Editor's Note: This is the first in a two-part series.
If, in the early ’90s, you had a drug or drinking problem, the desire for treatment, and a good insurance policy, you could expect to spend 28 days in a place with nice surroundings and good food, learning to deal with your addiction away from the stresses and temptations of everyday life.
Today, given those same conditions, you’d be lucky to get in the door of such a facility. At best, you might get a few days of detoxification. Then you’d be shifted to some sort of outpatient treatment—which does not require an overnight stay. The people deciding the level and duration of your treatment, moreover, would not be from the facility itself. They would be from the insurance company.
The same scenario holds if you were poor enough to qualify for government assistance. Under Medicaid, you might well have gotten a few weeks in treatment. Under its replacement, TennCare, you would not fare nearly so well.
The road between these outcomes—from a treatment industry that was everything you could ask for to one that is in near-total disarray—is paved with both greed and good intentions. It winds through medicine, politics, and religion. And it ends with the industry on the morning-after side of a horrific boom/bust cycle.
This state of affairs is partly the result of a relentless chase for the insurance money that many complain now runs the industry. There has also been a lack of accountability within the treatment industry, so that no one can really tell how many people have been helped or to what extent. Then there are the turf wars and philosophical battles that have raged among psychiatrists, counselors, and treatment professionals.
If there are beacons of hope in all this, they are awfully hard to spot. Metro Councilman Leo Waters has made drug and alcohol treatment an avocation. He’s been on the board of the Alcohol and Drug Council and has lectured, visited jails and halfway houses, and made it his business to know what Nashville offers. He doesn’t like what he sees.
“We’ve got to realize that what we do as a society is woefully inadequate,” he says, “and that there is no clear-cut direction or path to go in. Obviously, you look back on the war on drugs, that terminology, that was bullshit—it just didn’t get it. We have to come to grips with the problem individually, with education and prevention and awareness and involvement, and we may have to do that before we can do it collectively.”
The bottom line leaves him shaking his head. “I think it’s a commentary on our efforts as a society,” he says, “that probably the best treatment you can get is in jail.”
It was not always so. At one time, the treatment industry was awash in cash, and while those helping alcoholics and addicts might have had differing methodologies, the free flow of insurance checks helped keep potential skirmishes to a minimum.
The modern treatment business in Middle Tennessee began, for all intents and purposes, in the fall of 1964, when the late Bob Crichton decided to try to sober up. A generous, free-spirited Nashvillian with considerable business savvy, Crichton traveled through life by the seat of his pants. While he made a small fortune in businesses ranging from insurance to trucking, his impulses sometimes got the better of him. His wife certainly figured that out early on. Not long after their honeymoon, the young couple walked into an Arizona nightclub. By the time they left, Crichton had bought the place.
Following the lead of a handful of other Nashvillians who told him of their experiences, Crichton took his alcohol problem to Minnesota’s Hazelden, a pioneering treatment center. When he left, he was convinced Nashville needed a similar place.
Crichton and Hazelden’s chief counselor, Lon Jacobson, teamed up with some Nashville businessmen and built Cumberland Heights, a 135-acre facility at Whites Bend near Ashland City. For the rest of his life, Crichton would gladly drop what he was doing to drive someone who wanted treatment to Cumberland Heights. The center has since treated 20,000 people.
Cumberland Heights did not arrive without controversy. Many local members of Alcoholics Anonymous (AA) balked at the idea of charging money for a chance at recovery. To AA members who felt that God had given them their program for free, a for-pay center was the equivalent of selling indulgences. Nevertheless, Cumberland Heights worked for many people who were simply unable to walk into an AA meeting or clubhouse and grasp the program. Its seclusion and month of treatment gave them time and space to sober up, assess the situation, get exposed to AA, and then, perhaps, to get it.
