What I Love About This Job, Part II + Fraud in Kentucky
Why work in addiction treatment, with all its systemic problems? Part I of my answer was "Five And A Half Things I Love About This Job", and this is an addendum by request. I will address retention (keeping people in the field) more specifically next time. If you're just here for the Kentucky fraud, scroll down.
What I Love About This Job, Part II
"For the addiction treatment field to sustain itself, we must find ways to develop and refine [its] core technology, to infuse that technology into the field's institutions, and to transmit that technology to new generations of workers. If it turns out that we have no such core technology, then there is no long-term rationale for the field's existence."
- William White, Slaying The Dragon: The History of Addiction Treatment and Recovery in America (2014)
William White is the one and only model I have found for what I am trying to do: writing analytically about addiction treatment from a counselor's perspective. This means bringing all the conviction, knowledge and skill of direct service to the task of greater understanding– without defending what he calls our "sick systems" or pretending treatment can do more than it actually can. White is also good at recognizing where throughout the history of this field– despite organizational dysfunction, flawed providers and peers, and terribly wrongheaded understandings of addiction– some people have nonetheless been helped in deep and lasting ways.
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This is important for me because I honestly tend to forget. I am so absorbed in what is wrong with addiction treatment, and all the ways that it fails people, that I lose sight of the fact that it ever works. A CBT therapist might point out my cognitive distortion in "magnifying/minimizing": when my clients are suffering or stagnating, it's because treatment is failing or even doing harm. But when they're thriving or progressing, it's all their own doing; treatment gets no credit. If a client tries to attribute their improvement to me, I get squirmy. Sometimes a person in my community will praise the work I do and proclaim I am changing or saving lives. And I think to myself, "If only."
So I'm currently working on acknowledging what are real successes in my clinical work. This does not mean labeling certain clients as "success stories" who live happily ever after. No one's life is that simple. Moreover, framing someone as my "success story" is just as dehumanizing and solipsistic as if I were to call them my "failure story." But I need to recognize that sometimes the care I provide actually functions as intended! I have clients doing drastically better at present than they were when we started working together. Sometimes at the end of a session they will even say, "I feel better now." I have also come to see that for some clients in serious, long-term struggles, my main role is to help them prevent things from getting worse. This is another kind of clinical success in my practice.
Professionals have been trying to care for people with addictions since at least the 18th century. But addiction treatment is still a young, inchoate concept– partly because it keeps bending to financial and state interests that supersede real care. The smartest, most dedicated providers, like William White, understand that most of our potential is as yet unrealized. I love this about my job because it means new perspectives and approaches are not just fun or interesting. They are vital. Working in addiction treatment is more like experimentation and building than picking up where someone else left off.
If you want an established career path with lots of wise elders and peers in lockstep, addictions may not be for you. If you want to rebel, innovate, and make your own way, addictions has room for all of that. We have an "Establishment," to be sure, but it's not very credible or powerful. The world is still waiting to see what addiction treatment can do. We can take that as discouragement, or as a rare and special invitation.
Meanwhile, in Kentucky:
ProPublica reports: A treatment center called Addiction Recovery Care (ARC) looks to have been manipulating state funding policies and defrauding Medicaid.
The fraud tactics have already been documented at other treatment facilities nationwide. (Here's my review of Rehab: An American Scandal, a recent example of this kind of reporting.) The more remarkable aspect of the story is how ARC changed Kentucky's treatment billing rules to enable billing for "psychoeducation" as a standalone service. This does not make sense clinically, and I am not surprised by the bad patient outcomes it brought. Psychoeducation (practical education about mental health) is an important part of treatment– but there's no quality control to it, regardless of the credentials of the staff. And even within a greater clinical service (where it typically goes, as opposed to being a service in itself), psychoeducation is way overutilized across the treatment industry because it's cheap and efficient for facilities.
Rosalie Genova
Shoutout to all the ARC staff sources for this article, who showed no loyalty to their employer. I especially appreciate group facilitator Renault Shirley, who refused to fabricate notes on a canceled session and seems not to have faced any consequences. I keep trying to impress this upon my colleagues: We have the leverage to refuse violations of our ethics and morality! What are they gonna do?
Kudos also to ProPublica for featuring people in direct service so prominently in this report. If you care about what actually happens in addiction treatment, front-line staff have the most information to share. I hope more reporting like this will amplify our voices.
