Edited by Frank L. Greenagel II


In February of 2018,  American Addiction Centers (AAC) released a report that summarized three years of patient tracking and patient outcomes research. It was full of distortions and lies. Their press release falsely bragged, “American Addiction Centers is breaking new ground in addiction treatment with the release of its first patient outcome studies.”[i] AAC then offered an even more farcical utterance: the patient outcome studies show that 63% of AAC clients maintain abstinence one year after treatment. I was shocked to read that such a high percentage of clients stayed sober (this was actually the greatest treatment outcome claim I had ever heard). AAC continued to fluff themselves when they reported that the national benchmark for other treatment providers one year after treatment was only 30%. Intrigued by the news release which painted AAC in such a positive light, I dug into the report to learn more (editor’s note: What he found was horrifying).

The patient outcome studies began in 2015 and were the result of a partnership between American Addiction Centers and Centerstone Research Institute (CRI). AAC is a large, publicly traded, for-profit organization that provides[ii] substance abuse treatment in several different American states. CRI is an independent, non-profit research organization. Working together AAC and CRI conducted three studies. They started with a sample size of 4,399 patients. Patients from five different AAC inpatient locations were included in the study. The size and scope of the studies seemingly addressed any potential for geographical influences on data (i.e. the study was so large and spread out that the results should have been representative of the U.S. overall). The study was designed to include regular follow-up intervals (two months, six months, and 12 months) with clients after they discharged. This allowed AAC to track how patients did after they completed treatment.

They released the results of their studies in a 76 page report. The layout and design is visually stunning. The graphics included are clear, crisp, and informative. To a casual observer, this report portrayed AAC as one of the best treatment providers in the world. I could not reconcile this with recent news[iii] regarding American Addiction Centers[iv].

How was the company I was reading about in the report (portrayed as producing the best outcomes I had ever seen) the same company accused of fraudulent drug testing, with a history of lawsuits ranging from SEC violations to patient deaths, and who previously had five employees (including the former company president) charged with murder following the death of a client? Initially in reviewing the report, I thought AAC had moved on from its troubled past[v] and was producing tremendous patient outcomes. However, the more I delved into the report, the more disappointed and outraged I became.

There are several areas of concern I discovered after reading and analyzing the report multiple times[vi]. In particular, I am troubled by two bold statements in it. Additionally, I am concerned about one important section that is missing. I have provided an analysis below.


Statement 1: “At 12 months, 63% of patients were abstinent from all substances”[vii]

Seemingly with this statement AAC, is saying that 63% of their patients were still sober 12 months after completing treatment. However there are several problems with this statement:

  1. It does not mean that patients have been sober for 12 months. It only means that 63% of patients who were surveyed 12 months after discharge had been sober for at least 30 days.[viii]
  2. Per the report, 48% of clients had stayed sober since discharge (12 months sober). This is still an incredibly high percentage. Why report a misleading higher statistic (63% sober at 12 months) instead of just reporting the still industry leading statistic (48% of clients remained sober for at least 12 months after discharge)? That answer is provided below.
  3. These statistics (as are all the stats in their report) are based on patients’ self-reports. This means that none of the answers provided by the patients have been verified with drug tests, or speaking with study participants’ families, friends, and loved ones.
  4. These statistics are based on a sample size of only 80 patients out of the 4,399 patients who were included in this study. Why state the study included 4,399 patients but only include 80 for calculating the key statistics?[ix]


Statement 2: “Over a 3-year period, more than 4,000 people enrolled in the study”

I have taken several graduate level research courses and have professional experience in designing and running clinical trials. I have partnered with various universities including Princeton University, The University of Pennsylvania, and The University of Arizona to conduct clinical trials involving human subjects (editor’s note: He knows a bit about study designs and sample size).

Initially, when I read about the sample size used in this research (4,399 clients), I was impressed. A large sample size is ideal because it decreases the margin of error (it means that the results are likely accurate).

Including five separate locations across the U.S. was also smart because it eliminates geographical differences from impacting the data. For instance, West Virginia and Kentucky have incredibly high rates of opioid abuse. If clients in the study were only from those areas, they would artificially inflate the number of people abusing opioids and seeking treatment at AAC. By using multiple locations across the U.S., the study reduced the likelihood of skewed statistics.

