All posts by fgreenagel


Voices from Rutgers: a pair of sisters describe their experiences in NJ over the last two years

My name is Honeyah. I am currently a junior at Rutgers and I major in social work. I had Professor Greenagel for a public policy course last fall. He asked me to write about my experiences for his website.

My family moved to an upper middle class town in Central NJ when I was in second grade. It was easy for my sister and I to make friends. We knew most of the kids we went to school with and felt comfortable going to the usual hangouts within our community. On most days after school, kids from my elementary school would gather at the local park  to play tennis or basketball.

When I entered the sixth grade, the primary hangout moved from the park to the mall. Most of us dressed head to toe in either Hollister or Abercrombie; I jumped on that fashion trend. Like other girls my age, I also wore silly bands on our wrists and watched “Gossip Girl” religiously. In high school, most of us became obsessed with social media such as Instagram, Snapchat and Facebook (I was up to date on all the different platforms and apps).

There was a clear divide of students who prioritized their grades with those whom prioritized partying (I numbered among the former). Our school had a wonderfully positive and inclusive environment. Bullying was not really prevalent because of the significant diversity – no one really stood out or was considered a target. I was never bullied or made fun of throughout my time in elementary, middle and high school. I assume that this was because I was like other kids: I wore the same clothes, watched the same tv shows, and had the same social media accounts. Following trends made it seem as if I fit in with everyone else, however it was clear that I was and am different than most people living in the United States. This is due to the fact that I am a hijab (head covering) wearing Pakistani Muslim who was born and raised in America.

I started wearing a hijab in high school when I learned more about my religio and wanted to embrace it. Alhumdulillah (all praise to God), I was never bullied for this and had an overall positive experience in school because most of my classmates had known me for years and thought of me as Honeyah and not the “Muslim girl in the scarf.”

My experience at Rutgers has been positive. When President Trump announced the travel restrictions from the seven predominately Muslim nations early in 2017, there was a large protest at Rutgers. I was touched to see that most of the students who attended the march were not Muslim. There was a small counter protest – about ten Trump supporters came out holding signs anti-Muslim signs but they left after about half an hour. I feel welcome and safe at Rutgers.


My name is Iqra. I am Honeyah’s younger sister by two years. On January 20th, 2017, staff and students gathered around the televisions in our high school cafeteria to listen to President Trump’s inauguration speech. Many students clapped and cheered as the newly elected President spoke. Being a student in the same school district since kindergarten, I had grown accustomed to the way things worked in my district. After President Trump was elected, distinct changes started occurring in my school.

Although my hijab did make me an easy target for racist jokes, I was never really bullied for outwardly practicing my religion. During the last semester of my senior year, students who were previously quiet started openly uttering their anti-Muslim views to me. At one pep rally assembly (where students get together to support our sport teams), my classmates were shouting “Allahu Akbar” in a derogatory way. This was almost certainly done to make fun of the Muslim students in the bleachers.

Both the school newspaper and the local paper published stories about the bullying of Muslims at the high school, but they also detailed how we were not the only group that were being bullied. Many of the Jewish students were being targeted as well. Drawings of swastikas and Hitler, as well as comments directed at the Jewish students, were found on the desks at our high school. Although there were numerous other incidents, my school did little to alleviate the problem. Eventually, distraught parents and unhappy students, including myself, went to Board of Education meetings to express our disapproval and dismay of the way the school was handling the situation. Little was done.

I gave the Principal’s speech at graduation. The focus was on the importance of acceptance and diversity. Diversity is prevalent in the town I grew up in, which is a reason why many students in the school I attended were accepting of the differences among one another. However, it was unfortunate to note the change in the attitude and behavior of the students after Trump became President. I am now a Freshman at Rutgers and I have found that to be a very warm and safe environment.


The Three Questions You Should Ask of Treatment Programs

I advocate on behalf and work in the addiction treatment industry. I do this despite that fact that very few programs are any good and most are horrendous. This is true for both in-patient and out-patient programs. They dress themselves up with fancy websites, glossy brochures, and friendly marketers. Back in the late 90s when I was a private first class (PFC) in the Army, Master Sergeant Spadoni occasionally told me that “You can’t polish a turd.”

I repeated this to one of my Rutgers students a half dozen years ago and he responded with, “Yeah, but you can roll it in glitter.” That is an apt description of the four most common marketing methods employed by treatment programs:

  1. They have many photographs (maybe even videos) of their glimmering facilities.
  2. They describe the extras they offer: gym memberships, yoga, equine therapy, whirl pools, sauna, music studios, and other shiny add-ons that sound impressive. Most of these offerings have little to no research to justify their presence in a treatment program but are there to jack up the costs (I’m pro-exercise, a huge fan of yoga, and can see the benefits of equine therapy, but they are just glitter if the clinical program isn’t solid).
  3. They offer a heart-warming story about a successful client and/or provide quotes from happy parents and patients.
  4. The owner or one of the head counselors or the marketer is in recovery, and they lead with that information to show that they “really understand” and “really care” and that this “isn’t about money.”

