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“addiction treatment”

Day of the Asylum

Asylum William Seabrook.jpgThe topic of addiction recovery is illuminated by the stories of individuals and families, but there is a larger story that can be recounted in the classic three-part story style of recovery:  "what we used to be like, what happened, and what we are like now." That larger story sets the context for those more personal stories via the evolution of cultural responses to severe alcohol and other drug problems. Today's blog recalls one dark and prolonged chapter within this larger story.

If there is a dividing line in the modern history of U.S. responses to alcohol and other drug addictions, that line could well be drawn in 1970--the year landmark legislation was passed that laid the foundation for a national network of addiction treatment resources. Like the personal turning points found in so many recovery stories, what became popularly known as the "Hughes Act" cleaved the history of addiction treatment in America into the categories of before and after.  I am part of a fading generation of addiction professionals whose lives extend into the before era.  No discussion of specialized addiction and other recovery support resources is complete without reference to the time when such resources did not exist in most communities.

When 19th century addiction treatment institutions and recovery mutual aid groups collapsed in the early years of the 20th century, people with severe alcohol and other drug addictions were sequestered in four alternative institutions: the private "drying out" sanitarium, the inebriate penal colony, the "foul cells" of the public hospital, and the "back wards" of aging state psychiatric asylums. The role of the latter in the treatment--public control--of addiction extended from the late 19th century through the first half of the 20th century, and was memorialized in Ken Kesey's One Flew over the Cuckoo's Nest

I entered the addictions field in the 1960s in Illinois during the heydays of the movement to deinstitutionalize the treatment of mental illness in America.  Two of my earliest tasks were to help transition persons with histories of addiction from the states' psychiatric hospitals into the community and to help build systems of community care that could prevent such hospitalization and the frequent re-hospitalizations that often followed.  Part of that responsibility involved screening patients for potential community reentry from more than 20 of the state's psychiatric hospitals.  Most of these facilities were first opened between 1847 and 1925 and were scattered across Illinois in cities with institutions bearing their names, e.g., Alton, Anna, Chester, Chicago, Elgin, Galesburg, Jacksonville, Kankakee, Manteno, Peoria, and Tinley Park.  Here are my recollections of my visits to these facilities in the last days of the asylum era. 

Kankakee State Hospital.jpgInstitutions founded by reformers as places of sanctuary and healing had devolved into institution of isolation, control, and maltreatment.  Building complexes grown so large they existed as small cities filled with thousands upon thousands of longtime residents disconnected from family and community.  Once majestic buildings fallen into disrepair.  Big jangling key rings hanging from the sides of muscled orderlies who controlled entrance to and egress from locked wards.   Shadowed hallways so long they felt like highways.   People in large numbers in the "day area" sitting silently, endlessly rocking, or pacing.  "Alcoholic wards" filled with the wreaking pungency of paraldehyde, sweat, urine, and disinfectant. "Hydrotherapy" tubs and sweat-stained straightjackets.  Graffiti-decorated detox and seclusion cells.  A distinct patois used by staff that mimicked the voice adults use to speak to small children or old people.  A pervasive sense of despair and resignation that permeated the postures and communications of both patients and staff.  A special contempt for "hard core" alcoholic patients ("chronics"/"retreads"), whose perceived malingering demanded attention that was thought far more deserving by those who were "truly sick."  Heartbreaking stories not just of addiction and its devastating consequences, but of ill-chosen and ill-executed treatments gone horribly wrong: stories of hundreds of "shock treatments," stories of "discharge contingent upon surgical sterilization," stories of massive doses of psychotropic medications evident in stoned appearances and staggering gaits, stories of prefrontal lobotomies, stories of years of institutionalization after being branded "incurable," and stories of physical and sexual abuse experienced at the hands of staff and other patients.  Addicted patients also exploited via "work therapy" because of their skills and high level of functioning once detoxified.  Patients pleading desperately for help in getting out. 

That some people actually began their recoveries in such an environment is testimony to their resilience and the care of those staff who sought to make human what had morphed into a most inhuman environment. The day of the asylum ended in the wake of new ideas and new treatment methods that would later also come under attack, but the passing of that earlier era marks the birth of modern addiction treatment.  No matter what flaws exist in the present system of care for addiction, and those flaws are numerous, we must not forget what it was like in a world in which that system of care did not exist. To those who closed the asylum chapter and opened a new era of community-based treatment, we--as a country, as a profession, and as a community of recovering people--owe you a great deal. 