At first glance, the size and scope of this study seemed to be legitimate. The further I dug into the study design and statistics, the more the flaws were exposed. AAC stated they had 4,399 clients in the study, which is a massive sample size. However, this large sample size was not included in generating the statistics AAC cites as proving how amazing their program is. The chart below shows the actual number of clients include in the study at the different follow-up points.

Time Point Eligible Completed Follow Up Rate
2 Month 4,399 1,133 26%
6 Month 1,852 515 28%
12 Month 221 80 36%


The chart content and location raised several questions and concerns for me:

  • Why cite a sample size of approximately 4,399 clients but not make it readily known that not all of those clients were used to generate the statistics referenced in the study?
  • Why is there a discrepancy between eligible patients and completed patients?
  • How were the statistics (such as the 12-month abstinence statistic) calculated?
  • Why was such an important chart buried in the report on page 46?

The more I read the America Addiction Centers’ report, the clearer the answers became. AAC included and cited such a large sample size because it sought to give the public the impression that this was a very serious study and that the results found were legitimate.

Per AAC, they were not able to contact all patients who were enrolled in the study upon the regularly scheduled follow-up intervals. This is understandable and a common occurrence in almost all studies that include a follow-up component. Many study participants move or get new phone numbers or just disappear. However, AAC press releases conveyed that all 4,399 participants were followed up with 12 months after their discharge. In reality, only 1.8% of the 4,399 participants responded to follow-up at the 12-month mark[x].

The 12-month abstinence rate was calculated based on the number patients who responded to the follow-up. At the 12-month mark, 80 patients responded and 51 of them reported that they were abstinent for at least 30 days. 51/80 = 63%. While this math is relatively simple, AAC went against research norms and ethics when calculating it.

In the bottom row of the chat we see that while 221 clients were eligible to participate, AAC was only able to get in contact with 80 of them. The 141 clients AAC could not get into contact with are referred to as loss to follow-up. A common question is; how important is loss to follow-up? Simply put loss to follow-up is extremely important if patients lost to follow-up have different outcomes than those who completed the study. AAC was very proactive in following up with patients. Per the report, an average of 10 phone calls, 4 emails, 6 text messages, and 1 letter were sent over the course of a month to each study participant. What is the likelihood that 141 participants (those who did not respond) moved and changed both their phone numbers and email addresses? There is a very low likelihood that this is the case. Therefore, we need to look at alternative explanations. Based on my experience working with substance abusers as well as conducting clinical trials, I believe it is more likely that a high percentage of these 141 participants most likely relapsed and chose to not report their relapse to AAC.[xi]

Now that we have determined that loss to follow-up is important, we need to look at how it is calculated (editor’s note: bear with him here. I don’t like reading this math either, but this is a really important point. Read it a couple of times if you need to). With an eligible population of 221, 141 clients failed to follow up. We simply take the 141 and divide it by 221 (the eligible population) to get a percentage of 72.8% (the loss to follow-up rate).

Now a good standard is that when a loss to follow-up rates exceeds 20%, it poses serious threats to the validity of the study. AAC’s study has a loss to follow-up rate of 72.8%, which is 3.5 times greater 20% rate that threatens validity (editor’s note: the whole study is invalid. I would fail a college junior for turning this in).

I employed a common research technique to address the follow-up rate problem: treat every patient lost to follow-up as a worst-case scenario (patient relapsed). AAC claims to have a 63% abstinence rate. However, when we included the 141 people in the calculation and coded them as having relapsed, we get a abstinence rate of 23%. This is shockingly lower than the 63% reported. Based on standard practices in conducting clinical trials and studies, the AAC study has significant cause for concern regarding the validity of the findings.


