People Who Do Not Deserve to Have a Problem: Issues Related to High-End CareBHOPB
Seaside Palm Beach opened the doors to “high-end” treatment for substance use disorders in 2009. I would like to share the experience of having been the first Director, and as a person who has maintained his involvement with Seaside to this day.
When Seaside opened it was the only substance use disorder treatment program in Florida describing itself as “high-end.” It’s possible that we were the only one on the east coast. The number of programs currently describing themselves as “high-end” has grown considerably in Palm Beach County alone.
It’s worth taking a moment to ask what exactly “high-end” care is. Although there is clearly no precise definition, adjectives used to describe this manner of care have included “executive” and “luxurious.” The term “high-end” connotes “expensive,” “wealthy,” “rich.” It may not be politically correct to openly use these adjectives, nevertheless, they exist.
Discussing the reasons for the exponential growth of high-end care is not the purpose of this article; discussing the lessons learned since 2009 is.
Seaside Palm Beach is one of four treatment facilities owned and operated by Behavioral Health of the Palm Beaches (BHOPB). BHOPB’s experience in providing quality residential care for substance use disorders dates back to 1996. In 2009 providing high-end care was new for us, but providing high-quality residential care wasn’t. Seaside was planned by people who had years of administrative and clinical experience with the provision of quality care. Even so, there were lessons to be learned along the way. Sharing knowledge acquired through experience and research with our professional community has always been an integral aspect of BHOPB’s mission.
Selecting and Preparing Staff
When staffing Seaside, we looked for the most highly qualified, credentialed, and experienced staff that we could find. We searched from within our organization and externally. It didn’t take long for us to see, and to recognize within ourselves, that we held attitudes that were negatively impacting the delivery of care.
We had staff providing services who made less money in a year than our residents made in a week or a month. In fact, residents whose income was dependent on investments sometimes had more income during their stay than the staff member did. Residents often owned homes in attractive locations around the world while a staff member may have been struggling with rent (p.s. we do pay staff well). I could go on.
Staff, who ordinarily would go the extra mile for a resident, didn’t. Negative remarks about residents could be overheard among staff. Staff whom had demonstrated remarkable empathy in the past all of a sudden became unable to demonstrate that essential quality. How could they? Residents were perceived to be people who did not deserve to have a problem.
Residents were being talked about as people who lacked “humility.” How do people with extreme wealth demonstrate humility?
Staff who had been trained to help residents look deeply into themselves, now had to look deeply into their own selves. It became obvious that residents coming from wealth had to be treated as a sub-culture (NAADAC, 2009). As F. Scott Fitzgerald allegedly remarked to Ernest Hemingway, “The rich are different than you and me.”
We needed to do cultural sensitivity training with current and perspective staff. No one can change until the need to change is recognized.
We did locate some staff who did come from wealth and made the choice to give back by helping others.
What do High-End Patients Look Like?
This may be a good time to mention that residents seeking treatment at Seaside were and are significantly older than residents at BHOPB’s other centers. The average age at Seaside is approximately forty-eight years. At BHOPB’s other facilities it ranges from early to mid-thirties. There are numerous reasons for this. The most obvious is that it often takes some time to accumulate wealth.
Seaside residents tend to be proud people. They do not respond well to confrontation, particularly when it comes from a staff member perceived to be very young. Maturity should be a sought after characteristic for on-site staff.
Age and wealth are correlated factors. Wealth is likely to have enabled substance abusers to avoid the consequences of abuse.
It is also likely that wealthier residents have not been confronted in the workplace. They don’t get referred to management, they are management. Sometimes the wealthy substance abuser is simply too powerful to confront.
Confrontation as a therapeutic tool needs to be used very carefully.
It is also likely that the Seaside resident comes from a sub-culture who could not possibly be addicted. After all, they don’t deserve to be. They feel the stigma more than any other sub-culture. “With everything you have, how could you let this happen?”
They are more likely to be referred for mental health care as opposed to care for a substance use disorder.
Want to know who else didn’t think that people from this culture could have a problem. We didn’t. I feel certain that there have been patients whom I’ve treated over the years whom I perceived to be not in need of intense services because of the privileged culture they came from. Possibly I recommended people from this culture to a lower level of care than was necessary.
We Are Products of the World We Live In
When we opened our doors in 2009 we did not expect residents coming to us who had more substance use related physical deterioration than we had previously seen. There were more frequent occurrences of high blood pressure, unstable blood sugar, impaired liver and pancreas functioning, and organicity than we had previously experienced. There were ambulatory problems, particularly among women.
