Review of "Rehab: An American Scandal"
Rehab: An American Scandal by Shoshana Walter, Simon & Schuster 2025
This book caught my attention because Walter is an investigative reporter focused on the criminal justice and child welfare systems. As she points out, the addiction treatment industry is "under-scrutinized" given how frequently treatment is held up as the solution to substance use issues– from the personal to the population level.
I mentioned earlier that this book looked like a companion/update for Inside Rehab by Anne Fletcher (2013), and in many ways it is. However, the new book is more narratively driven, focusing on four individuals' experiences over a span of years where Fletcher drew point-in-time reflections from many more interviewees. A more important difference, for me, is that Fletcher included the subtitle "How To Get Help That Works" and offered practical advice for patients, prospective patients, and their families on how to find decent services and avoid getting ripped off. Walter has the more incisive analysis of the industry, but makes no suggestions for people navigating it. (Granted, this kind of advice is difficult! I'm currently working on a presentation on this topic for the Debt Collective Health Care Worker Solidarity group. I'll invite y'all to the public-facing event once it's scheduled.)
What The Author Gets Right
Rehab is an excellent overview of the treatment industry today, particularly in how it is shaped by criminal-legal and insurance policy as well as corruption and lax regulation. Selected highlights:
- Devaluation of patients' lives. Walter recognizes that the "scandalous" standards in substance use treatment, as well as facilities' lack of accountability for harm and even death, ultimately come down to our collective disregard for people with addictions.
- Unenforced standards even for regulated and licensed programming. Time and again, the book shows disastrous violations of health, safety, and patient care standards– and authorities who either ignored them or considered them resolved solely by a "corrective action plan." These "plans" are not enforced either. Yet another reason that credentialing is not the answer!
Rosalie Genova
- Inequity in, inequity out. Walter demonstrates how a person's outcomes after treatment reflect the same advantages and disadvantages with which they began. Even after a beneficial course of treatment, recovery and stability are much harder to sustain for someone dealing with systemic barriers like poverty, racism, housing insecurity, and criminalization.
- Drug companies are not on our side. Walter manages to argue for better access to medications like Suboxone without pretending manufacturers are in it for anything other than maximum profit. She discusses manipulations in marketing and patents around Suboxone, which followed the opioid playbook, and even around overdose antidote Narcan. Both are now owned by Invidior.
What The Author Gets Wrong
I have one beef with this book: it dismisses the contributions of 12-step members and the recovery community to treatment practice.
I fully recognize that the 12-step model is not for everyone. Its spiritual essence is a nonstarter for many people. For some who do participate, it has serious gaps that can cause harm. 12-step communities are not automatically supportive or safe for all. And again, I'm a normie who is not even eligible for membership. But Walter's one reference to 12-step influence in treatment chalks it up entirely to cost savings, citing only this article on hospitals replacing medical and mental health providers with AA members at lower pay during the 1970s. (There's that circle of chairs again!)
This summary is inaccurate and unfair. From AA's inception in the 1930s, 12-step members played a foundational role in developing modern treatment practices. Hospitals often declined to treat people with addictions at all, due to their tendency not to pay their bills, until 12-step groups started pooling funds to pay for strangers' treatment. And AA members' presence in hospitals and role in direct care was a form of peer support far ahead of its time.
William White's history of treatment and recovery, Slaying The Dragon, provides greater detail. White has his own biases, as each of us does. But to channel him further: all these prized health professionals, with their specialized training and premium pay, never showed much success in treating addiction either. In many cases, they didn't even care to try (and still don't).
It is not AA's fault that hospitals (and other treatment facilities) saw peer workers as a way to save money. 12-step principles and practices have been coopted by the treatment industry toward coercion and profit– and the same thing is happening to "harm reduction" today.
One Resonant Note
Wendy McEntyre is the only of Walter's four characters who has not experienced addiction herself. After her son died of an overdose, age 20, in a sober living facility, Wendy made it her mission to expose abuse, neglect and malpractice in the industry. She does not keep up appearances and does not mind looking crazy. (Which is absolutely appropriate! More of this, please!)
Wendy has three labels for the evidence she collects, including on "Angels," the patients who died while supposedly under care, and "Evil Doers," facility owners who are always dodging their responsibilities. The third group is "Devils or Angels:" front-line treatment staff, who may have played a role in evil-doing, and then provided evidence against their employers. Doing patient care in the addiction treatment industry has made me feel, alternately, like a transcendent force for good or a torturer in hell.