Addiction Treatment (By Itself) is Not Enough

Treatment is Not Enough.jpgI have spent more than four decades providing, studying, promoting, and defending addiction treatment, but remain acutely aware of its limitations.  As currently conceived and delivered, most addiction treatment programs facilitate detoxification, recovery initiation, and early recovery stabilization more effectively and more safely than ever achieved in history, but most fall woefully short in supporting the transition to recovery maintenance and the later stages of recovery, particularly for those who need it the most--those with the most severe and complex problems and the least recovery support within their natural environment. 

Addiction treatment as a stand-alone intervention is an inadequate strategy for achieving long-term recovery for individuals and families characterized by high problem severity, complexity, and chronicity and low recovery capital.  In isolation, addiction treatment is equally inadequate as a national strategy to lower the social costs of alcohol and other drug-related problems.  Here's why.

Specialized addiction treatment as a system of care in the U.S.:

1) attracts too few--only about 10% a year of people in need of it and only a lifetime engagement rate of 25%,

2) begins too late--with years and, in some studies, decades of dependence preceding first treatment admission,

3) retains too few (less than 50% national treatment completion rate),

4) extrudes too many (7.3% of all annual admissions--more than 130,000 individuals--administratively discharged, most for confirming their diagnosis),

5) ends too quickly, e.g., before the 90 days across levels of care recommended by the National Institute on Drug Abuse,

6) offers too few evidence-based choices,

7) fails to engage and support affected family members and friends,

8) is too disconnected from indigenous recovery community resources,

9) offers minimal continuing care--far short of the five-year point of recovery durability, and

10) fails to alter treatment methods in response to patient non-responsiveness, e.g., blaming substance use disorder recurrence on the patient rather than the treatment methods. (Click here for elaborations and citations related to the above points.) 

As a result, we as a country invest billions of dollars in repeated episodes of addiction treatment (59% of people admitted to addiction treatment in the U.S. have at least one prior treatment episode, and 34% have 2 or more prior treatment episodes).  We are providing respites within addiction careers for far too many but sustainable recovery for far too few. The current acute care model of intervention could be significantly improved by re-engineering addiction treatment to provide early screening and intervention and long-term care (sustained monitoring, support, early re-intervention), as is increasingly done with other chronic conditions whose acuity waxes and wanes. As a country, we have invested inordinate attention on person-focused interventions (clinical models) to the exclusion of interventions focused on shaping recovery landscapes (public health and community development models). 

Professionally-directed addiction treatment should not be the first resort for AOD-related problems; it should be the last resort--a safety net to protect individuals, families, and communities.  The first line of response should be support imbedded within relationships that are natural, reciprocal (non-hierarchical), non-professionalized, non-commercialized, and potentially enduring.  Such relationships are to be found, not within a treatment center, but within the larger community environment.  However, significant effort is required to build and sustain such natural resources. 

It is time we nested clinical models of care within larger efforts to develop, mobilize, and sustain sources of support for resilience and recovery within the larger community.  Grassroots recovery community organizations and new recovery support institutions offer vehicles for long-term recovery support that bridge the clinic and the community.  The clinic can bolster the will to recover and the means to recover, but it is the community that must provide the welcoming space in which one can live as a person in long-term recovery.  It is time we balanced recovery support within the clinic with recovery support within the community.  The good news is that such a balancing is underway as state after state and community after community wraps acute care models of intervention within larger models of sustained recovery management nested within recovery-oriented systems of care--with the "system" being the community rather than just netowrked treatment resources.  This shift marks a revolution in the design and delivery of addiction treatment in the United States.  What in its isolation addiction treatment has failed to achieve may well be achieved within newly emerging partnerships with the community.   




Volunteerism and Addiction Treatment

Volunteerism.jpgA 1976 national survey of addiction treatment programs in the United States revealed a workforce of nearly 60,000 workers.  The treatment workforce at that time consisted of 31,000 full-time workers and 15,000 part-time paid workers.  The paid professional workforce included 20,000 counselors, 5,000 nurses, 3,000 social workers, 2,500 psychologists, and a small and slowly growing cadre of physicians.  But what is most striking to me in this survey is the reported presence of more than 1,000 full-time volunteers and 13,000 part-time volunteers. As volunteers disappeared from the addiction treatment milieu during the 1980s and 1990s, the story of their role in early addiction treatment and what they meant to people seeking recovery also disappeared. 