As Cumberland Heights opened, two other mainstays of recovery took hold. The Alcohol and Drug Council of Middle Tennessee—then called the Mid-Cumberland Council on Alcohol and Drugs, Inc.—was founded as an information center. It later expanded into prevention, intervention, and treatment. At about the same time, a group of businessmen founded the Friendship House in a rambling, white Spanish-style structure that quickly became known as “202” for its location at 202 23rd Ave. N. A privately owned clubhouse for AA meetings and fellowship, it became a hub for the city’s recovery community. It was a temple, a hangout, a mission, a way-station, a networking opportunity, and a hideout all in one. Judges started sending DUI offenders there. Psychology, sociology, nursing, and other classes sent students to observe.
During the 1980s, as AA membership doubled to a reported 1 million in the U.S., other clubhouses and meetinghouses sprang up: the Last Stop Club in Woodbine; the Dickson Area Fellowship of Alcoholics; the College Street Fellowship House in Lebanon; the Murfreesboro Meeting House; Serenity House in Madison; and 5612 on Charlotte Avenue. In 1984, New Life Lodge, near Dickson, opened its doors. Founded by two Cumberland Heights staffers, Moe Holleran and Harold Gilliland, the facility hoped to capitalize on Cumberland Heights’ huge waiting list while concentrating more on the philosophy of AA. Cumberland Heights, they felt, had introduced extraneous matters when it performed psychological evaluations and hired recreation directors and dietitians.
As these and other facilities took hold, employers were eager to include treatment in their insurance plans. After all, many found that some of their key employees had drinking and drug problems. By the late ’70s, they were asking insurers for help.
Recognizing the opportunity, insurance companies logged on. Generally, they let the treatment facilities determine the level of care, which was fairly standard: Most abusers were given a month of treatment, whether they’d drunk for decades or only had a few wild weekends. Halfway houses sometimes stretched the stay to six months.
Soon, the money spigot was wide open, fueling terrific growth in the industry. Nearly any hospital with a spare bed could open its own in-house treatment center. While treatment at many places in Middle Tennessee cost anywhere from $3,000 to $9,000, well-known facilities, particularly those that offered psychiatric services as well, could charge nearly $20,000 for a 30-day stay.
The major shift in treatment center operation came with managed care in the early ’90s. Managed care is the opposite of “fee for service,” where an insurer will pay for treatment you decide on. It tries to limit care to what is essential while holding down costs. Increased competition among insurers operating under managed care led them to begin holding the treatment industry’s feet to the fire. In particular, they wanted treatment centers to prove they were successful.
Unfortunately, they couldn’t. Many centers claimed impressive recovery rates, but the figures were often sketchy. Studies tracking sobriety rates were notoriously sloppy. Alcoholics and addicts have been known to lie, and some statistics suggested that many people quickly fell back into abuse. Aftercare meetings, where patients met weekly to reinforce what they had learned in the treatment center, were lucky to see 15 percent of patients a year after treatment.
“We made guesstimates of how many were clean and sober, and there was not a lot of long-term follow-up,” says Frances Clark, who once ran an outpatient treatment facility. “Now we’re being held accountable and having to do follow-up studies and show outcomes.”
Recent studies seem to suggest strongly that the longer the treatment, the better the recovery, but there is still nothing like consensus on what works and what society can afford.
In any case, by 1994, the gravy train had all but stopped. The insurance companies simply quit paying for extensive treatment. “When I first came here in 1990,” says Vicki Neal, clinical director of Pathfinders, whose inpatient and outpatient treatment facilities are headquartered in Gallatin, “we could really do treatment, and not just put out fires. We could keep them 28 days, then get them into aftercare and AA meetings, and maybe send them to halfway houses. Now if we had somebody 28 days we’d probably pay them a salary. We do as much as we can while they’re here.”
Firms like American Airlines, which had long sent many employees with addiction problems to Cumberland Heights, reduced the length of stay from 28 days to as few as three. “What happened,” says Joe Morgan, who was part of the management team at Cumberland Heights in the early to mid-’90s, “is the insurance companies wised up and the pendulum swung the other way. And now, in my opinion, they run the damn treatment centers.”
To some degree, that’s true.
Pathfinders, for instance, started outpatient programs because, Neal says, “insurance was pushing for it.” At Cumberland Heights, outpatient programs were developed “to please and to appease the insurance companies,” according to Janine Clayton, the center’s point person in dealing with insurers. Even so, she says, the insurance companies have now tightened up on the outpatient treatment.
