The rich-poor difference in treatment

Rainey Temkin, PhD

Rainey Temkin, PhD

Alta Mira Recovery Programs, Clinical Director

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While affluent individuals in fully equipped rehabilitation centers and homeless addicts may not be equal in some respects, their singular and most significant commonality is the similarity in their pain!

Luxury rehab evokes the image of the wealthy receiving top quality treatment at the cost of more than some people earn in a year; the domain of the rich and famous. I began my career as a psychologist working in community mental health and specializing in serious mental illness. 


From sessions on the streets to luxury clinics…

When I transitioned into the work of treating addiction and co-occurring disorders at a high-end residential treatment center, I imagined that my work would consist mainly of supporting the “worried well” with their substance use disorders. Coming from a job where many of my clients were either homeless or precariously housed, and often meeting my clients in the streets for “sessions,” I was struck by the public mental health system’s lack of sustained support critical to long-term recovery. I was frustrated with what seemed to be the endless cycle of crisis stabilization, inpatient hospitalizations, and minimal continuing care planning leading to life back on the streets – ultimately a direct road to relapse. The cycle continued, the suffering unbearable, the system underfunded to create real and lasting solutions.  

Although my mission has always been to bring increased access and higher quality mental health services to vulnerable populations, those that tended to be the most complex in nature but served by the least experienced, I was offered a position as a clinical psychologist on staff at a treatment center that served the extreme opposite of that spectrum – private pay and extremely expensive. We offer top quality therapists, addiction psychiatrists, addiction physicians, 24/7 nursing team and medical detox, neuropsychological testing, experiential programming, intensive workshops, dedicated continuing care coordination, robust alumni programing, and caring residential support staff always available. Clients are seen three times weekly for individual psychotherapy and weekly by the internist and addiction psychiatrist to manage both psychiatric medication management as well as any physical issues related or unrelated to their addiction. They engage daily in evidence-based treatments such as dialectical behavior therapy on a group level, learn about the disease of addiction, relapse prevention, mindfulness meditation, and are offered a monthly family program where family members can come and with the client learn about addiction and their specific dynamics that are contributing to or maintaining the unhealthy behaviors. Twice weekly clients are offered experiential outings where they can learn how sobriety does not impede on maintaining a robust and active life – sailing, equine therapy, kayaking, zip-lining, rock climbing, hiking, and mountain biking are just some of these activities. Community is highlighted as a cornerstone of successful recovery; fellowship meetings in any domain whether that be Alcoholics Anonymous, Narcotics Anonymous, SMART Recovery, or Buddhist centered are all offered and encouraged as those who work in the field know this disease cannot be treated in isolation. Weekly massage and acupuncture, yoga, fitness, and specific modalities of Somatic Experiencing Therapy or EMDR (Eye Movement Desensitization Reprogramming) are offered when clinically indicated. Ahead of discharge our clients are given access to top quality continuing care coordination for what we hope is a seamless and supported transition back to “real life.” 

Lucky minority

And now for the stark reality. This treatment works. It is by no means perfect and since I have started my career in residential treatment, we have lost clients to the disease, yet in so many cases our clients thrive and succeed. And when they don’t, they can come back to a system that can specifically tailor and strategize as to what went wrong to modify and reset for another chance at success. Those with affluence have the ability to afford top notch resources to battle mental health issues and addiction. Those without means are forced to utilize a system of care that is underfunded, under-resourced, and exhausted. Those that work in this system often face burnout, vicarious trauma, and hopelessness. Which begs the question; how do we provide more effective treatment to those without means to utilize the cutting-edge treatments available to those with means? 


Some of my observations and musings on working in such starkly different environments are important to consider. From the beginning of my transition from community mental health to state-of-the-art residential treatment for addiction and co-occurring disorders, I have been challenged on many of my assumptions. The homeless man on the street in San Francisco, shooting up heroin in public, and tortured by hallucinations carried out in sometimes incoherent ramblings, is in many ways no different than the CEO that comes into our treatment center on his private jet, more properly medicated for his mental illness, and motivated to detox and recover from his opioid addiction. The only difference outside of affluence and means is that the homeless man on the street has a very different “bottom” than the affluent executive. Money affords individuals to avoid some of the worst conditions that lead to seeking treatment. The opportunity to engage in treatment before the shackles of substance induced psychosis turns into a permanent schizophrenia diagnosis can be the difference between living out a normal life or one that often leads to permanent homelessness or inpatient psychiatric hospitalization. Even the available public inpatient psychiatric centers are usually full and unable to accept more patients. The downside of affluence related to addiction and mental illness is that many times individuals can avoid treatment due to having money and resources to support their addictions. This additional time to afford the substance of choice and avoid environmental discomfort often puts these individuals at greater risk of overdose, liver failure, suicide, and years longer in the active phase of addiction. Sometimes these individuals are being supported by family members and friends who lack education on addiction in general as well as how to create healthy boundaries and not inadvertently enable the disease. 

There is always hope!

When I left community mental health, I assumed that I would rarely be treating serious mental illness and that I would experience less suffering than my previous clients had endured. To be clear, the suffering is a different form of suffering, but I have come to recognize that addiction and mental illness knows no socioeconomic boundaries. The debilitating emptiness of major depressive disorder, the chaos and risk associated with a manic episode, the terrifying experience of verbal hallucinations or persecutory delusions, and the interpersonal turmoil of those suffering from borderline personality disorder, are not any different experiences between populations. Significantly, and what I have found across the board working in private pay residential treatment is related to the concept of shame. Time and time again I sit across from clients who not only are suffering in their addiction and likely secondary diagnoses be that depression, anxiety, trauma, or personality disorders, wracked with shame that they “shouldn’t” be sitting in front of me. They believe that due to their affluence, they should never have succumbed to these issues, and the subsequent self-hatred or sense of failure is often profound. In addition, this sense of shame can create a barrier to treatment and leave those in desperate need of treatment suffering much longer in isolation, again putting them at greater risk of falling victim to the disease. 


How do those of us that work in mental health and addiction grapple with these inconsistencies? How do we take what we know works and put it in action for the more underserved and vulnerable populations? How do we reduce the stigma of mental illness and addiction within the more affluent populations? As idealistic as it may seem, I am committed to taking what I have learned from my personal experiences and looking for ways to create more equity in the field. I fundamentally believe that housing must be the first step in battling addiction and mental illness within homeless populations. Our current system that prevents those in active addiction from accessing long term housing is completely misguided. We know from experience that without proper housing the possibility of maintaining sobriety and accessing the proper psychiatric medications are next to impossible. For those with means to afford treatment, I believe that battling the stigma of addiction and mental illness, talking about it more in the media and schools, and educating families on how to hold clearer boundaries around entitlement and privilege, will allow those in need to more readily access treatment. I am hopeful that the encouraging research around psychedelics, psilocybin therapy, and MDMA therapy will create more efficient methods to combat mental illness and the effects of trauma. These methods may be easier to offer and make available to underserved populations. There is much to do, and the data on relapse rates in the field of addiction are less than encouraging, but I am certain that we can do better and save countless more lives. 

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