What that story would reveal if it were fully told would be six striking facts.  First, volunteers made up a significant portion (nearly a quarter) of the addiction treatment workforce of the early 1970s.  Second, many early programs, because of the limited financial funding of that period, could not have functioned without those volunteers.  Third, nearly all of those volunteers were individuals and family members in recovery, including former patients and their families treated within these facilities.  Fourth, those volunteers, along with the high percentage of persons in recovery among the paid staff, brought a level of recovery representation in the addiction treatment milieu that had never existed before nor has existed since.  Fifth, this recovery-infused milieu provided powerful testimony--living proof--of the potential for long-term personal and family recovery.  Recovery volunteers infected the treatment environment with faces and voices of recovery that exerted an unmeasured but contagious effect on recovery outcomes, above and beyond the treatment philosophies and techniques of these programs. And it provided human connections to processes of mutual identification that led many people into the rooms of mutual aid fellowships that would support their recoveries long after memories of their treatment had faded.  Finally, capitalizing on the "helper principle," such volunteerism bolstered the recovery of the volunteers as much as it stirred the recovery germ within those being treated.     

So what happened to this army of volunteers?  Sadly, the vibrant volunteer programs of the 1970s faded in the wake of the field's growing professionalization and commercialization and the growing disconnection between addiction treatment "businesses" and the grassroots communities that had birthed them.  Now, this is not one of those delusional laments of an aging addiction professional about the lost "good old days":  there was much in the days of early addiction treatment that were unequivocally not good.  But it is a brief reminder that there may have been some precious things lost on the road to professionalization of addiction treatment. One of those lost gems was what can happen to a person equally ambivalent about continued addiction and the prospects of living life without their pet poison when he or she encounters a virtual army of people willing to share their experience, strength, and hope and to do so without one penny of financial composition.        

Now in 2014, as treatment programs seek to increase their recovery orientation and rebuild lost connections to the communities they serve, proposals for the creation of volunteer programs are again afoot.  History does have a way of repeating herself and perhaps this time, we will recapture those lost lessons about the power of volunteer service.

Survey results were reported in:  Dendy, R.F. (1979).  Developments in training. In DuPont, R.L., Goldstein, A. & O'Donnell, J.  Handbook on Drug Abuse. Washington, D.C.:  National Institute on Drug Abuse, pp. 415-421.


Brain Surgery as Addiction Treatment?


In 1935--the founding year of Alcoholics Anonymous, Portuguese neurologist Egas Moniz introduced a surgical procedure into psychiatry that came to be known as the prefrontal lobotomy (recall One Flew Over the Cuckoo's Nest).   Drs. Walter Freeman and James Watts pioneered the use of this technique in the United States in 1936.  By 1960, 100,000 psychosurgery procedures had been performed in the U.S.  Patients targeted for this procedure included those judged to have "compulsive hedonias"--alcoholism, drug addiction, excessive eating and sexual deviations.   The prefrontal lobotomy procedure severed the connecting nerves between the thalamus and the prefrontal and frontal lobes of the brain.  Its intent was to induce significant changes in thinking and personality that could alter the course of intractable psychiatric illness. 

The total number of people with substance use disorders who underwent this procedure is unknown.  One could assume that the prefrontal lobotomy is one more chapter of "harm in the name of help" long ago cast into the dustbin of addiction treatment history in the U.S., but when exactly did use of this procedure stop?  The following story suggests it may have gone on much longer than once thought.


My first drinking experience was when I was five but drinking did not cause a lot of problems for me until after I got married and went on birth control pills. I've learned since that they can affect alcohol tolerance, but I certainly wasn't aware of it at that time. I continued drinking and, because I was also quite frugal, I ended up drinking spirits of peppermint mixed with rubbing alcohol.  This turned out to be a near-lethal concoction that I did to get what I needed out of the alcohol as my alcohol tolerance increased. So, in my early twenties, I ended up in a hospital on March 7, 1971, with alcohol poisoning.  I had passed out several times before this, but my doctors never asked anything about my drinking and, in fact, had diagnosed me with "somnambulism" (falling asleep at unusual times) and had prescribed Ritalin for it with other medications to help me sleep when I needed to.  While on these, I ended up in the hospital with alcohol poisoning because I had passed out at the supermarket where I had gone to buy more spirits of peppermint and rubbing alcohol.