When a sweating, shaking applicant walks through the doors of Cumberland Heights, the intake people often argue with insurance company representatives over the appropriate level of treatment. The insurance companies, of course, have the hammer. In most cases now, intake people know what level of reimbursement to expect. If they’re certain an applicant won’t qualify for treatment, they simply recommend an individual counselor, or AA or NA (Narcotics Anonymous) meetings.
That, says Kevin Duvall, senior vice-president of New Life Lodge, is simply not enough. “If treatment was just about AA and the Big Book [AA’s basic text],” he says, “you wouldn’t need a treatment program.... It’s not just about stopping drinking.”
Tennesseans with insurance at least had some options. They and their employers could shop in an open marketplace for coverage. The state’s uninsured and uninsurable drug and alcohol abusers, on the other hand, took what was available, which often meant relying on a governmental entity. And while many argue that drug and alcohol prevention among the state’s poorer citizens would cure a host of society’s ills, there is little political will to move on that front. In Nashville, Mayor Phil Bredesen has stepped more than once into the treatment game, only to find himself buffeted by whirlwinds. His first attempt at a comprehensive approach to drug and alcohol addiction ended when the man he brought in to head an Office of Drug Policy checked himself into treatment 10 months into the job. Bredesen simply let the office drop from the budget.
More recently, Bredesen appointed a blue-ribbon Crack Cocaine Task Force. That didn’t go any better. Jim Boyd, a member of the state board for the Department of Corrections, calls it “an absolute joke—I can’t say enough bad things about it.
“These were good people—excellent people—that he picked,” he continues, “but none of them has ever been on the streets. How do you take people from the right side of the tracks and impose what they believe on people across the tracks when they’ve never been there?”
The mayor says while he thought the committee did excellent work within the parameters they were given, he saw no consensus regarding either the cost or the effectiveness of treatment for addicts.
Bredesen may also simply have different priorities. “If someone commits an assault, my first thought is for the person who has been beaten up, not about anger management classes for the assaulter,” he says. “That attitude flows through my whole view of this issue.”
Many hold that helping criminal addicts does indeed help potential victims and society as a whole. At the core of a host of issues involving crime, education, health care, and social services are alcohol and drug problems. A Metro grand jury last year estimated that 80-85 percent of the crimes presented to it “were related to the use and sale of illegal drugs—particularly crack cocaine.”
“If we don’t deal with addiction problems,” says Waters, “we can spend millions in those other areas and we’re just spinning our wheels.” Yet the question is how much anyone—government, in particular—can do.
Bredesen is not alone in his skepticism. Morgan, who has been intimately involved in three local treatment centers, says, “Anybody who tells you their recovery rate is higher than 40 percent is lying.” Given today’s quick-hit methods, much lower rates are often bandied about. The efficacy of putting money into treatment does not enjoy the same kind of factual basis that, for instance, either funding inoculation, which society generally supports, or funding prenatal care, which it generally does not, enjoy.
“I’ve found there are a lot of people who have had programs who make great claims for those programs,” says Bredesen. “I’ve found very little independent corroboration from somebody who doesn’t have an interest in the thing that in fact they are useful or cost-effective. The anecdotal evidence is awful, in the sense that for every person somebody knows who’s been cured of a cocaine addiction I swear there are 10 of them who, despite heroic efforts, continue to persist with the addiction.”
Part of today’s problem may be that the people coming forward are sicker. Crack addicts, for example, may only have a success rate of 5 or 10 percent after serious treatment, let alone outpatient treatment.
“If a crack addict goes back to a crack house at night,” says Harold Montgomery, executive director of the Jackson Area Council on Alcoholism and Drug Dependency, “there’s not a chance in 10 million they’re not going to relapse on a daily basis.”
In other words, some treatment may simply not be worth the cost. Says Hershell Warren, executive director of the Lloyd C. Elam Community Mental Health Center of Meharry Medical College: “Those individuals probably need a more intense, different level of care than we are able to provide.”