Over the last four years, I’ve written or edited a number of pieces that addressed a variety of the problems in the addiction treatment industry. You don’t need to read these to grasp the point of this article, but it will give you a much deeper understanding about my complaints.

  1. Frank Jones and I wrote a piece about how insurance companies deny coverage to pay for treatment and how the industry uses it as an excuse to act badly.
  2. Very few centers have a rigorous family program with a multi-family group. I’ve written about what multi-familly groups are and some basic advice for parents of young adults.
  3. Andrew Walsh investigated the 1-800 numbers and the conman tactics that treatment programs use to lure clients. Mr. Walsh detailed how much attention he got with good insurance and how they quickly got off the phone if he didn’t.
  4. Mr. Walsh wrote a piece about the lack of treatment beds for Medicaid patients. Substance abuse facilities are not interested in them. As a result, your chances of getting treatment depends upon your finances. It’s a true modern day civil rights issue.
  5. The Florida model is the industry’s end-around move to get insurance to pay for seeming residential care when they reject it. The companies house clients a few blocks or miles from an intensive outpatient program (IOP) and shuttle them back and forth. In theory, it is a decent idea. The major problem is that the housing is not licensed or regulated. The staff often suffers from a lack of experience, education, training and supervision. I wrote a basic plan to address this.
  6. Treatment centers brag about their CARF and Joint Commission certifications. These are non-government agencies that rate programs. Even terrible ones can get their approval, which makes the whole rating system virtually worthless.

Treatment program owners, directors, and marketers often call me or email me or try to connect with me on LinkedIn. I tell them I don’t really have clients to send them and that I am highly critical of the treatment industry. They respond that they have high standards too and push for meetings. Over the last few months, I’ve held court at Rutgers and had a number of colleagues and supervisees attend those meetings. We ask them a grueling set of questions and every single program has come up sorely lacking. Here are the three most important questions that you should ask:

  1. Are all the therapists and workers supervised? How often do they get supervised? By whom? What are the supervisor’s credentials? What proof do you have of the supervisor’s expertise?
  2. How much individual therapy do the patients get?
  3. What data do you have to show the effectiveness of your program? Is it internally collected or do you have a neutral outsider do it? What metrics do you have to show how soon patients get a physical, visit the dentist and see a gynecologist? Do you measure stable housing and reduced involvement in the criminal justice system? What is the percentage that you help enroll in GED or vocational training or college courses? How many clients are set up in aftercare? How do you vet those aftercare programs?

Here is why those questions are important:

  1. Substance abuse and mental health counseling are difficult to master and are quite draining. Staff needs to be well trained and supervised at least one hour a week (two hours is my base standard). This provides better care, reduces staff burnout, and results in fewer ethical problems.
  2. Individual therapy is far more effective than group therapy, partly because most professionals that run group are not actually skilled in educating, room control, or handling a diverse set of people. Minimally, people should get one hour of therapy a week from a masters or doctorate level professional with a license (I’ll accept a masters level intern performing it if they are getting real supervision). The data is quite clear on this. Ideally, it is more than once a week.
  3. Even the worst program has a success story. It doesn’t tell us anything about the quality of the program. Data does. Very very few have any kind of data.

Most programs have unsatisfactory answers to these three questions. They try to make up for it by rolling their shitty programs in glitter; hence the glossy brochures, glimmering facilities, touching stories of success, and assurances from owners/workers that are in recovery. All that glitters isn’t gold – in fact, it’s probably covering up a lot of shit.


This is from a brochure that was given to me by a marketer that visited us at the Rutgers Center of Alcohol Studies in January. We asked lots of questions, including the big three. I won’t go into what happened, because you could learn a lot by just calling them up and asking yourself. But their brochure had a statement in it that I haven’t come across before (Andrew Walsh pointed it out to me). The second and third lines celebrate the presence of a “12 Step guru” that helps the clients. It doesn’t state how much sobriety time the man has or if he has any education or credentials. I have never heard of anyone allowing themselves to be described as a 12-Step guru. The AA 12 and 12 book has a name for the guru types: bleeding deacons. From page 135: “At times, the A.A. landscape seems to be littered with bleeding forms.” In the same chapter, there is a stern warning against the professionalization of AA.

