ADDICTION: A COMPLEX, LIFE-THREATENING COMPULSIVE BEHAVIOR WITH TREATMENT PROVIDED BY . . . . NO, SERIOUSLY
The victims of a cronyism treatment industry – Americans trapped in increasingly lethal substance use epidemics – end up under pressure, due to lack of real treatment options, or court mandated back into an ineffective human treatment mill that benefits only the owners, regulators, managers and grossly unqualified employees of the sham programs.
By Clark Miller
Published January 23, 2019
Updated April 7, 2021; September 24, 2021
With compulsive use of mood-altering substances (“addiction”) driving a steadily worsening public health crisis, highly lethal, the standards and regulations controlling what types of healthcare professionals are qualified to treat the lethal conditions based on their levels of training, competence and credentialing should be clear and reassuring – but you don’t want to know.
You need to know, though. It’s a life and death matter.
Imagine a visit to your doctor’s (primary care provider, “PCP”) clinic based on concerns about new symptoms (bleeding, dizziness, sharp pain, something else), and as naturally happens, you have some worries about a serious or life-threatening condition, possibly heightened by family history or personal history of a condition. You are taken to an exam room (“roomed”) by a Medical Assistant (MA) – a medical healthcare team member with about two years of education – trained and qualified to record your complaints, draw blood for labs if needed, take and record blood pressure and other “vitals”, ask about medications, provide other important support for the licensed medical professional (LMP) – your doctor, nurse practitioner (NP), or physician’s assistant (PA) – you came to see for diagnosis and treatment.
That LMP (your doctor, NP or PA), in contrast to the medical assistant, is trained and qualified, through 10 or more years of training, to provide diagnosis, clinical formulation (the complex clinical “picture” of the condition and what is required for effective treatment as impacted by patient history and complex medical, social and psychological conditions), and based on that formulation, the appropriate medical referral or direct treatments for medical conditions.
Now imagine that Medical Assistant informing you that she, instead of your PCP, will be providing all medical care for you today and ongoing including: diagnosis based on your reports, labs, etc., clinical formulation (treatment planning) and direct treatment for your medical problems including ongoing visits and treatment for chronic or acute conditions.
Right.
Of course, that would never happen, is absurd on its face, and if attempted would result in lost employment, revoked medical licenses, and closed clinics at the least, depending on who was involved in what would consist of, among other things, criminal misconduct.
It is unthinkable that someone with the level of training possessed by an MA – despite being highly valuable and competent clinic team members within their limits of competence (“scope of practice”) – would be allowed to independently provide clinical formulation and treatment for any medical conditions, let alone including difficult-to-treat, life-threatening conditions.
Unthinkable – unless the healthcare industry is the medically-driven and overseen U.S. “rehab” and addictions treatment industry,
where the treating “addiction professionals” providing assessment, clinical formulation, and all treatment for complex, difficult-to-treat, life threatening compulsive behaviors (“addictions”) that have become a national epidemic typically have about the same or less training than an MA. Then the unthinkable and criminal are business as usual. Big business. Followed by predictable treatment failure, public health crises, and mass head-scratching and hand-wringing over America’s “addiction crisis”.
That situation is terrible, astonishingly inept, and tragic.
It is criminal.
The victims of this scam – Americans trapped in increasingly lethal substance use epidemics – often end up in jail, on charges related to their never-treated drug problems, or court mandated back into a “treatment” program where there is no conception of how or capacity to provide treatment, funneled back into a human mill that benefits only the owners and grossly unqualified treatment staff of the sham treatment programs.
Who knew? We did, all along, or should have.
Because it’s obvious, and because: the exposés, the reports, the complete lack of evidence for effectiveness of treatment as usual (TAU), and the take-downs of a failed addiction treatment industry that is at best ineffective or harmful that have come in a steady stream for years: here, here, here and here, here, on websites, in books, in feature major media reports, in this ABC news special aired 15 years ago.
“What we simply need is a a nice bulldozer, so that we could level the entire industry and start from scratch . . . There’s no such thing as an evidence-based rehab. That’s because no matter what you do, the concept of rehab is flawed and unsupported by evidence.”
