Selling Hope to Families in Crisis: The Business of Recovery

By Amy Dresner

(Originally posted on THE FIX on 05/26/15)

The Fix talks to Greg Horvath about his unflinching examination of the rehab industry and its reliance on 12-step facilitation.

Greg Horvath has produced a very disturbing documentary called The Business of Recovery, shining an unflinching light on an industry that is “selling hope to families in crisis” and making a fortune in the process, fleecing desperate parents and addicts of hundreds of thousands of dollars while getting less than stellar results. He interviews a slew of addicts who have been to treatment upwards of 10 times (some of whom died from addiction after the filming), as well as some top addiction experts and a few of the rehabs themselves.The Fix sat down with Horvath to ask him some questions.

What made you decide to make this film? Are you a recovering addict or have you ever been in rehab? Or do you have family or friends that have spent a small fortune to no avail?

I have experience with [the] 12 steps, rehabs, and worked in the industry for many years. I felt the way we were treating addiction wasn’t working nearly as well as was portrayed. I wanted to dispute or confirm this feeling.

How did you hook up with Adam Finberg (the director)? His background seems to be as an editor of reality and documentary TV.

Adam and I met at the Sundance Film Festival about 12 years ago. We have collaborated on a couple of other projects over the years. He is a very talented filmmaker and I hold him in the highest regard.

You interview a lot of experts and also laypeople on the street regarding the nature of addiction. What is your personal belief about addiction?

That’s an interesting question, always sparks heated debate, and that’s why we put it in the film. The one thing I noticed over my years of working with addicts was that they never wanted to debate with me whether addiction was a disease or not…they just wanted to get clean and/or sober.

I’ve been in quite a few rehabs (which might make your point). Most seem to be owned or run by people in recovery who actually believe that the 12 steps work because it worked for them. Do you think all these places are corrupt or do some have a true desire to help but it gets murky when profit is involved?

I have never questioned the passion or commitment of most of the people who work in the industry that believe that 12 steps work, because it worked for them. Just like I have never questioned the passion and commitment of most nurses and other medical staff that work at hospitals. However, if you had a child that has cancer, would you want them treated by nurses and medical staff who believe in a particular support group, or would you want your child treated by someone who is using what the science says is the best treatment for the cancer your child has?  

You mention in your film that 10% of US rehabs are not 12 step-based. What is their main methodology? What is their claimed success rate? 

Actually we did not say that, we said that 90% of the treatment in the US is 12 step-based.

How do you feel the rehab industry has changed now that many of them take insurance?

No opinion.

There are free treatment centers like Freehab or religious fellowships. What are your thoughts on those? 

I think they are great options for indigent people.

You mention the problem with addicts, who aren’t stable, treating or supervising other addicts. It’s definitely risky. Many people, new in recovery, choose to work in recovery because they’re so gung ho or they have no other real training or education or possibly a criminal background. How can we minimize risks aside from mandatory training or do you think treatment centers should only be run by medical professionals without addiction backgrounds?

I go back to education. I really don’t care if the nurse or doctor that is treating my cancer has had cancer, as much as I care about their professional credentials. And to be clear, a six or 12-month certificate and a year or two of sobriety is not a credential.

What kind of changes would you ideally like to see made to the rehab industry aside from offering non-12 step-based methodologies and some type of accountability or policing from government agencies? Refunds if the client relapses or leaves? 

I never said that I want the rehab industry offering non-12 step methodologies. As a matter of fact, that’s one of the fundamental flaws that annoys me the most about treatment. Support groups are not treatment, they are support groups. We need to stop referring to it as treatment. 

Why do you think the rehab industry has such a loyalty to the 12-step model when you elucidate via many researchers that it is only effective for a very small percentage of people? 

It’s a free program, and a free after-care program.

I must say I was pretty horrified by the salaries (from $200,000 -$900,00) that many of the executives at these “nonprofits” were making. It reminded me of religious organizations. How many of these places offer scholarships or sliding scale? 

Most of them offered some scholarships.

I was amazed that so many of the rehabs that you interviewed seemed to just fall into the trap of saying exactly what would support your points that a) they were primarily 12-step based and that b) they have no way of truly proving their success rate aside from self-reporting and that c) there was no real data supporting 12 step but that it does work. What did you tell these rehabs that your movie was about to get them to go on film? 

There were no traps or hidden agendas. We told them exactly what we were doing, we were making a documentary about the treatment addiction. And they agreed to talk to us about their methodology.

There are over three times as many treatment centers now as there were in 1986 but drug overdose rates have tripled. Why? 

I think there are some strong factors associated with JCAHO declaring pain as the 5th vital sign in 1999. However, if what we were doing was working so well, and we tripled the number of facilities doing it, would the death rates be tripling? By comparison, in the same time period that overdose death rates tripled, cancer death rates have gone down by 22%. That should really shock anyone still clinging to the myth that the current addiction treatment modalities are working.

The accreditation companies of rehabs are themselves nonprofits that appear like government agencies and look very official but they only look at building codes and documentation, not the efficacy of treatment. How can parents, friends or partners make more educated decisions regarding choosing a rehab? 

Two words: “Buyer beware.” If the accreditation companies do not look at whether the treatment offered by a facility works or not, it is an absolute roll of the dice to think you can pick a “good" facility. A facility is much like a used car salesman, they are going to tell you everything that’s right with their facility, I would be more concerned with what’s wrong with it. Buyer beware…ask questions about educational requirements, refund policy, do they drug test their staff, are they treating you with science/empirical treatments, or just teaching how to do a support group. If they answers are vague, move on. Buyer beware.

Many addicts go into rehab and come out worse. I certainly have had that experience but is that the rehab’s fault or just a matter of having addicts living together, just like some inmates get worse in prison? 

You kind of answered your own question. However, the rehab has to own its share of the problem/failures. You can’t expect a much different outcome when all you offer are quasi-scientific treatments, administered by unqualified staff, in a largely unregulated industry.

If you had a loved one who had an addiction problem, what would you do? Where would you send them?

I would need much more information before I could even attempt to answer this question. And that’s the greater problem, addiction is far more complex than just a matter of: “Where should I send them?” 

Many of these rehabs have paid referrals and kickbacks but one of the rehab-heads defended it by saying it’s a “relationship-based industry.” How much does this compromise the integrity of the whole system? 

People we interviewed were absolutely shocked that it went on, and thought it was one of the most shameful practices in the industry. Please refer to the Stark Legislation, it was passed for a very good reason. It is a dangerous conflict of interest for a doctor to be prescribing a treatment he owns or gets paid to prescribe.

Many of these rehabs pay more in public relations and ads than they probably invest in their actual programs. It’s all marketing and reputation. Although this is a terrifying way to pick a treatment for a condition that can kill you, it doesn’t seem like science has all the answers yet. 

That’s an interesting comment, you would first have to “ask” science a question, in order for science to “have” an answer. Having said that, predatory and misleading marketing is a large part of the problem as well. We have to start with some honesty in the industry about expectations.

In the light of all of this, if you could construct your ideal rehab, what would it be like?

1) The use of science-based treatment (empirical, not evidence-based). 

2) Better educated professionals in charge of treatment. 

3) Regulations that have value to the addict and that are in line with the medical field.