The Third Major Problem: Conflict of Interest

Reporting conflicts of interest in publications is a standard best practice. However, this does not always occur. In reviewing the report, I noticed that there were no disclosures regarding conflicts of interest.  They want the reader to assume that there must not be any conflicts. In researching American Addiction Centers, I made an interesting discovery: AAC hired the CEO of Centerstone Research Institute (CRI) in 2016, in the middle of the studies. Throughout the report CRI is depicted as an “independent third-party non-profit research center.” CRI was theoretically employed in this capacity to ensure the integrity of the data. By hiring the CEO of the company who was supposed to provide independent analysis AAC has threatened the integrity of the study.[xii]


Taken alone, any one of the concerns I have outlined is troubling:

  • American Addiction Centers crowed about their 4,399 person study but used as few as 80 people for some of their key statistics.
  • American Addiction Centers sought to distort the public’s perception by presenting the data in manner in which it could be easily misinterpreted.
  • The company (CRI) that conducted the study was billed as an independent non-profit, but the CEO was hired by AAC before the study was completed. It is a vicious conflict of interest.

Examining all three concerns while simultaneously taking into account recent events involving AAC including locking out employees at its NJ facility in 2017 and a $7 million dollar jury verdict following yet another patient death in February 2018 , an apparent and devastating pattern starts to emerge. American Addiction Centers has a long and well-documented history of putting profits before patients. With gleaming websites, shining brochures, and a visually beautiful report, AAC portrays themselves as a strong treatment program. The websites and brochures hide the dirty reality. The report is invalid, though it is not useless. It gives a first hand account (written by them) of the fraud and lies that they regularly and willfully engage in.



[ii] Provides is used very loosely here. I also thought of adding (substandard) ahead of “substance abuse treatment services” but decided that you already probably knew that.  – Frank Greenagel



[v] “moved on from their troubled past.” Andrew must have been joking here. We mean to show that lies, distortions, death, stealing and dozens of other ethical and legal violations are baked into American Addiction Centers’ DNA. – Frank Greenagel

[vi] He really did. The first time he read it, he gave me a summary. I said we needed an article on it. He went back and read it again and provided more details to me. We then discussed how he should take AAC’s report down, blow-by-blow. This required several readings and copious notes. – Frank Greenagel


[viii] What a horrific distortion. – Frank Greenagel

[ix] A few brutally honest answers before you get to Andrew’s more measured response: their substandard programs produce terrible results, so they need to cherry pick their data, manipulate figures, distort perceptions and sometimes straight up lie. They assume that most people won’t read all 76 pages, so they bury these problems deep within it. – Frank Greenagel


[xi] Let us speculate a step further – American Addiction Centers knew that the clients relapsed and then cut them from the study in order to improve their reported percentages of sober clients. – Frank Greenagel

[xii] Andrew is too kind here. The integrity of the study wasn’t threatened. There is no integrity. The people that conducted the studies are either inept or evil, and possibly both. – Frank Greenagel


Andrew Walsh 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 HotlinesMedicaidMedicareA Fix For Addiction Hotlines, and how treatment programs keep clients rather than sending them to get appropriate care.


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 NJ non-profit. 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 the non-profit’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 the program (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


  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.


[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 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.


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:

When my friend Pat died, I wrote this in 2014:

This is a (near) copy of a speech I gave at an Overdose Vigil to 350+ parents who lost a child to addiction:

A long-time patient of mine died in December of 2016 and I wrote this for myself and other counseling professionals:

A cousin of mine lost a baby in 2017 and I wrote this:

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.


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 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

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.


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.


They own these websites:,, and 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.


* update: I checked this on 10/20/2018 and found that the link to 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:


A Soldier and a Wonderful Leader





Master Sergeant Greg Spadoni. Served in the United States Army for 35 years. Our time in the NJ Army National Guard lasted from 1996 to 2002. This is a brief tribute that will not nearly say enough about the man.

I met him in September of 1996 when I joined my NJ National Guard Unit, fresh out of Ft. Knox. He introduced himself as a friend of a family friend and told me to find him if I had any questions. “Or if anyone bothers you,” he said.

“Why would anyone bother me? We’re all in the Army together,” I replied.

He knowingly smiled. “Well, just in case.”

He was the NCOIC (non-commissioned officer in charge) of the Battalion S-2 (they handle Intelligence). I had been assigned to the Battalion S-3 (training and the Tactical Operations Center (TOC)). Our sections worked very closely, and we usually shared the same tents. Whenever I could, I spent time with him in his section or when he hung around the TOC.