I am friends on Facebook with at least 32 people who have 20+ years of sobriety (I know a lot more than that though). None of them call themselves a guru or an AA expert. About a dozen of them work in the treatment field and do not advertise that they are in recovery; significantly, they have all been educated, trained, credentialed, and supervised (their expertise comes from that, not because they are in long-term recovery). Treatment programs continue to shock and amaze me.


The Last Republican?

John McCain has served in the Senate since 1987. He occupies the seat that used to belong to Barry Goldwater (a conservative who lost in a landslide in the Presidential election in 1964; Senator Goldwater would eventually repudiate a number of his ultra conservative policy stances from earlier in his life). Senator McCain is 81 years old and has been getting treatment for  brain cancer that was publicly announced in the summer of 2017. This piece is an appreciation for his service to the United States in both the Navy and Congress. A recent dual biography on the Bush Presidents is titled The Last Republicans, but that label fits Senator McCain much better (that said, even the latest Star Wars title shows that the “last anything” is probably hyperbole, except in cases like this or this).

John McCain was born in 1936. His father and grandfather were both four-star admirals in the Navy. Mr. McCain graduated from the Naval Academy in 1958 and became an aviator. He was shot down over Hanoi in October of 1967. His ejection from the plane broke both arms and his right leg. Those breaks were not properly set. During his captivity, he was tortured by the North Vietnamese, causing further injuries. Because of his family connections, he was offered an opportunity to be repatriated (swapped for other prisoners) before other Americans that were captured. Mr. McCain always refused such offers. His captors tried to break him, hanging him by his broken arms for hours (you can read about it in Robert Timberg’s The Nightingale’s Song). He was finally released in 1973. He was elected to the House of Representatives in 1982 and served two terms before successfully running for Senate.

In his masterful book on the 1996 Presidential Primaries and Election, The Losers, Michael Lewis met and fell for John McCain (to be clear, Lewis identifies as a liberal but deeply liked and admired the Senator anyway). The Senator was not running for President, but was serving as a surrogate for Senator Bob Dole. While Mr. McCain was imprisoned in the Hanoi Hilton, American anti-war protest speeches were broadcast into the prison cells in an effort to break the men. The leader of one of the protests was David Ifshin. In a story that wasn’t known until the Clinton Administration, Mr. Ifshin apologized to Senator McCain in 1986. During the 1992 campaign, Mr. Ifshin served as a legal counsel to Governor Clinton but did not immediately work in the administration. When Senator McCain learned that his Vietnam protests were holding up an appointment, he called an unprompted press conference to help Mr. Ifshin. Here is another telling passage by Mr. Lewis:

I visited him at his home in Phoenix and at his cabin in the Arizona desert. I came to know his wife and children. But — and here was the amazing thing — simply by being weirdly insistent on hanging around I came across all sorts of little habits he had that said something about who the man was. McCain was clearly ambitious as they come; even then you could see he was talking himself into running for president. Yet he had developed a trick to ward off the ill-effects of ambition on his soul: he did many things that were of no possible benefit to his political career. For instance, he made a habit, once a week, at the crack of dawn, of visiting the hospital bed of retired Arizona congressman Mo Udall. Udall, who was dying of Parkinson’s disease, was unaware he had a visitor. When he’d been in power everyone wanted to see him; now no one but McCain came to visit. There was no one to witness McCain’s gesture. The visit was McCain’s way of paying tribute to a man he had admired, and who had guided him early in his career. Since Udall no longer responded to visitors, the visits were of no possible benefit to him. McCain did it for himself: the trips were a tool for reminding himself of the transience of political success. (304)

Senator McCain would run for President in 2000, but he was defeated by Governor Bush in the Republican primary. Senator McCain had upset Governor Bush by 19 points in New Hampshire and had momentum heading into the South Carolina primary. Karl Rove convinced George W. Bush to “take the gloves off” and Mr. Rove engineered a series of false and disgusting attacks that would ultimately help Bush win South Carolina and the nomination. One was that his wife Cindy was a drug addict (she had abused pain killers after a surgery in 1994). Another was that McCain had slept with prostitutes and given his wife STDs. Yet another was that he was turned in the Hanoi Hilton and was now mentally ill. The coup de grace was that he had a Negro child out of wedlock. This played into the racism that strongly existed (and still exists) in South Carolina and was a twisted distortion of a wonderful story: the McCains adopted a Bangladeshi orphan with a cleft palet named Bridget in 1991 after Cindy McCain met her during a relief mission. I am extremely proud that I voted for Senator McCain in the 2000 Republican primary.