On the streets, one of the city’s better-known treatment centers is, actually, the Nashville Union Rescue Mission. The Rev. Carl Resener, who recently became its president emeritus, has seen more addicts and alcoholics pass through his doors than any treatment center in the city. Resener holds out for a straight Christian salvation through Jesus Christ. “Our mission has always used a biblical approach in treating drug and alcohol recovery,” he says.
Nashville suffers from a shortage of detox facilities for its uninsured, homeless or not. Because of this, a handful of AA members are currently helping to sober up drunks in homes and motels. Such action, which was common in the early days of AA, is rare now. “It used to be when you got a call you’d say, ‘I’ll come right over,’ ” says Morgan. “Now it’s, ‘What kind of insurance have you got?’ ”
For the homeless, there is always the Guest House, part of the downtown Campus for Human Development, a collection of services funded by city and private agencies for the homeless. Men can take 72 hours to sober up and get some food in them, and can then be assessed through the Downtown Clinic, part of the Metro Health Department. Those who seek inpatient treatment can be sent to the Samaritan Center or another treatment center, often through the Alcohol and Drug Council. Other facilities include Renewal House, a residential community for mothers seeking to overcome addiction, and Base Camp, which provides a variety of services for homeless veterans.
If there is one place where society gets an alcohol or drug abuser’s undivided attention, it is in jail. And there are several bright spots here in Nashville.
One is Corrections Corporation of America’s alcohol and drug program. “Anyone who wants to see an effective A&D program needs to visit CCA’s LifeLine unit,” says Waters. Even here, though, good intentions must be tempered with reality.
“CCA has a pretty impressive program,” says Jim Boyd, who has much experience in working with alcoholics and addicts in prisons, “but in one sense it’s like a revival—it’s fantastic when they do it, but it can be short-lived when they get out of jail. Still, it’s better than most anything else going.”
Another program inspired by CCA’s venture is Judge Seth Norman’s drug court, which has received good reviews on many fronts. It is aimed at nonviolent felony offenders, and includes both inpatient treatment in its own facilities, and outpatient treatment. “We keep them isolated for the first 90 days or so and really find out the issues we’re dealing with,” says the program’s Tom O’Brien. “They’re in therapy every day, they go to work every day, we collect payment so they pay their child support and retribution, we get them connected with outside 12-step groups...and we have zero tolerance for unacceptable behavior.”
Elsewhere, the Sheriff’s New Avenues Program is drawing high marks. It is a state-licensed drug and alcohol program that has turned out 1,600 graduates and, like the CCA program, is used as a model for other jail-based programs.
Bredesen says he is supportive of both Judge Norman’s and Sheriff Gayle Ray’s programs, but adds, “I have never seen the evidence to be moved to say, ‘Let’s turn the world upside down here and put multi-millions of dollars behind this program because it’s going to dramatically reduce crime in the community.’ When you look at cities that have actually cut crime, it’s been through other things, not through drug treatment programs.”
If political leaders have questions about the number of addicts who can be cured by treatment, they are not alone. The people who are doing the treating disagree enormously about what works best.
Early efforts at treatment—from Hazelden and Cumberland Heights to similar facilities across the country—relied heavily on AA’s steps, principles, and spiritual approach, making the organization the 600-pound gorilla in the treatment industry. Its 12 steps involve admitting defeat, finding and surrendering to a self-defined higher power, conducting a moral inventory, and discussing the results with another person. They also involve making amends for harm done to others, and carrying the message to other alcoholics.
As treatment centers absorbed the tenets of AA, they adopted a method that was widely copied and came to be known as the “Minnesota Model,” after the location of its early development. It consisted of the 28- or 30-day stay, counseling by recovering alcoholics, educational lectures, individual and group therapy, family counseling, and a healthy dose of AA. Such facilities also taught that recovery lay in lifelong attendance at AA meetings.