When he wasn’t serving in the Army, Greg taught middle school math in Easton, PA. He talked about his students, other teachers, and gave me an entertaining view of what the job was like.

It seemed liked we were always in the field. We camped when it was 30 degrees and when it was 100 degrees. The food was awful. The tents were loud and musty. People got up early. To this day, I’m pretty much ruined for camping. Greg would entertain me with his life’s wisdom. He told funny stories. He would bring a piece of carpet and a coffee pot into the field. The carpet was for his feet in the morning and the coffee was for all of us. “Creature comforts, Frankie, creature comforts. It makes all of this easier. Don’t forget it.”

I haven’t.

Eventually, I ran into problems with other soldiers. Sometimes it was busy body NCOs, other times it was officious officers. I occasionally brought some of it on myself, but usually it was those motherfuckers. Greg would step in. Calm things down. Later, he’d say, “Frankie, you can’t say stuff like that. You have to go with the flow sometimes.”

I would listen to him. You know why? Because he was smart and competent and funny and I knew he cared. He was a great leader.

By the time he retired, he had been an E-8 for 18 years. Years before I joined, he had been the First Sergeant (1SG) of Headquarters Company (HHC). Everyone told me that he was the best 1SG they ever had. He took a lateral assignment as a Master Sergeant (same rank, but he was in charge of six people rather than 150). Whenever we got a new company commander, they inevitably went to Greg and would ask him to move back to the 1SG role. He would say, “I’ll do it if you let me kick out 10 people. We have a truck driver that can’t drive because of his DWIs. We have all kinds of people that shouldn’t be here.” The Captains always said no, because our unit was always below strength (not enough people). Later, he would tell me, “I can be in charge of you or 150 people. Being in charge of you is a better job.”

The first photo is from November of 2001. Our unit had been activated after 9/11. Our Battalion was assigned to monitor and guard the Hudson River Crossings (the GW, Lincoln Tunnel, Holland Tunnel and Journal Square in Jersey City). The command center was back in Port Murray. I was tasked around the other crossings for part of it, but I got to spend some time at the command center. Greg was in charge of one of the 12-hour shifts. Being in the TOC exposes you to everything the unit does and the high ranking officers. When VIPs visit, they usually come to the TOC first. Greg was doing such a bang-up job that a colonel came by and pretended to pin an officer rank on him. I insisted on capturing it with a photo. It shows his good humor.

Don’t be mistaken though. He could rip people apart. When he was in Cuba in 2004, he was in charge of a Joint Task Force full of Sailors, Airmen and Marines. I heard stories. One time, an E-6 in the Navy gave him some shit about a task and Greg ordered his superior to stand before him at 0600 the next day. Greg tore into him. The Chief Petty Officer was aghast and promised that his sailor would cause no further problems. A Marine colonel heard all of this and came in after the the ass chewing was over. “Jesus, I have never heard anyone rip into people like you. What I don’t get is that everyone still loves you.”

It’s easy. Because he was smart and competent and funny and everyone knew he cared.

Don’t worry. He’s still alive. This ends well.

I drove out to Easton, PA to see him today (9/11/18). We got lunch. I updated him about my life. We talked about other soldiers and what happened to everyone. We commiserated over the fallen and for those whose families fell apart. We also told jokes and laughed. At one point, Greg looked at me and said, “It’s great that you don’t have your cell phone out on the table. Everywhere I go, people are on those fucking things.”

“I know. Then they wonder why they are isolated and feel bad. Our culture is so fucked up that I’m going to be able to work forever. This is why I drove out here. To talk in person. Nothing beats that.”

Then we moved on to other stories. I let out my full throated cackle.

“There it is,” he said, “There’s that crazy laugh.”


An Easy Fix for Addiction Hotlines

by Andrew Walsh


A few months ago I was invited to speak to a class of students at Rutgers in the addiction certificate training (ACT) program at the Graduate School of Social Work. I shared my experiences from graduate school and working in the field of substance abuse. While I was with the students, I was prompted to share some of the writing and undercover work I have done in the field of substance abuse treatment.