– Dr. Mark Willenbring, former director of treatment and recovery research at the National Institute of Alcohol Abuse and Alcoholism (NIAAA)
In another more detailed post, we’ll look at the four core elements – fake models and practices, harm-predicting policies based on folklore and ignorance – in the medically-managed treatment industries that have led at least one establishment authority to brand “rehab” as a failed treatment system without evidence for benefit.
Here, for now, let’s focus on one of those elements: the medically-driven treatment industry that allows “addiction professionals” often with about the same or less training than the Medical Assistant who takes your blood pressure, to independently provide diagnosis, treatment formulation, and direct treatment for the life-threatening compulsive use of substances, “addiction”, that is fueling a national epidemic.
Two things at least we can bank on: 1) a high-pitched backlash (or “counterargument”) to any suggestion that these systems are doing harm and engaging in criminal deceit – despite it being clear that they are – from an entitlement system that is a $35 billion dollar industry and 2) arguments to rationalize the fraudulent practices.
Let’s take a look at those reactions and begin a critical discourse.
Counterargument 1
But . . . it may well be argued, doctors and other licensed medical professionals – LMPs (like nurse practitioners NP and physician’s assistants PA) – treat the full range of medical conditions, so of course they need much more extensive education and training. Addiction professionals like CADCs or CDPs, in contrast, treat a relatively narrowly defined condition – “addiction”.
First, that’s not true on two counts.
1) Family practice or primary care provider LMPs are trained to refer to specialists when they diagnose or recognize conditions outside of their scope – a vast range of conditions they encounter.
2) More fundamentally, as we’ll see in additional posts and below in the next Counterargument, no one treats a condition known as “addiction” because it is clear that there is no such thing as “addiction”, no such disease, or medical condition, or disorder.
Instead, all relevant lines of evidence establish that “addiction” represents a compulsive behavior, a behavioral symptom, that is driven by some complex state of inner distress including memory, thoughts, emotional states, experienced stressors that is unique to each individual.
The profound failure and harm done by existing models of substance use and its treatment is explained largely by this historical fiction of “addiction” and is driven, perpetuated, by the need to protect status and power of the oxymoron and entitlement system “addiction medicine”, dismantled here. When we resist and reject the fictional account of “addiction”, fabricated to protect and preserve control of cultural capital and social resources for gain, it is clear that effective treatment of substance use is as or more challenging than treatment of medical conditions by a LMP, because it requires effective clinical formulation and associated treatment for each unique individual struggling with substance use and including understanding of that individual’s history, personality, psychology, inner emotional world, and social and material environments and functioning. That type of work – the effective treatment of substance use problems – sets a standard of practice for treatment as requiring advance practice behavioral health professionals like psychologists and clinical social workers.
In any case, the argument that CADC and CDP-level “addiction professionals” are qualified to independently provide clinical formulation and treatment for substance use problems because they are a defined range, or type of condition is as absurd, facetious, harmful, and criminal as arguing that an MA is qualified to treat a subset or defined range of life-threatening, complex medical conditions, like . . . what? only infectious diseases ? just lymphomas? only heart disease, diabetes, type 2 diabetes?
Right.
The victims of this scam – Americans trapped in increasingly lethal substance use epidemics – often end up in jail, on charges related to their never-treated drug problems, or court mandated back into a “treatment” program where there is no conception of how or capacity to provide treatment, funneled back into a human mill that benefits only the owners and grossly unqualified treatment staff of the sham treatment programs.
Counterargument 2
But . . . it may well be argued, “addiction” is different in nature than other life-threatening conditions, so treatment looks different.
It is indeed different, fundamentally, but in ways that even more solidly establish that treatment by “addiction professionals” with current levels of training and standards of practice is grossly, criminally substandard and at least ineffective, if not harmful.
It is radically different from other conditions because it is not a condition at all – not a disease, nor medical condition of any type, not a disorder, but a behavioral symptom driven by underlying compulsions, as established by 1) the consistent reports of individuals with the symptoms, 2) by congruence with other types of compulsive behaviors, and 3) by the longstanding invalidation of “disease” or medical models of substance use.