Senator McCain championed campaign-finance reform and worked across the aisle with Russ Feingold in 2002. During the next few years, he rebelled less against the Republican establishment and sometimes went against earlier positions. He did this in an effort to shore up his base to run for President in 2008. His running mate was Sarah Palin, an unmitigated disaster that he thrust upon the nation when his advisors discouraged him from naming Senator Lieberman (a conservative Democrat) as his running mate. Senator McCain has never spoken poorly of her in public, but Steve Schmidt, his campaign manager, has voiced both his opinion on Governor Palin and where the GOP has been headed in recent years. In the general election that year, I voted for the other guy. Over the next few years, Mr. McCain would return to his maverick ways.

Fast forward to June of 2015. Donald Trump said this about Senator McCain, “He’s not a war hero. He was a war hero because he was captured. I like people who weren’t captured.” In previous elections, such a statement about a decorated veteran would have been disqualifying. More so than anything else in 2015, that moment was the one that signaled shift in the Republican party and its voters. Numerous people that claim to support the military have twisted themselves with irrational verbal gymnastics in order to justify Mr. Trump’s anti-veteran statement about Senator McCain.

Just after his cancer diagnosis and treatment, the Republicans attempted to repeal the Affordable Care Act. Senator McCain ripped the Republicans for their terrible legislative process (no hearings, fast votes) and flew back to Washington to cast his vote. You can read about it here, but this video and picture say it all.

This December, there have been a number of moving moments and tributes. Vice President Biden appeared on The View, co-hosted by Meghan McCain. He was discussing his book about his son Beau, who passed away in 2015 from a similar form of brain cancer. Ms. McCain understandably was teary, and Mr. Biden moved over to console her. He said, “One of the things that gave Beau courage, my word, was John. You may remember when you were a little kid, your dad took care of my Beau. And Beau talked about your dad’s courage — not about illness, but about his courage.”

If you pay attention, you’ll see this over and over again in regards to Senator McCain. Political opponents having gracious and moving words to say on his behalf. Regardless of their fields, anyone who can garner such respect out of so many opponents is truly a special individual.

A few days later, Fred Hiatt, the Editorial Page Editor of the Washington Post wrote an opinion piece on Senator McCain and his role in U.S. global leadership, something that is very much lacking in the present:

Like many people, I’ve been alternately cheered and disappointed by McCain’s stances on domestic matters over the years — admiring when he helped save Obamacare a few months ago, disappointed when he went along with the Republican tax-cut bill this month. But McCain has never wavered in his support for democracy and human rights, and in his conviction that the United States needs to provide moral support to those who fight for freedom around the world. With President Trump often expressing more admiration for dictators than for democratic leaders, McCain’s advocacy has become lonelier — and more essential.

But he does not disguise how worried he is by the deeper currents that recall to him the darker movements of the 1930s: the nativism, the assaults on freedom of the press and the rule of law, the blaming of foreign competition for all ills, the rise of extremism. “I worry about the polarization that’s going on here, I really do,” McCain said. “The terms of the debate is what is really disappointing. The other day I was flipping the channels, and I saw Bannon just beating the crap out of Romney,” he continued, alluding to Bannon’s attacks on Romney for his service as a Mormon missionary in France during the Vietnam War. McCain, who more than did his part in Vietnam, made clear he didn’t share Bannon’s view. “I didn’t think there was anything wrong with serving your church. I had no idea that was a crime.”

Two days before Christmas, Larry Fitzgerald, a potential Hall of Fame wide receiver for the Arizona Cardinals, wrote a piece about Senator McCain for Sports Illustrated. Of the Senator, Mr. Fitzgerald said, “One of the reasons I admire Senator McCain is that he doesn’t always just vote his party. He votes his conscience, and that can seem like a rare quality these days.” The article is decent, though not nearly as good as the other ones I’ve referenced. It is further testimony to yet another impressive relationship that Mr. McCain developed.

I met Senator John McCain on Memorial Day in 2009. My ex-wife and I traveled to Arizona for the week around my 33rd birthday. We hiked the Grand Canyon (almost to the bottom), biked around Sedona, walked around Flagstaff, took in the Meteor Crater, and attended an Arizona Diamondback game in our quest to visit every MLB park (I’ve done them all and April is more than 3/4 through). Before the game started, I noticed Senator McCain sitting alone. No one had seen him. I felt conflicted. I like to give people their privacy (I sat next to Philip Seymour Hoffman at a steakhouse in NYC once and convinced April to leave him alone, despite the fact that Mr. Hoffman uncannily looked like my longest serving college roommate). Even back in 2009, after having just recently voted against him, I wanted to go over and shake Senator McCain’s hand. I went up to him and told him that I voted for him in the 2000 primary and that I appreciated his service in the Navy and his work in the Senate. I told him that I didn’t agree with him on a lot of issues, but that I had no question about his integrity. He was neither warm nor pleasant, but shook my hand and agreed to pose for the photo that begins this article. After our photo, a bunch of other people realized that someone famous was down behind home plate and they began to line up. I mouthed “sorry” to him but he didn’t respond (he is also known for being difficult and cursing a lot). Before the game, he appeared on the field with his wife and children, one of whom (Jack) was currently serving as a Naval Aviator. Mr. McCain stayed for most of the game and shook hands and signed programs for people that approached him. He never shooed them away.