For legions of alcoholics, AA, which currently claims 80,000 groups and 2 million members worldwide, has been all or part of the answer. Anyone can walk into an AA meeting and find somebody willing to help. It has several advantages. Like its counterparts, Narcotics Anonymous and Cocaine Anonymous, it offers free, unlimited support and the potential for genuine friendships with people who share a common problem and solution. In the long run, it offers a spiritual anchor and a continuous way of life. Most counselors, whatever their approach, agree that AA is an invaluable resource, and many cite it as what Kevin Duvall called “the best support system out there in recovery.”
As treatment centers proliferated, however, they oftentimes came under the guiding hands of mental health professionals who brought a much broader interpretation of addiction into play. To them, addiction was a complex mix of behavioral, psychological, and physiological processes, and treatment was an individualized blend of elements designed to address all of them. While AA viewed addiction as an illness, others saw it as a modifiable habit.
The no-frills embrace of the straight-ahead AA message and the more complicated behavioral model with its own therapeutic methods are on either side of a gaping chasm in treatment. To the AA adherent, the other side is guilty of New Age psychobabble. To the behaviorists, the AA exponents are often rigid, legalistic, and simplistic.
The founders of AA expressed in the Big Book the desire to work with the psychiatric profession, but there has long been some antipathy between the two groups. One reason AA worked, old-timers maintain, is that there was no professional class. While many psychiatrists, doctors, ministers, and others came to AA to sober up, when it came to the program, they were on equal footing with truck drivers and dishwashers.
Counseling, on the other hand, takes in a variety of shifting elements, which gives it flexibility but leaves it open to some AA members’ charges that it can embrace the ephemeral, the questionable, and the downright loony. Still, many AA members were referred to AA through treatment and counseling programs.
Psychiatry, say its proponents, can take the best of both methods and add even more elements.
“Addiction is a psychiatric illness,” says Dr. Peter Martin, an addiction psychiatrist and director of the Vanderbilt Addiction Center (VAC), “and the psychiatric model takes into consideration the biological, the psychological, and the social.” The method he follows at VITA, the VAC’s inpatient and outpatient treatment program, is one of individualized treatment involving a combination of psychiatry, counseling, medication, and the Steps’ spiritual approach.
“The people that go into AA,” he says, “are the people who say, ‘I know I’m an alcoholic and I need help.’ There’s a standard way of treating them, and it works pretty well—the Hazelden model. But to treat most of the other people who have drug-abuse problems, a different approach is needed. AA is an important part of that approach. I think that’s a very helpful thing. But alone it’s not sufficient.
“AA is very good for the people it is very good for, and the rest have to go elsewhere. ‘You’re not working your program hard enough,’ they’ll say. ‘That’s why you’re relapsing.’ It’s much more complex,” Martin says, citing the legions of drug and alcohol abusers with other mental and psychological difficulties. “If a person is, for instance, severely depressed, no amount of AA, by itself, is going to help.”
On the other hand, Joe Morgan contends that the psychiatric and counseling models can interfere as much as they help.
“In my opinion,” he says, “the recovery is in that Big Book and in the Twelve and Twelve [another key AA textbook]. That’s spiritual recovery. True, a lot of us have got mental and physical problems, but my contention is first get them to accept the spiritual program. Now, if they’ve got a mental problem, take them to a psychiatrist, but at least they’re going to be sober when they go there.”
Psychiatrists, he contends, have been key players in forcing many treatment centers to hire social workers and degreed counselors, driving up prices and forcing many centers out of business. “I really believe that they can’t understand how a truck driver and an insurance salesman can carry a message that can save somebody’s life,” Morgan says.
The argument has many offshoots, since there are many combinations of approaches in treatment. Which side is ascendant may depend on whom you talk to.
According to Dr. Robert Stuckey, who has developed both psychiatric and addiction centers, and was chairman of the Treatment Committee for the Trustees of Alcoholics Anonymous, the influence of 12-step programs increased nationally until 1990. Then, he maintains, “the power...shifted back to the psychiatric field” through their control of the Joint Commission of Accrediting Hospitals Organization, which performs a widely recognized accreditation review for treatment centers and hospitals. The JCAHO, he contends, supported by state health departments, “forced counselors to treat symptoms rather than teach a new lifestyle.”