For a year and a half, I did full-time work and full-time graduate school. While my schedule was hectic, I was able to compare what I was learning in the classroom with what I was experiencing in the field. I was horrified.

Under the guidance of Professor Greenagel, I set out to start documenting and writing about the ever widening gap between best practices and what was actually occurring in the substance abuse field. One of the first subjects I tackled was addiction hotlines. My previous piece on addiction hotlines can be accessed here.

I found that the majority of the hotlines ranged from negligent at best to operating illegally. One of the main takeaways from my undercover work with the addiction hotlines was the lack of consideration that people with Medicare, Medicaid, or no insurance received. When I posed as a 27 year old with insurance seeking substance abuse treatment I could not get my phone to stop ringing. However, when I posed as a 26 year old with seeking substance abuse treatment with Medicaid, I could not get a phone call to last more than three minutes.

I was thoroughly convinced that the horrors of the substance abuse field would cause some of the students to reconsider their career paths.  A few months passed and unexpectedly one of the students from the class contacted me. She posed a simple question that stopped me in my tracks. She asked

With state treatment facilities in a state of stagnation due to lack of beds for Medicaid, Medicare, and the indignant, how can private centers work to meet this need for people with Medicaid, Medicare, or no insurance?

I recognized that I left my previous work half-complete. I did a mournful job of illustrating and summarizing the problem but I did not provide any solutions.

I set out to remedy the situation and decided that I first needed to quantify the demand for substance abuse treatment among Medicaid recipients, Medicare recipients, and those with no insurance. After quantifying the demand, I then sought out to quantify the services available; i.e. where can these people go to get help. My work on the Medicare population can be seen here and the piece on the Medicaid population can be accessed here. The main takeaway was that the demand for substance abuse services for these populations far exceeds the supply.

I spent one year working in the call center of a psychiatric hospital. Working as an addictions triage specialist, I took anywhere from 50-100 calls a day from potential clients or their family members looking for substance abuse services. I was fortunate that Medicare was accepted for treatment at that psychiatric hospital. However, I still received dozens of daily calls for patients with Medicaid or no insurance seeking services. After I did some research, I began to end those conversations by saying, “We can’t provide services to you here but if you get a pen and paper I am happy to give you the name of the facilities that can and their phone numbers.”

Inevitably, the callers would express sincere gratitude with some variation of: “Thank you so much. I have been calling around everywhere but I couldn’t figure out who could help me.”

I hold advanced degrees, have a few years of direct practice experience with substance abusers, and am familiar with the majority of substance abuse providers in the tri-state area. All of my experience and research has made it possible for me to know which facilities accept Medicaid, Medicare, and those with no insurance.

When I reflect back on my work, education and directed research, I come to two clear conclusions:

  1. The demand far exceeds the supply of services for Medicaid, Medicare, and those with no insurance
  2. Services exist but substance abusers and their families get worn down trying to find the programs that will accept them

I am a social worker, which means I am an idealist. But I am also a pragmatist. Ideally, I would like to see an expansion of offerings for the Medicare, Medicaid and uninsured populations. Pragmatically, I know this will take a long time. Additionally, it is unrealistic to hold private facilities responsible for expanding services to those populations.

That written, I believe private treatment providers can help clients access the services that do exist. The best practice would be for these private entities to call the appropriate facilities with the client and do a warm hand-off to the appropriate party. Pragmatically I realize that this causes a significant burden on the private entities and will be met with significant opposition. The practice that will encounter the least resistance from the private treatment providers but still produce a significant effect is providing the clients they cannot treat with the names of the facilities that can help them. As my previous work has shown, these lists are relatively small and should not take more than two minutes to share with these clients.

While I am troubled by the fact that there are waiting lists for Medicaid, Medicare and those with no insurance, I am horrified that people cannot even find these facilities to get on the waiting list. Private treatment provider hotlines are often the first point of contact for many substance misusers and their families. Even if they cannot provide services directly to these clients, ethically they should refer the clients to the facilities that can provide the services. With people dying because they can’t even get on the waitlist to keep the flame of hope alive, treatment providers that fail to refer clients are in essence saying a life may be worth less than two minutes.


Andrew Walsh 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.

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