How To Support Your Family Member in Early Recovery During the Holidays

I received several versions of this question in recent weeks:
In the parent portion of group last night, we discussed the upcoming holidays and how we were handling alcohol. I am hosting, XXXX is coming home, and I have decided to not serve alcohol. When I presented that to everyone else at my home last night, other family members’ reactions were not what I had wanted. If you could help me with a quick response,as I’m sure he won’t be the only one as I spread this word. I used the “support XXXX” and other things I have learned. The bottom line is one family member thinks that alcohol wasn’t XXXX’s big vice and therefore it shouldn’t be a “big deal”. Any words of wisdom would be greatly appreciated in me helping other family members understand. 
While the last five to six weeks of the year are traditionally supposed to be joyful celebrations with family and friends, many people describe the holidays as “stressful” and “to be endured” or “survived.” Over the years, clients have told me that the holiday stress can be related to any or all of the following:
a) unresolved conflicts with family or friends
b) forced to see relatives that you otherwise would not see
c) the self-perception that one has not accomplished enough and the low self-esteem that accompanies that
d) being single (or recently broken up or divorced)
e) not having children
f) being separated from one’s children
g) financial stress
h) legal stress
i) being around alcohol or other substances at holiday gatherings
j) arguments over politics
The data on the time between Thanksgiving and New Year’s Day show increased rates of depression, drunk driving, domestic violence, suicide attempts, and emergency room visits. All of those aforementioned problems can be caused or exacerbated by alcohol and/or other substances. I realize I’ve done my typical professorial reaction, where I provide a lot of background before addressing a simple question. Here it is in numbered points:
1) I define early recovery from alcohol and other drugs as the first two years (very early recovery is the first 90 days).
2) People are more likely to relapse in early recovery than in long term recovery.
3) Those in early recovery are often still unsure of themselves. They may not be good in advocating for themselves or setting boundaries. They may have a desire to appear unaffected or “normal.”
4) If someone had a problem with heroin or opioids (or cocaine or meth), they should avoid all other substances as well. I have known hundreds (it’s probably thousands, actually) of people who quit those harder drugs but then thought they could use alcohol or marijuana. Almost all of them found out that they could not. Some of them eventually abused those substances, while many others returned to their preferred heavier substances.
5) People in early recovery are often asked some variation of “Does that mean you can’t drink a glass or wine or have some champagne at New Year’s?” or “Does it bother you if I’m drinking?” Some of them are not equipped to answer those questions well, and they are particularly vulnerable to those questions when asked in front of a group of people.
6) If you want to be supportive, have alcohol (and other drug) free events during the first two years of your family member or friend’s recovery. They might tell you it’s fine and that they don’t want to take away from other’s holiday enjoyment. In the first two years, just go substance free. Don’t make it a vote or debate – just do it. If other family member’s or friends take issue with it, invite them to attend a family group education session or AA meeting or Al-Anon meeting or read this article. Those that are really difficult about it may potentially have a substance problem themselves. Having substance free holidays in early recovery is a wonderful gesture of support.
7) I encourage people in early recovery to avoid events where there is substance use. In long-term recovery, some people choose to continue to avoid situations with substances while others feel comfortable at sporting events, concerts, dances, work dinners, and parties. Everyone is different. I don’t mind when people around me drink, but I very much dislike being around most drunk people. I find that they are more likely to be rude, loud, rowdy, inarticulate, not funny and potentially chaotic. I avoid certain family members and events. I throw substance free functions and no one that means anything to me seems to mind. Decades ago, I was greatly touched by those that were supportive.



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. 




To the Parents Who Lost a Young Child

In the last week, three couples that I have some connection to lost a child. Two of the deaths were the end result of a long struggle with severe medical problems, while the other was because of a car crash. I have worked with people on grief for many years, and spoken with hundreds of parents who lost an offspring, usually as a result of a drug overdose. But I have also counseled several who lost a young child or baby, and it is clear to me that burying a child is the most painful of all human experiences. This loss will always be with you, and may, in fact, define you.