John Mulloy, former longtime head of the Alcohol and Drug Council and a major presence in the local recovery community, is convinced that when mental health and psychiatric centers stepped into treatment, there was a shift away from AA’s 12 steps, and treatment centers “lost their bedrock foundation.”
If one of the fundamental tenets of treatment is that individuals must make a firm decision to stay sober, there are many who see some sort of community action as essential.
Kaki Friskics-Warren, who works with addicted mothers at Nashville’s Renewal House, says, “One of the things people say is, ‘If you want it badly enough, it’s out there.’ But these mothers may not have child care or a car to get to a meeting.”
“What we know for sure,” says Mark Brakebill, executive director of the Turning Point Recovery Residence, “is that without an alcohol- and drug-free living environment, early recovery is next to impossible.”
For those whose alcohol or drug use is severe, “I think inpatient treatment is absolutely the answer,” says Holleran. “I think there are executive-type people who can go in as outpatients and make a go of it, people who haven’t gone into that final, chronic stage of alcoholism, who still have some stability in their family and health and financial life.... But for those who can’t, given the nature of today’s insurance industry, there’s no way to take them anymore.”
Treatment is certainly not a high priority right now. “I think most people share the view that nobody wants to be uncharitable or un-Christian,” says Bredesen, “but this is one of those things that to get there you had to have done some things you shouldn’t have done, and therefore help is more a matter of charity than obligation. I guess I would put it that way.”
But part of the problem is that the standardized way of judging problems and solutions, by quantitative analysis, may simply not work with regard to drug and alcohol addiction.
“People who look for outcome and productivity measures aren’t wrong, but there are other measures,” says director of Metro Social Services Michael Miller. “Treatment ought not be measured just in terms of a long-term cure.... There are some compassionate measures [involving] quality of life. It’s a meaningful thing if you can bring somebody out for a year and that’s the year they bury somebody or are reconciled with somebody. Of course, compassion is pretty expensive, and you don’t want to think you have to buy compassion on the market or that the government has to provide it. I want to think there are families who could provide compassion, but substance abuse alienates most people who could.”
Or, as Leo Waters states, “There’s some people you can help, and some people you can’t, and I don’t know what distinguishes them, and I don’t know that I ever will. But that doesn’t mean I stop trying to help. When we’re talking about government we’re talking about the will or sense of the society moving. I still think that we are naive as to the pervasiveness and destructiveness of this disease. Even though we see and hear so many times about alcohol and drugs being involved in crime and tragedy and accidents and poverty, I still don’t think it’s registered. There is a sense of denial, and an unwillingness to come to grips with those secrets and those fears that we have. It’s an individual as well as a societal problem, and you’ve got to deal with it on both levels.”
Most people involved with any aspect of the treatment industry can point proudly to profoundly moving recoveries, to people brought back by treatment from the gates of insanity and death. They can also talk of people with many chances who died brutal, ugly, wasteful deaths because they couldn’t or wouldn’t take advantage of the help they were offered. It is an industry that touches the most holy and most profane places people can know, a profession dealing with people who soar and who wallow.
There is resistance to spending taxpayers’ money to treat criminals for drug and alcohol dependency. There is resistance to spending stockholders’ money for excessive treatment in the private sector. There is plenty of anecdotal evidence to suggest some of that resistance may be short-sighted, but there is little compelling, hard evidence to back that up—at least not enough to convince many legislators or insurance company personnel.
One person who juggles the hard realities of the situation is Frances Clark.
“I think we need treatment for people who can’t afford it,” she says, “and the only way we’re going to get it is through state and federal funding.” Still, she says, “At some point you have to cut the revolving door off. If we let them come in over and over, we’re enabling them. And I think even if they pay only a dollar a session, they should have to pay for their own treatment—to take responsibility.”
“This problem calls for tough love,” says Waters, “and we don’t do tough love well.”
Editor’s Note: Next week’s story will deal with TennCare Partners, the state program that targets, among other things, substance abuse.
Rob Simbeck, a recovering alcoholic, has had personal dealings with some of the people and entities in this story.