After a day or two in the hospital, the head psychiatrist, a very prominent psychiatrist at a very prominent hospital, asked for a meeting with me and my family.  He said it was obvious to him that I had a serious alcohol problem and that there were very few options for people with this kind of problem.  He presented two potential solutions.  I could spend a minimum of one year in treatment at the Norristown State Hospital--a  state psychiatric asylum, or I could save myself and my family a lot of difficulty and undergo a surgical procedure on my brain that would take away any compulsion I had to drink.  He recommended the surgical procedure because he thought it would be more effective and that it could be scheduled far quicker than admission to the state hospital where waiting lists often delayed admission. 

My parents and my husband were a bit taken back with all of this, and my sister began researching these options.  In the meantime, my minister saw my name on the hospital roster and why I was there--this was before HIPAA.  There had been a recovery support meeting at our church that he used to visit and he asked one of the women from this group to come with him to visit me.  She just came in and told me what her problem had been and what she had done about it. I had really tried to control my drinking myself but I had never been to any kind of support meeting.  After hearing of the options I had been presented, she said, "Well, I can't tell you what to do, but here's what I did and here's what worked for me and I've now had a wonderful life." She told me her recovery story, so that's what I chose to do, much to the chagrin of the psychiatrist.  She became my sponsor and the rest, as they say, is history. 

It wasn't until much later that I realized that the surgery that was proposed to me was a prefrontal lobotomy.  When I first shared this part of my story publically, a family came up to me afterwards and told me that this very situation had happened with the mother in this family. I can still remember the daughter saying of her mother, "I really never saw my mother smile or be happy after the day of her surgery." I now know how fortunate I was not to have had that surgery. (From 2014 Interview with Beverly Haberle)

Bev Haberle Speaking at Philadelphia Recovery Walk 2013.jpgThe woman at the center of this close call is none other than Beverly Haberle (left, speaking at the 2013 Philadelphia Recovery Walk), who went on to live a life of sustained recovery and service and to become one of the most effective administrators and recovery advocates in the U.S. Following her escape from psychosurgery, she volunteered for a church task force creating an addiction treatment resource guide.  Through that project, she was introduced to the work of the Bucks County Council on Alcoholism, began volunteering there and went on to become the Volunteer Coordinator, the Program Director and then the Executive Director.  The Bucks County Council grew under her leadership and subsequently changed its name to The Council of Southeast Pennsylvania, which includes the City of Philadelphia and the four surrounding counties.  Beverly Haberle sits on numerous state and local boards, is the Project Director of PRO-ACT and is a member of the Board of Directors of Faces and Voices of Recovery.  This wife, mother and grandmother received the 2013 Ford Hansel Lifetime Achievement Award.

It gives one pause to wonder how Beverly Haberle's life would have been different if she had not heard the experience, strength and hope of another woman in recovery and if she and her family had instead chosen that proffered "surgical solution" back in 1971.  One also wonders of the stories of those nameless individuals whose families did choose that solution.   


A Grieving Parent on Parity

Bill Williams and Son WilliamParents who have lost children to addiction are speaking publicly in unprecedented numbers.  Their stories provide a biting critique of addiction treatment as a system of care--and suggestions that addiction treatment has yet to operate as a "system of care".  They also provide painful accounts of how fiscal gatekeepers operate to restrict access to care and prevent continuity of care at times that such access and continuity are most critical.  On April 4, 2014, Bill Williams testified before the Bi-partisan Congressional Alcohol, Treatment and Recovery Caucus co-chaired by Representative Tim Ryan (D-Ohio) and Representative John Fleming (R-Louisiana). Bill shared the experiences he and his wife Margot encountered in their unrelenting efforts to get needed help for their son, William.  Bill's eloquent testimony is offered here without further commentary.            


Bill Williams

In early December of 2012 our son, William, entered Columbia University's College of Physicians and Surgeons at the age of 24.  His arrival there was off the beaten track, beginning with visits to a psychotherapist. Over the next two years stops on the way included an addiction psychiatrist, out-patient treatment, treatment with Suboxone, in-patient detox, in-patient treatment, out-patient treatment, out-patient detox, treatment with Vivitrol, more out-patient treatment, another in-patient treatment, more out-patient treatment, a revolving door of well over a dozen trips to and from the emergency rooms of at least four different hospitals, an attempt to work with another addiction psychiatrist, Alcoholics Anonymous, Narcotics Anonymous, and a home life fraught with tension and despair, sometimes hopeful during intermittent periods of sobriety, and always filled with the apprehension of misfortune.

