Saturday, March 20, 2010

Sometimes Good Intentions Aren't Enough Part I

My little corner of the world has gone through a lot in the past few months. We have been in the national news because of the four deaths involving teenagers at a local high school. The first, a car accident, appears to be linked to the next two, the result of a pact in which two girls stood in front of a train, together. The fourth, a suicide by hanging, does not seem to have a direct connection to the other two.

Of course, the school has brought in counselors who have done a heroic job of helping the other students to deal with the deaths, and there has been an outpouring of public support for the families of the dead teenagers. There have been articles in the press about how to discuss the issues with your teens, what to look for as indicators of suicidal thinking and what to do if you fear that your child is suicidal. Everyone working with teenagers in the county is urging them not to keep a peers suicidal leanings a secret; to tell a responsible adult.

All of this is good, and right, and the way to handle such things. In no way do I want to discount or minimize any effort that anyone is making to help our kids deal with this and to prevent it from happening again.

I do have a few issues to raise, however.

How willing is a kid going to be to talk to someone about were they are hurting when they are going to a school where they have to dress a certain way or be punished; where drug-sniffing dogs roam the halls (and perhaps there is even an in-school police station or probation office)?

How often is a teenager going to open up about insecurities, fears, drug use, sexual pressures, intimidation and all of the myriad emotional hurdles of adolescence in an environment that seems to value only achievement?

If that makes you uncomfortable, or defensive, or angry, think about these statements made by kids I have worked with:

  • "I tried to talk to my counselor at school but they won't let me out of class to do it."
  • "They don't have much time for me because I'm stupid."
  • "I'm getting threatened every day but I can't fight back because I'll get arrested."
  • "The counselor said that I could talk to her in confidence. Then she called my parents."
  • "I don't want to get in trouble!"
I don't mean to sound as though I am pinning it all on the schools, but let's be realistic. Public education has not exactly been the best place to foster an atmosphere of mutual trust. Frankly, I don't like to go into public schools much anymore. They don't feel like schools. They feel like lock-ups. Something about the dogs and metal detectors, I think.

And before anyone jumps to one of those worn-out arguments that measures like that are necessary, think about this. There are several excellent schools, right here in our county, that operate on a completely different philosophy, and they are doing just fine. No drug-sniffing dogs or metal detectors. Just trust and a mission of instilling a love of learning in their students. In my perfect world, the Public Schools would spend the money on a staff psychiatrist or other trained and independent mental health worker, instead of the metal detector and the drug dog or the in-house cop. Imagine that comment.

So, while there are excellent people in the public school system, the system itself is less likely to inspire the trust of a kid than the Juvenile Probation system.

I'm afraid the job of addressing issues like suicide and other tragic deaths with our teens is up to us.

(to be continued)

Saturday, March 13, 2010

Empty Rooms: A Film By Tara Acquesta

This is an excellent film by a very talented young woman about the impact of a family member's addiction. Please watch it!

Empty Room from John Clements on Vimeo.


Heaven knows, I like to beat a dead horse as much as anyone, and because of a few things that happened this week, I am going to take a few more whacks at this one. Insurance. Specifically, health insurance.

When I am working with a family or other group of appropriately concerned individuals to develop an intervention, one of the questions that invariably arises, is who is going to pay for treatment? In the past, it wasn't much of a concern: the insurance company. After all, isn't that what we pay those premiums for? As an addiction counselor with many years experience, I certainly wasn't going to make an inappropriate referral. An experienced intake worker and solid treatment team would do the rest. The individual at the center of the intervention would receive the treatment they need at the appropriate level of care, for the right amount of time. The family would be included in the treatment plan; there would be a good, well thought-out aftercare plan to take the individual and the family through their first six months to a year of recovery.

Treatment like this is available, it exists, and surprisingly, it is not as expensive as many people think. But here's the thing: insurance won't pay for it. It sounds like a bad joke, but insurance companies have figured out that if you rake in the premiums, but don't pay out more than a fraction of the income, you make one heck of a lot of money. It's nothing new. I think Myer Lansky first defined the principle in the 20's, and the Casinos have run on it for decades.

In short: over a period of time, the house always wins and the mark always loses. Always, ever, forever, 100% of the time. Exactly the way your insurance company plays, with one exception. Casinos operate on the up and up. They will show you exactly the odds that they will pay. Insurance companies don't.

They lie.

And here is how they do it. They publish a list of what they pay for, very thorough, very comprehensive. In Pennsylvania, the say in their benefits that they pay for 30 days of inpatient substance abuse treatment. That's what they say. What they do not say is that they pay this according to their criteria of need. In other words, they will pay it, but first, that means they have to decide that it is needed, that it meets their criteria.

Now, let me give you a little primer in addiction and alcoholism. Addicts and alcoholics are often in denial, they tend to be dishonest and unreliable reporters, they may not remember what they have taken, in what quantity or when. They may be motivated once the car ride to the rehab starts, change their mind fifteen times before they get there, (and twenty after admission.). When threatened they can become manipulative, panicky, and sometimes just run away. The effects of many of the substances they ingest can mimic other mental illnesses, from depression, to bi-polar disorder, to schizophrenia. The only way that their immediate treatment needs can be assessed is by a thorough, eyes on, in person evaluation. 

So, one would think that an experienced assessor meets with the client, relates the outcome of the interview to an insurance company rep, satisfies the criteria for admission and that is that, treatment begins, right?

Wrong. It is just the beginning of an agonizing, time-consuming process that drags on and on and on. More information is needed. Then more. Someone hasn't consulted with the psychiatrist that the client saw ten years ago, and how can we admit without that?  Did he take diazipam or Dexedrine? Is he compliant with his blood pressure medication? 

I have seen families sit in the lobby of a rehab for over 12 hours going through this crap, only to finally be told that their patient is authorized for 3 days of inpatient care. Or worse, that they are referred to an Intensive Outpatient Program 10 miles away and have an intake appointment for next Wednesday. The client will go three days a week--shame about that DUI, someone will have to drive him, and, oh yes, the co-pay will be $50.00 per session. But you can use a credit card.

These are things I have seen, over and over again, to the point where I find it hard to believe that this is not intentional. Aside for denial, addicts and alcoholics have notoriously low frustration levels, and are extremely prone to just get up an walk out.

And if you think about it for a minute, that is a really nice windfall for the insurance company. Then they don't have to pay anything at all. As for the client--he was unmotivated. As for the family? Insufficient support.

It's a disgrace. So, for now, do what I get my families to do. Learn to be a negotiator, a persistent advocate and a squeaky wheel. In therapy, we learn to ask for what you want. In this setting, learn to demand it! If we tolerate a broken, dysfunctional system that allows us to pay top dollar for virtually nonexistent treatment, then we get what we deserve. Shame on us.

But if we truly believe that addiction is an illness, then let's demand the kind of treatment that we would expect from any duly licensed facility; and let's demand that the insurance company pay for it, without qualification.