Because no two persons’ life experiences are the same, nor their inner complex worlds of emotional/belief systems, memories, triggers of memories with emotions and emotional distress attached, etc., no two persons have the same needs for treatment therapies required to address, manage, gain relief from the inner distress and triggers of inner distress driving compulsive use of mood-altering substances (there are reasons we call them “mood-altering”). That simple and basic fact, established by all lines of evidence and everything we know about the behavior of compulsive substance use, throws everything about current accepted knowledge, Doxa, about substance use and its treatment, out the window.
Effective treatment for substance use problems is all about treating the underlying causes driving the compulsive behaviors, not the behaviors themselves, which are symptoms.
Consider: Obsessive-Compulsive Disorder
Obsessive-Compulsive Disorder (OCD) is a mental health condition in which inner distress in the form of distorted fears about bad things happening drives compulsive behaviors that can have serious physical effects, like skin abrasions from compulsive washing. Effective treatment for OCD does not target the behavioral symptoms, for example by rewarding or punishing them, instead targets the distorted underlying beliefs and associated emotional states driving the compulsive behaviors. The appropriate, effective treatments are types of psychotherapy, by advanced practice behavioral health clinicians, that identify and target the underlying fears and sources of fear (including from early experiences) driving the symptoms (behaviors).
Attempting to treat or manage the behaviors themselves without addressing those underlying obsessions driving them would predict treatment failure.
Consider: Chronic Pain
Patients experiencing the most common form of chronic pain, pain that is “centralized” – not due to ongoing tissue damage or inflammation or cancer – typically engage in compulsive behaviors associated with that pain, like grimacing, moaning, complaining, and behaviors that more severely limit and impact their functioning and quality of life like restriction of body movements and activities. We know that centralized chronic pain is psychogenic in nature – driven by distorted, false beliefs about the pain and its causes – and treated effectively by psychotherapies, not biomedical interventions.
Two important points:
1) We don’t doubt those patients when they tell us, consistently, that their pain behaviors are compelled, driven by complex inner states involving physical sensations, self-defeating beliefs, fear and other associated emotional states. We accept that because we have no reason to doubt them, because it makes sense, and because we’ve experienced it ourselves. Exactly the same thing occurs in settings where individuals whose lives are impacted by problem use of mood-altering substances feel safe and comfortable talking about it – they consistently report that they are driven, compelled to engage in the behaviors of using drugs by the urge or need to relieve or change some distressing inner state(s). We have no reason to doubt them, for the same reasons.
2) As with obsessive-compulsive disorder (OCD), we don’t attempt to treat the behaviors themselves – the guarded, restricted body postures, self-limited mobility and movement, other pain behaviors, by for example punishing them or rewarding their avoidance – that would not be effective at all because those are the compelled behavioral symptoms of an underlying complex state of memories, interpretations, beliefs, and associated emotions making up the pain experience. Attempting to treat the symptoms, the pain behaviors, would not address the underlying condition driving them.
On the other hand, as firmly established by longstanding research, therapies that address those underlying beliefs and states are effective and durable in moderating the pain and consequently the associated behaviors. Those CBT and other therapies are provided by advanced practice behavioral health professionals, targeting the complex inner states unique to each individual, not by individuals with the training of a CADC or similar level.
So, substance use problems are radically different from medical conditions because they are not conditions, syndromes, or disorders at all, but compulsive behaviors that are symptoms of some non-medical condition. As distinguished in OCD and with other compulsive behaviors driven by inner distortions and distress, a symptom is a symptom, and not a disorder.
Yet there are similarities between problem substance use (PSU) and many serious medical conditions:
PSU may be difficult, challenging to treat, requiring highly-skilled practice
PSU is often life-threatening
PSU is complex, shaped and driven by: history of experiences including trauma and ACE; complex inner states that include beliefs, personality traits, sensations, psychological associations, interpretations, and associated emotions; and stressors and triggers of inner states in the environment, social and other.
The evidence and these considerations establish that effective treatment for the life-threatening condition of compulsive substance use requires services provided by advanced practice, highly trained behavioral health professionals and predicts treatment failure when provided by unqualified individuals – the type of failure that defines the addiction treatment industry and drives worsening national substance use epidemics.