His credentials for Columbia were unorthodox, "acute and chronic substance abuse," which caused "complications of acute heroin intoxication".  William was admitted, not as a medical student, but as an anatomical donation. A cadaver.  His credentials came from his death certificate, not any academic transcript.  

As a result of his acute intoxication, when his heart stopped beating for too long, when he was hospitalized for six weeks until it became clear that William had withered to a vegetative state, we made the decision to remove him from life support and have him become an organ donor.  Organ donation for someone in a vegetative state requires an expedient demise.  William did not expire within the necessary one-hour time frame, though his mother, sister and I were with him in the operating room, telling him he could let go.  Rather, he lasted another 21 hours before drawing his last breath in our arms.

Determined that his death not be in vain, his mother, sister and I made the following pledge:  "We promise to do everything in our power to educate and inform people about drug abuse and its prevention, to provide ever more enlightened treatment for addicts, to help make treatment options for addicts more readily available, and to remove the stain of shame surrounding this disease."  A very first step to honor that pledge was the anatomical donation of William's body.  We continue to honor that pledge by appearing before you today.

Shortly after we were invited to appear at this briefing, we received another invitation.  William's contribution at Columbia has reached an end.  This coming Wednesday his family, including his seven week old niece who will only know him by story and photographs, has been invited to a ceremony at Columbia honoring those whose bodies helped train and educate this year's class of medical students.  We will meet and hear from these medical students, their professors and other families who have donated kin.  We will have an opportunity to speak to them.  What we say to them will differ little from what we say to you today, which is to say that ignorance about substance use disorder remains the order of the day. It is the plague of our time.  Anything we say that is repetition bears repetition until it manifests itself as policy change and practice of substance and consequence.

Parity is about more than receiving equal health care insurance for substance use disorder and mental health issues.

  • Parity means an individual can say, "I have a substance use disorder," without discrimination, judgment or censure.  Parity is when family members can stand beside the afflicted and say, "...and we are all getting counseling and support to aid in our loved one's recovery."
  • Parity means that substance use disorder is recognized by laymen and professionals alike as a brain disease.
  • Parity means that funding for research for substance use disorder is on the same level as that for heart disease, cancer, or diabetes.
  • Parity means that people with substance abuse disorder are treated with the same compassion and understanding, treated with the same urgency, accorded the same dignity, as any other patient with any other medical or surgical need. 
  • Parity is when physicians, not health insurers practice addiction medicine, when physicians, not actuaries determine the best course of treatment.
  • Parity is when physicians are trained to recognize and treat substance use disorder in medical school with the same rigor given to any other disease.
  • Parity will be when physicians in any specialty can recognize, treat, or refer patients to a proper source of treatment. 
  • Parity will be when there are sufficient numbers of physicians board certified in addiction medicine.
  • Parity will become practice when more than a mere 10% of the 23 million plus Americans who suffer from substance abuse disorder are properly diagnosed and treated. 
  • Parity will come about when rehabilitation facilities have medical doctors on staff, all the time.
  • Parity is when physicians, politicians, school principals, police, and parents all realize that not only are they responsible for helping to treat this disease, but also that they and their families are as susceptible as anyone else to being afflicted by the disease.
  • Parity will arrive when we stop pretending will power is a cure for a neurological problem.  Will power needs to be exercised, not by the afflicted, but by policy makers who can help change the course of this epidemic.

 We are, indeed, in the midst of an epidemic.  Data, like much else in the treatment of substance use disorder, is slow to arrive.  However, we do know that, overall, overdose deaths from pills and heroin now exceed automobile deaths in this country.  Every day, 105 people die of drug and alcohol overdoses in this country.  While the latest data is from 2010, it is most likely that the number of drug deaths in 2014 exceeds the number of deaths at the height of the AIDS epidemic. 

William's cause of death could have been listed as "Institutional Indifference".  Failed insurance, clumsy coordination between health care providers, and antiquated treatment practices doomed him. 