This is not an area I specialize in nor claim a particular expertise. Though I have experienced my own difficult losses (my grandmother in 1995, my friend’s overdose in 2002, a divorce a few years ago), they are not as soul-searing as the loss of a child. Still, those losses, a highly developed sense of empathy, and my experience helping people with grief compels me to offer the following advice:

  • If you have another child, you should talk to him or her about what happened in clear and honest terms. Do not lie or us euphemisms. Your child or other children know that something incredibly awful has happened – children are incredibly attuned to their parents moods, facial expressions, body language and presence. Even if your other child is 2 1/2 years old, tell them.
  • It is also very important that you tell your other child (children) that he or she is not sick nor likely to die. All too often, when kids see this kind of thing happen to a sibling, they wonder if it will happen to them and they never ask or tell an adult what they are worrying about.
  • Your friends and family don’t know what to do or say. Some will avoid you completely, because they do not want to intrude or do not know what to say. Others might hang around or call all the time, hoping to comfort you with their presence or some activity. Though this is very difficult, it will help everyone involved (including you) to let people know what you need. And please be aware that what you need during the first week may be different than month three or year two.
  • The previous point may be tough to accept. You might think, “Who cares if my sorrow makes other people uncomfortable? Why should I worry about them when I’m the one who has lost my world?” Those are fair thoughts, but you still need other people. As does your family. Being clear that you need space or company or words of condolence or silence will ultimately help you.
  • There may be some people who say things like “his time was up” or that “God called her home” or “he is in a better place” or that it “was God’s will.” You may find it consoling, or you might find it incredible offensive and aggravating. People that say this to you mean well. They just don’t know what else to say. If it offends you, let them know and ask them not to repeat it.
  • Regarding your spouse, partner or ex: they are the person that also suffers this tragic loss the worst. He or she will grieve differently than you. It may come out as constant crying, silence, rage, withdrawal, throwing oneself into work, talking, some combination of all of the above, or perhaps something else entirely. I have seen couples get angry with each other at how the other grieves. You have each experienced the most terrible thing, don’t compound it by attacking each other.
  • Even though you are in a daze, you need to leave your home each day. Whether it is to go to work, school, church, therapy, the gym, grocery shopping or something else, you must venture out into the world. Time is going to feel incredibly slow and miserable, and walking around the house from room to room and staring at the walls or outside will not help. This is extremely common behavior.
  • Consider going to a support group or therapy. This may be an anathema to you, but a support group will be filled with people who have the same experience and can show you how they got better or worse. The support groups can be helpful years down the road, when other people have a hard time comprehending that this loss is still very much an active part of your life. A therapist who specializes in grief can provide positive support from a neutral source over a period of months or years.

Waking up each day may be the worst part of your day – as you come to and remember your loss and the wave of pain washes over you. The days will keep coming. I have no special words of comfort – there are no special words. There is the aforementioned advice, which may or may not work. You may not want it to work, but please consider trying.


An Incredible Free Service for Veterans, Reservists, National Guard members, and their Families

On August 8th, I toured the Steven A. Cohen Military Family Clinic in Philadelphia. It is located on the University of Pennsylvania campus, just west of Center City. There are other clinics in NYC, San Antonio, Dallas, El Paso, and Fayetville, NC. There are several more slated to open within the next year. To find the contact information for each clinic, click here.

Steven A. Cohen was born in New York. He went to Wharton and made his money on Wall Street. The 2017 estimate of his wealth is around $13B. His son served in Afghanistan. Mr. Cohen and his wife established the Cohen Veterans Network in 2016 with an initial donation of $275M. The clinics currently provide services for veterans, reservists, and National Guard members. They also provide counseling for family members. They see people for one hour a week. If people need a higher level of care, the professionals at the clinic work tirelessly to find appropriate services.

I had the pleasure of meeting with Pete Freudenberger, a social worker who earned his MSW from UPenn. He is also a veteran with a very interesting story. He is the Outreach Manager for the Philadelphia clinic and can be reached at

The Steven A. Cohen Military Family Clinic was featured in an article on on June 15. You can read it here.

This photo was taken from the aforementioned article on



Are You Suffering Work Burn Out?

Social Workers and other helping professionals have high rates of burn out. People in the field will talk about it without describing how to actually look for it. I’ve put together a 20-question self-quiz that professionals can take to evaluate themselves. While it is not scientific, it should give you a good feel for where you are and whether  (and what) you need to change (this can be used to gauge burnout in other professions as well, though questions 2 and 18 should be altered or eliminated).

For a printable version of this, click here.