Other voices have been as or more direct
in their critical assessments of the profound deficiency and inadequacy of level of professional qualification and competence of “addiction professionals” – like CADCs, CDPs – providing treatment for complex, life-threatening substance use disorders.
In Anne Fletcher’s seminal book “Inside Rehab”, citing information from a comprehensive and damning review and analysis (2012 The National Center on Addiction and Substance Abuse at Columbia University – Addiction Medicine: Closing the Gap between Science and Practice) of quality of provided substance use services she writes that:
“Addiction counselors provide most of the treatment in programs, and “states have widely varying requirements in both educational level and training for a person to become a drug and alcohol counselor. Some states don’t require any degree . . . and many require just a high school diploma, general equivalency diploma (GED), or associate’s degree . . . Although there’s been a movement to professionalize treatment, much counseling still is provided by minimally trained addiction survivors-turned-counselors whose own rehabilitation forms much of the basis for their expertise.”
From interviews with healthcare professionals and other observers in the remarkable new documentary film The Business of Recovery (view trailer below in this post), frank voices like that of Dr. Lance Dodes, author of The Sober Truth:
“The idea that only an addict can treat an addict has led to the rise of thousands of “addiction counselors” whose only credential is their status as recovering addicts. At minimum, this treatment community does a disservice to addicts by practicing therapy without formal education; at worst, some of these recovering addicts may be seriously unfit to perform this work.” – The Sober Truth.
Dr. Dodes notes that Hazelden, the premier treatment center featured in The Business of Recovery on its website encourages individuals “in recovery” (that is, struggling with a substance use problem, to “Become an addiction counselor in as little as one year”.
William Miller is the developer, with Stephen Rollnick of the therapy approach, Motivational Interviewing.
“So we developed this history of providers being people who are themselves in recovery ‒ originally with no educational requirement at all. In New Mexico, we now have a Bachelors degree required to be a substance abuse counselor and it was quite controversial to do that. I don’t know of any other life‒threatening illness where it’s controversial if you should have a college education to treat it, but it has been in the addiction field.”
“If you go to your doctor to be treated for cancer or heart disease you expect your doctor to be doing what the science says is the best treatment available for what you have. That has not been the standard in addiction treatment.”
– William R. Miller, PhD in “The Business of Recovery”
And
“The even more honest people will tell you that the [treatment] system as it’s currently set up and construed is incapable of ever delivering meaningful and worthwhile service.”
– Rick Ohrstrom, Chairman of C4 Recovery Foundation in “The Business of Recovery”
“There is no mandatory national certification exam for addiction counselors. The 2012 Columbia University report on addiction medicine found that only six states required alcohol and substance-abuse counselors to have at least a bachelor’s degree and that only one state, Vermont, required a master’s degree. Fourteen states had no license requirements whatsoever ‒ not even a GED or an introductory training course was necessary ‒ and yet counselors are often called on by the judicial system and medical boards to give expert opinions on their clients’ prospects for recovery.”
– Gabrielle Glaser ‒ The Irrationality of Alcoholics Anonymous (The Atlantic)
How Did We Get Here ?
Doxa – fabricated “knowledge” made up to protect and serve interests of those with the influence, the “cultural capital” to construct that fake “knowledge” that is accepted as valid no matter how grossly wrong – creates and protects the harmful, criminal practices of the medical, institutional and private-profit addiction treatment industries. Partly driving the Orwellian, post-factual fabrication is a $35 billion-dollar treatment industry and entitlement system providing employment to tens of thousands of “professionals” entirely unqualified yet securely employed. Many members of this remarkable workforce – akin to trained phlebotomists working as surgeons – arrived in their secure positions and advanced to supervisory and management positions in a career trajectory that began with their status as “in recovery” – having been in treatment for substance use problems themselves, and importantly, as acolytes in the religious subculture Alcoholics Anonymous driving the history of addiction treatment in the U.S.
Maintaining the fabricated and invalidated lie of “addiction” as some type of condition (medical, disease, disorder) with common (medical or other) treatments for all individuals with the “disease” is also necessary to maintain the status, cultural power, and lucrative grant, contract, and academic funding doled out to individuals within the “addiction medicine” entitlement system.