In another time, in a better era, William might have entered the College of Physicians and Surgeons, not as a cadaver, but as a gifted and talented young man, prepared to serve others. 

We ask you as a body to summon the will power to make these possibilities realities.

We WILL prevail.

Thank you. 

For additional writings from Bill Williams, click here.  

Personal Failure or System Failure?

System Failure.jpgIn my writings to people seeking recovery from addiction, I have advocated a stance of total personal responsibility:  Recovery by any means necessary under any circumstances. That position does not alleviate the accountabilities of addiction treatment as a system of care. Each year, more than 13,000 specialized addiction treatment programs in the United States serve between 1.8 and 2.3 million individuals, many of whom are seeking help under external duress.  Those who are the source of such pressure are, as they see it, giving the individual a chance--with potentially grave consequences hanging in the balance. 

Accepting the mantra that "Treatment Works," families, varied treatment referral sources and the treatment industry itself believe that responsibility for any resumption of alcohol and other drug use following service completion rests on the shoulders of the individual and not with the treatment program.  This is unique in the annals of medicine.  With other medical disorders, continuation or worsening of symptoms is viewed as an indication that the initial treatment is not effective for this particular patient and that changes in the treatment protocol are needed.  In contrast, when symptoms continue or worsen following addiction treatment, it is the patient who is blamed and often punished.  The stance is, "You had your change and you blew it!  You must now suffer the consequences of your actions."  And those consequences are often quite dire, including divorce, loss of children, loss of housing or educational opportunities, termination of employment, discharge from the military under less than honorable conditions, loss of professional licenses, loss of driving privileges, and incarceration, to name just a few.  Such punishments are often meted out with an air of righteous indignation in the belief that the person for whom we have done so much has failed this chance we have given them.  The question I am raising in this blog is:  Was it really a chance?

Put simply, we are routinely placing individuals with high problem severity, complexity and chronicity in treatment modalities whose low intensity and short duration of service offer little realistic hope for successful post-treatment recovery maintenance. By using terms like "graduation" and ending the service relationship following such brief clinical interventions, we convey to patients, to families and to all other interested parties at "discharge" from treatment that recovery is now self-sustainable without continued professional support.  And this is true just often enough (but often attributable to factors unrelated to the treatment) that this expectation is maintained for all those treated.  For those with the most severe problems and the least recovery capital, I believe this expectation is not a chance, but a set-up for failure with potentially greater consequences than might have naturally accrued. 

What we know from primary medicine is that ineffective treatments (via placebo effects) or an inadequate dose of a potentially effective treatment (e.g., as in antibiotic treatment of bacterial infections) may temporarily suppress symptoms.  Such treatments create the illusion of resumed health, but these brief symptom respites are often followed by the return of illness--often in a more severe and intractable form.  This same principle operates within addiction treatment and recovery support services.  Flawed service designs may temporarily suppress symptoms while leaving the primary disorder intact and primed for reactivation.  But now the treated individual has three added burdens that further erode recovery capital.  First, there is the self-perceived experience of failure and the increased passivity, hopelessness, helplessness, and dependency that flow from it.  Second, there are the perceived failure and disgust from others and its accompanying loss of recovery support--losses often accompanied by greater enmeshment in cultures of addiction.  Finally, there are the very real other consequences of "failed treatment," such as incarceration or job loss that inhibit future recovery initiation, community re-integration and quality of life. 

The personal and social costs of ineffective treatment are immense.  If we as a society and as a profession want to truly give people with severe and complex addictions "a chance," then we have a responsibility to provide systems of care and continued support that speed and facilitate recovery initiation, buttress ongoing recovery maintenance, enhance quality of personal and family life in long-term recovery, and provide the community space (physical, psychological, social and spiritual) where recovery and sustained health can flourish.  Anything less is a set-up for failure.

As addiction professionals, we should always be mindful of the power we wield and its potential effects on people's lives.  That power comes from our professional decisions and actions, but it also flows from the treatment designs within which we operate.  If we are going to participate in giving people a chance, then we need to make sure it is a real chance and not a set-up for what is ultimately more a system failure than a personal failure.  Self-inventory, inventory disclosure and making amends have been among the essential steps of recovery within AA, NA and other 12-Step groups.  Perhaps it is time for leaders of addiction treatment to conduct a similar series of steps.  Perhaps addiction treatment as a system of care is itself in need of a recovery process.