Are You At Risk of Burning Out?

A Self-Test for a Social Worker/Drug Counselor/Preventionist/School Counselor/Advocate

  1. Are 10% or more of your hours unpaid? (consider work from home, or emails & phone calls outside of your regular work day)
  2. Do you get weekly supervision of at least one hour per week?
  3. Do you have a self-care plan?
  4. Does it take more than 15 minutes for you to fall asleep at least 2x a week?
  5. Do you wake up in the middle of the night at least 2x a week?
  6. Do you sleep longer or shorter than you planned at least 2x a week?
  7. Do you wake up and feel like you haven’t had a restful sleep at least 2x a week?
  8. Do other people get credit for your work?
  9. Are you happy with your exercise routine?
  10. Does your work schedule or stress cause problems with your family (parents, significant other, kids) at least twice a month?
  11. Do you take an out-of-state vacation at least once a year?
  12. Do you feel like you have neglected friends?
  13. Do you feel like you have neglected hobbies?
  14. Are you in therapy at least 2x a month?
  15. Do you have conflicts (passive or aggressive) with co-workers at least 2x a month?
  16. Do office politics interfere with your job?
  17. Can you talk to someone about work stress other than your significant other?
  18. Have you had a client or student die within the last year?
  19. Do you know exactly what is expected of you at work?
  20. Does your job cause you to compromise any of your values?


Scoring guide:

+1 for yes: 1, 4, 5, 6, 7, 8, 10, 12, 13, 15, 16, 18, 20

-1 for yes: 2, 3, 9, 11, 14, 17, 19

-3 – -7: You have a very good work-life balance and are a model for others

-2 3:   A worker with good mental health and decent job satisfaction will fall into this range

4 – 5:   Your job is a minor problem. Make a few tweaks to increase your health and possibly productivity

6 – 8:   Your job is a major problem. You should talk to your supervisor and therapist about making some major changes

9 – 13:  You should consider leaving your job in order to get your sanity back


Seniors on Dope: What Medicare Is and Isn’t Doing in NJ

This article was written by Andrew Walsh that I edited. Andrew is a grad student of mine at the Rutgers School of Social Work. This is the third article that he wrote under my guidance this year (his first piece was on addiction hotlines and his second one on Medicaid in NJ was published last month).


Substance abuse continues to be a topic that receives coverage on both a state and federal level. While the main focus is on opiate abuse and deaths among young adults, there is another population that abuses alcohol and drugs at a higher rate. On January 1st 2011, the first baby boomer turned 65 years old, marking the transition of baby boomers into the older adult population.  The United States has a baby boomer population of 76 million. New Jersey has a population of 2.2 million baby boomers, 1.2 million of which are over the age of 65. With the onset of physical and cognitive decline associated with aging, this population will put strain on medical and behavioral health facilities. Unlike prior generations, the baby boomer generation has had extensive exposure to alcohol and drug use growing up. This exposure has created an attitude of acceptance among baby-boomers regarding the continued use of illicit drugs and alcohol later in life. The Substance Abuse and Mental Health Services Administration (SAMSHA) estimates that approximately 17% of this population is actively affected by the misuse of alcohol and/or prescription drugs. In New Jersey this translates into 204,000 older adults actively misusing alcohol and drugs. In 2015, approximately 1678 individuals over the age of 60 received inpatient treatment for substance abuse and misuse. Statistically, less than 1% of seniors who would benefit from substance abuse treatment actually received treatment. Seniors face unique problems with alcohol and drug misuse and abuse:

  • Physical and cognitive changes decrease seniors tolerance for alcohol and drugs
  • Increased rate of prescriptions places them at risk for adverse medication interactions
  • Common symptoms of substance abuse such as unsteady gait or forgetfulness are often mistaken as decreasing physical functions or dementia
  • Seniors are less likely to seek professional help for their substance abuse
  • Seniors are more likely to be isolated so their substance abuse goes unnoticed
  • Health care professionals rarely screen seniors for substance abuse
  • Current screening tools are designed for use criteria that is not relevant to seniors such as adverse impact performance in school and work
  • Lack of senior specific substance abuse programs

Older adults have significant physiological differences than younger adults that increase their sensitivity to alcohol and drugs.  As individuals age, they start to lose lean body mass and water which both decrease metabolism. With slowing metabolic rates, the body’s ability to metabolize alcohol and drugs slows, thereby accumulating in fat stores in the body. Prescription use is very common among older adults. A survey on women over the age of 65 showed that 94% took at least one medication daily, and 57% took five+ medications daily. The same survey showed similar rates among men. Cognitive decline is often associated with aging and can interfere with older adults’ ability to monitor their intake of alcohol and drugs and compliance with their prescriptions.