Those are immensely powerful forces maintaining the lies – Doxa – to protect their interests and status while predictably causing harms like the persistently worsening national substance use epidemic with associated deaths and illness.
Rendered acceptable by virtue of the pervasive, mass-media-fueled authoritative power of Doxa (Orwell’s “propaganda”, or misinformation), addiction treatment industries and institutions and their practices – despite being bizarre and wrong in ways that assault critical thought, common sense, and the evidence – instead become normal and accepted, as Doxa.
“Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.”
– Pierre Bourdieu Outline of a Theory of Practice (1972)
In Bourdieu’s Theory of Practice, heterodoxy is dissent, challenge to what “goes without saying” – the accepted, constructed doxa, “knowledge”, reality, that goes without saying precisely because it “comes without saying”, without real scrutiny, untested, unquestioned. The function of doxa is not knowledge or truth or promotion of the collective good, but to protect and serve the interests of those with the power, the cultural capital, to create it.
Insider’s view: the addiction “treatment” industry is like no other
A profession in which job postings routinely include language to the effect that “individuals who are in recovery must have had two years of continuous sobriety”. Think about that unique “qualification” for a moment. That is about employers 1) acknowledging preferential hiring of individuals who have and often continue to struggle with compulsive use of substances (and necessarily the mood and cognitive disturbances always driving those compulsive behaviors) and 2) that individuals with that history and preferentially hired often are challenged in functioning related to those ongoing problems – individuals hired to be models for and effectively treat others struggling with problem substance use.
Remarkably, applicants benefit from preferential hiring due to a history of being members of a religious subculture – AA or NA – involvement in which predicts return to problem substance use (at the rate of about 90% to 95%, likely higher than for individual without any involvement in that subculture, due to the associated detrimental effects) and in which addictive use of arguably the most lethal and addictive substance known is rationalized and socially reinforced.
Candidates for positions of employment as treatment professionals in this industry, despite being entirely unqualified, benefit from a truly remarkable argument: that individuals are qualified, or more qualified to provide therapies for life-threatening, complex conditions by virtue of having a history of experiencing those problems themselves. Often, in treatment industry culture, this argument is strengthened to the position that only individuals who have struggled with the condition are effective in treating it because I’ve been there man. By this logic, we would preferentially select, or require, for example, that neurologists have a history of neurological disorder, that cardiologists have a history of heart disease, that psychiatrist have a history of psychosis and/or mania and/or severe depression, etc. I’ve been there man.
In practice, this remarkably odd presentation of institutional and social pathology masquerading as healthcare results in a treatment industry culture that:
Lacks capacity to provide the indicated and required services for the conditions
Often discriminates against and/or excludes individuals who are actually trained as professionals and in evidence-based practice for the conditions, but who may fall outside of allegiance or deference to the religious subculture system, with common reports of hiring and institutional discrimination
Toxic work environments in which professionally-oriented staff are expected to participate in the religious subculture meetings, prayers, and rituals in the workplace
The dysfunction and harm to public health resulting from this remarkably pathological system has been described, here, here, here, and here for just a few examples. Its evolution and cultural significance less so.
Incremental or moderate change will not suffice
to reduce the avoidable harm – mounting deaths and illness and a continually worsening national substance use epidemic – predictable from an entitlement system entirely without capacity to provide the needed services yet funded and entrusted to provide treatment to vulnerable Americans trapped in substance use epidemics. No more than moderate change would be helpful to stop harm caused by any fraudulent healthcare practice that promises treatment and provides instead harmful practices or at best no benefit.
Radical, fundamental change will be necessary to begin to stop the deaths and other harms caused by a healthcare “treatment” system most accurately portrayed as a lethal criminal scam.
That will require strong voices unafraid to say, and keep saying, “No, wait, that’s not right, that is not true”, dissenting voices, more and more of them.
Demand for change won’t come from the entitled, the comfortable, the beneficiaries of made-up truths, of social pathology and doxa.
It will come from the harmed, the fed up, the courageous, renegades.
