Monthly Archives: October 2017


CARF and the Joint Commission: Two Major Reasons Why Addiction Treatment Programs Continue to be So Bad







I’ve been giving a keynote speech over the last eighteen months called “The Medical Industrial Complex and the Opioid Epidemic” (the term is mine, though modeled after President Eisenhower’s warning about the Military Industrial Complex in his farewell address). The Medical Industrial Complex is made up of the following:

  1. Medical Professionals, particularly doctors and their professional organizations (American Medical Association is one example)
  2. Insurance Industry
  3. Big Pharma
  4. The Federal Government (Congress and Executive Branch agencies like the FDA). State Governments also have a role, though it is much smaller.
  5. The Treatment Industry
  6. Consumers

I’ll be releasing a series of articles over the next few months about these six groups and how they have each contributed to the problem (if you’ve paid attention recently, you’ll know that the Washington Post/60 Minutes released an expose on the Big Pharma-Government relationship and the New Yorker hammered Purdue Pharma last week).

Even if Big Pharma is reined in, doctors get more training and prescribe opioids less, insurance companies pay for the appropriate treatment and President Trump urges Congress to spend billions of dollars on a variety of programs, it will do little to improve the outcomes for people in addiction treatment programs.

Treatment programs are often understaffed and focus on paperwork over services. The senior counselors at programs rarely actually see clients; instead, they are monitoring clinical notes. They do this in order to meet standards set up by insurance companies and some state regulators (not all states are regulated). The idea behind this is noble, as documentation of individual, group and medical services let third parties know if and how treatment was provided. In theory. In practice, the notes are almost always better than the actual services provided. Supervisors are often not properly meeting with, training or observing their staff, and they evaluate them based on their notes (I’ll write a lot more about this in the future).

Treatment programs take in money the following ways:

  1. private pay from clients or their families
  2. medicaid or medicare
  3. county or state grants to provide free or discounted services
  4. private insurance

While most treatment providers would prefer #1 above all others, those kind of clients make up a tiny percentage of the population. Clients with private insurance are essential for for-profit treatment programs, and are highly desirous for non-profit programs to offset the costs of medicare/medicaid recipients and other indigent people. A number of insurance programs will not pay for services rendered by a treatment program (detox, inpatient or outpatient) unless they are certified by either CARF or the Joint Commission (JCAHO). Because they are often the gate keepers to insurance money, treatment programs scheme hard on getting CARF or Joint Commission accreditation.

CARF is an international program. It is not a government agency. JCAHO is an American non-profit (be cautious about when making snap judgments about programs just on their tax status). I want to spin you back to the housing crisis of 2008 and its aftermath. We learned about how high-interest mortgages were given to people without the means to pay for them, and that those crap mortgages were chopped up and sold as investments with AAA ratings (the highest rating, and often the only ones that state pension and certain retirement funds can buy). These mortgages were highly volatile, but only a handful of people knew that because the rating agencies (S&P, Moody’s, and the Fitch Group) rated B and C investments as AAA. When people couldn’t pay their mortgages, those investment products’ value plummeted. Several banks failed, the insurance companies teetered on the brink and our economy pulled the rest of the world into the Great Recession (for more on this, read “All the Devils are Here” or “The Big Short”). The rating agencies failed to do their job and protect the public.

One might argue that CARF and the Joint Commission have failed to properly rate treatment programs. There are terrible programs all over the country that brag about their CARF and/or Joint Commission accreditation, and proudly display it on their websites. These are not government agencies, but private companies. Their first goal is money, not consumer protection. Here is how the process seems to work:

  1. The treatment program contacts CARF and/or the Joint Commission.
  2. The treatment program pays a fee for the inspection and accreditation (this is a classic conflict of interest folks).
  3. CARF or JCAHO come out for a multi-day inspection. They usually let the program know in advance when they are coming.
  4. The treatment program spends the weeks leading up to the inspection getting their notes in order, cleaning the floors, making sure that files are locked, checking fire extinguishers, and getting paperwork signed that says that emergency drills and policy reviews have been conducted.
  5. CARF or JCAHO visit the agency. They may talk to a couple of clients. They meet with administration. They examine the physical aspects of the program and look at the notes. They might talk to clinicians or look into other aspects of the agency.
  6. Shortly thereafter, the program is either accredited or not accredited. Both CARF and the Joint Commission are a bit reluctant to provide data about pass/fail percentage rates for the programs they inspect. I suspect that the accreditation rates are quite high.
  7. Every couple of years, the program gets reinspected. They often get a notice of when the inspectors are coming. They write a check to pay for the re-accreditation.

Neither CARF nor Joint Commission certification means that staff are not abusive or neglectful. It doesn’t measure the effectiveness of group or individual sessions, or the ability of the supervisor to monitor and train the staff. CARF or JCAHO certification does not guarantee that there is a decent discharge plan, or that the discharge summary accurately reflects what happened throughout the course of treatment. A program does not need to show if (or how) it evaluates itself or what outcomes are actually achieved.

Some people consider CARF and JCAHO to be scams. They don’t ensure good treatment. They do not protect the public. This is regulation in a terrible form. We need better state and national regulation of treatment programs. This means clearer guidelines, more monitoring and observation, short and long term evaluation and third party outcome studies, and real punishment (huge fines, suspension, forced closing) for those that fail to comply.