Older adult substance abusers can be broken down into two distinct groups. One group is comprised of substance abusers who had early-onset substance abuse prior to the age of 60. This group of early-onset substance abusers is typically male and is medically compromised after years of substance abuse. The later-onset substance abuser-group is mostly comprised of women and is less compromised medically due to their short exposure to the harmful effects of substance abuse. Later-onset substance abusers typically start abusing alcohol and drugs following stressful life events such as the death of a partner or friends, retirement, changes in loving situations, and declining physical health.

Pharmacology is used extensively with substance abusers for abstinence purposes. However, the physiological condition of older adults prevents the use of pharmacologic treatments for substance abuse. The medications for alcohol abuse put seniors at risk for dehydration as well as cardiovascular issues. There are opioid blocker medications that are effective in reducing the pleasurable effects and craving of opioids. However, the blocking agents also prevent the relief of pain, which is common and usually chronic with older adults.

In New Jersey, the government is pursuing a number of actions to actively combat substance abuse among the elderly. Governor Christie pushed for legislation that limits the initial prescription of opioids for acute pain to five days. New Jersey has also joined the prescription monitoring program (NJPMP). This system allows doctors to access patient prescription records for the previous two years, thereby decreasing the frequency of doctor shopping. From 2014 to 2016, New Jersey opioid prescriptions decreased 11% while physicians use for patient searches increased from 1.4 million in 2014 to 2.5 million in 2016. Governor Christie has also called for an additional 864 beds for inpatient substance abuse treatment. However, at this time none of these beds are earmarked for Medicare recipients. The NJ Department of Health and Human Services provides educational seminars to seniors about medication management and substance abuse. In 2015, 154 presentations were attended by approximately 3,300 seniors.

Individuals who abuse alcohol and drugs typically experience withdrawal when they stop using. For older adults who are already in a medically compromised physical state, withdrawal places significant stress on an already stressed body. Withdrawal in older adults places significant stress on the respiratory and cardiovascular systems. The safest treatment option for older adult substance abusers is that they use a medically monitored withdrawal management process. However, according to the New Jersey Connect for Recovery hotline, there are only six facilities in New Jersey that accept Medicare for in-patient detox.

The facilities that accept Medicare are Princeton House, Core Health, Summit Oaks, Bergen Regional, and St. Clare’s. Combined these facilities have approximately 200 beds that are available for Medicare recipients for withdrawal management. With the average withdrawal management stay being seven days for older adults, 10,000 older adults will be able to receive substance abuse treatment on an in-patient basis in New Jersey.  This means 1 in 20 older adults who need in-patient detox will actually receive it.

However, not all beds available for Medicare recipients are actually earmarked specifically as only for Medicare recipients. Bergen Regional accepts clients Medicare, Medicaid, and those with no insurance. Princeton House and St. Clare’s accept clients with Medicare, Medicaid, and private insurance. Summit Oaks and Core Health accept those with Medicare and private insurance. This decreases the number of beds available for Medicare detox to approximately 100 beds. This means that 1 in 30 older adults who need in-patient detox will actually receive it.

There are a number of actions to be taken that will help address substance abuse among seniors:

  • Expand current DHHS educational seminars to reach more seniors
  • Create public service messages geared toward the adult children of seniors to educate on the signs, symptoms, and dangers of substance abuse among seniors
  • Expand the number of Medicare beds available for inpatient treatment
  • Make the use of NJPMP mandatory
  • Use screening tools that do not underreport substance abuse among seniors
  • Develop senior specific outpatient programs
  • Encourage seniors to attend mutual help groups such as Alcoholics Anonymous or Narcotics Anonymous

Even if all of these changes are implemented, the overall number of seniors who are substance abusers most likely increase as more baby boomers turn 65. The actions described above are meant to produce sustainable decreases over time. As more baby boomers retire and start to decline physically and cognitively, coupled with an utter lack of senior specific services, substance abuse among baby boomers is likely to get much worse. Even if all of these changes are implemented, the design of Medicare reimbursement for doctors on a fee for service basis encourages doctors to spend less time with patients. Unless this aspect of the Medicare system is redesigned, no sustainable progress can be made among seniors with substance abuse problems. A tremendous amount of work needs to be done if there is to be any improvement in substance abuse among seniors.

Andrew Walsh, MHRM, MSW Intern is currently pursuing his MSW and LCADC at Rutgers University. Prior to returning to Rutgers, he worked in the Gulf of Mexico oilfield as an internal business consultant. Andrew is a lover of books, cuisine, and theater.