When looking for a treatment program, here are some basic questions to ask:

  1. How long has the clinical and executive director been there?
  2. What percentage of counselors have at least a masters level license?
  3. How often do clients get to meet with counselors one-on-one? How long do those sessions last?
  4. How often do clinical staff get supervision? Is it individual and/or group supervision?
  5. Does the supervisor observe individual and group sessions by staff?
  6. How often do techs, housing staff and night workers get supervision? Are they observed?
  7. How does the program measure success?
  8. Does the program evaluate itself? Does it have a third party evaluate it?
  9. Who does the aftercare plans? How do you ensure that the places/professionals you refer to are good?
  10. Who does the diagnosing?  How long do they meet with someone before giving them a substance misuse disorder and/or mental health diagnosis?

Programs can get CARF and JCAHO certification without having good answers to most or all of these questions. It’s the housing disaster all over again, but in the treatment industry.


Note: I would be happy to discuss my concerns with representatives from either CARF or the Joint Commission and assist them, free of charge, in improving their process for the benefit of the public.


How To Become Immortal







Last week I took my mother to see an incredible production of A Raisin In the Sun in Red Bank, NJ (it’s really good and there is a Surf Taco nearby, but the show ends on October 8th). Afterwards, we went for an early dinner. At the next table, two older women where talking about a current social/political issue. They lambasted the other side as being selfish and stupid, spouted off incorrect facts and statistics, and proudly clinked wine glass about how they agreed with each other. While I found their comments to be noxious, my bigger issue was with their process. People from both sides of the political spectrum often engage in personal attacks, have a lack of understanding of the issue (economic, historical), have incorrect or cherry-picked statistics, and tend to talk primarily with others that already already agree with them. They kept going on and on, and I found myself growing irritated. My first thought was a Larry David-esque “This is why I can’t go anywhere” and then I made the command decision to not engage them. This decision was made on the basis that (a) they are very entrenched in their position; (b) there were just two of them; and (c) they are old and not going to be voting too much longer anyway.

The first guest lecture I ever gave was to a sophomore honors English class when I was a high school senior. I was invited to talk about A Catcher in the Rye by a teacher who gave me a D a year and a half earlier. I finally read the book a year later after it was assigned and it spoke to me at 17 – it also inspired me to dive deep into other literature. Early on in college, I was invited to talk at both Rutgers and other colleges on the topics of addiction, Shakespeare, or 20th century American literature. By my third year in college, I was substitute teaching in high schools regularly, and I jumped at the chance to give lessons in history and English (ironically, the first class I ever subbed was French 3, which I failed as both a sophomore and senior). After graduation, I taught English to students as young as 12 and as old as 79 in Tokyo for all of 2003. After finishing a social work degree in 2006, I took a job teaching high school English in Elizabeth for the next three years (I’ve written about that before).

In 2008, I started teaching at the Summer School of Alcohol Studies at Rutgers, and have taught there continuously ever since (I also teach seminars throughout the year and have also been training NJ, NY and PA police through the Center for over a year now). In 2009, I started teaching at Essex County College. I taught multiple courses there for three semesters. In 2011, I began teaching at the Rutgers School of Social Work and also started co-teaching a course with Dean Lea Stewart at the Rutgers School of Communication. I have taught 2-4 courses each term between the two departments continuously now for 13 straight semesters.

During my last year of teaching at Elizabeth High School, I used a book titled Poetry 180. Every day, I read a different modern poem to my students and we discussed it. My favorite poem from that book was written by a woman who remembered herself as a high school sophomore writing to her father, “Dad, you are most yourself when you are swimming” it began (along with Shelley’s “Look on my works ye mighty and despair,” it is the two lines of poetry I utter the most). This has led to the question that I ask all of my students and everyone who has since sat in on a training that I’ve conducted – when are you most yourself? To answer this question, you might want to talk to your family, friends and co-workers.

Despite all of the many wonderful relationships and interesting activities I engage in, there is nothing that defines me nor shows me at my best nor makes me happy like teaching. And as much as I like conducting trainings and giving speeches, there is no teaching I like more than my in-person classes at the undergraduate level at Rutgers. This semester, I have 27 students in my Social Welfare Policy Class. I was asked to teach the course in August and it came with a ready-made, departmental syllabus. I’ve found the textbook to be quite good and I’ve kept the assignments but tweaked them a bit (the lectures are all mine). In our lessons on social and cultural issues, I spend a great amount of time talking about the history of the issue, how other states or countries have addressed it, the conservative and middle and liberal positions, and how it both currently and potentially could affect the budget. I have my students read pieces on the importance of listening to people you disagree with, which states take the most money from the Federal government, and a variety of other topics. I’m careful not to teach them what to think, but rather how to look at issues, know the economics, consider your opponents’ view (even if it is personally offensive), and how to talk to people that you disagree with (so basically, don’t be like those two old ladies at lunch last week).

Regardless of your politics, you may be frustrated by the fact that most issues that are topical today were being argued about 20, 50 and even 100 years ago. It takes a long time to finally settle social and political issues (it was 80 years between Seneca Falls and the 19th Amendment). Economic ones are constantly being refought. I’m not a fan of social media activism (though it may be able to swing elections). I don’t see the point of like-minded people sitting around and complaining to each other. Shouting at family or friends isn’t effective either. Change is often a long, slow process (water on a rock…the water eventually wins).

For those of you that are worried, concerned, or even outraged at recent events or regarding a number of social, political or economic policies, take some solace that I’m training these young people to be policy problem solvers. I have 100-150 undergraduate/graduate students a semester for 50 hours of instruction. This is my ninth year of university teaching, so I’ve put my thumbprint on somewhere between 1800-2700 young minds (I hope to do this for another 40+ years).

Some of my former students are now teaching and/or supervising others. For those of you that are horrified with the current state of things, I encourage you to take the long view. If you can, guide, mentor, supervise or teach someone younger than you. Each mind we truly touch eventually reaches out to someone else and thus, we become immortal, as our lessons are passed on long after we’ve shuffled off this mortal coil.