Having to treat chronic pain as a co-occurring disorder was also more likely. Consequences like pancreatitis are painful. So are things like falls and neuropathy. The list is long.
Severe alcoholism often requires a longer period of withdrawal management.
Since the issues mentioned above are more likely to occur, lengths of stay for withdrawal management and treatment are likely to be longer. This was recognized by the American Society of Addiction Medicine (ASAM 2013) when their recommendations included five levels of withdrawal management.
It is important that expected lengths of stay be talked about at the outset.
As part of its pre-treatment assessment process BHOPB asks each patient, including Seaside patients, to complete the Millon Clinical Multiaxial Inventory-III (MCMI III). The resulting personality profile is used to help the therapist and the patient identify both problem areas and strengths to focus on during the course of treatment.
The initial three scales (Disclosure/Desirability/Debasement) can give the therapist some insight into how the patient presents for treatment. They are referred to as “validity” scales. Patients being treated at BHOPB represent a cross section of patients who have been presenting themselves for treatment since BHOPB’s opening in 1996. Wealth may well be represented in this randomly chosen sample of 100 patients being treated in 2010. If you look at the first three scales in Figure #1
You will notice that “Disclosure,” and “Debasement” are high relative to “Desirability.” A reasonable hypothesis would be that BHOPB patients are self-debasing (low self-esteem, self loathing) and are willing to tell you about it. This pattern on the “validity” scales tends to falsely elevate scores on clinical scales. In other words, BHOPB patients may not be as impaired as their personality profiles would indicate. Whatever their issues are, the issues are probably complicated by low self-esteem.
A major goal of treatment would be to increase the patient’s self-esteem. Continued low self-esteem could be counted on to be a relapse issue.
Now look at Figure # 2. For Seaside patients, “Desirability” is elevated when compared to “Disclosure” and “Debasement.” This pattern is totally opposite that seen in Figure # 1.
This “validity scale” pattern is indicative of patients who are suppressing clinical issues. The remaining clinical scale scores will be artificially low. Therapists will have to pull teeth to get issues to work on from these patients.
This is not to say that Seaside patients are lying. They may be totally unaware of where to start.
Ironically, it’ easy for the therapist to follow them into the trap. At the end of a busy day it may seem delightful to have a patient without problems walk through the door.
Perhaps this is another argument for lengths of stay. It will take these patients a longer time just to scratch the surface.
Are “High-End” Patients More Narcissistic? If all you do is look at Figure # 2 you might conclude that they are. However, it’s probably worth stopping to think that the MCMI III was normed on a broad range of people, not just a “high-end” group of people. Are patients seeking “high-end” care using self-centeredness and grandiosity as a means of avoiding issues, or are they really that important?
These are not people who think they are God; people have been treating them that way. OK, that’s an exaggeration, but not by much.
Point is that a sense of self-centeredness and grandiosity may not be a means of avoiding issues for this population. It may be who they are.
In that case, it would not be an issue to work on.
What is Powerlessness and Unmanageability to this Group?
We’ve treated people at Seaside who have been pushed out of companies they may have started. When this occurs there’s usually a financial package, a golden parachute that goes along with the departure. Golden parachutes have ranged up to $40,000,000.
There are other times when there isn’t a severance, but the person is simply not involved in the company. Their name may remain on the door, but they are basically ignored and everyone knows it. However, the person is still receiving a very significant financial benefit.
Question becomes would a salaried therapist recognize this as powerlessness and unmanageability? A skilled, mature therapist who recognizes the downside of wealth would. It could be said that the head of a company has taken a bigger fall than a salaried person losing a job. Having spent time with a high-end population, I know this to be true.
There have been instances when relatively young people have sold companies and have looked forward to a life of leisure. They soon realize that playing golf goes only so far.
Of course people who have experienced wealth have also experienced powerlessness and unmanageability. Therapists need to be trained on where to look for it. They also have to be trained to empathize with a patient who has made more money than the therapist can imagine. This is not always possible, skilled therapists have to be selected.
There’s no evidence that high-end patients differ from more traditional patients seeking treatment for substance use disorders when it comes to abandonment issues/attachment issues. Having observed high-end patients for a considerable period of time I’ve come to believe that their abandonment/attachment issues are just different.
We’re used to seeing patients who have been abandoned by sexual abusers, substance abusing parents, parents who left the household, etc.
High-end patients may never have felt that they were abandoned by a parent. The parent was never available. They were brought up by a series of nannies some of whom they became attached to. Inevitably, that nanny was replaced.
As they got older it was a matter of moving from one boarding school to another.
It’s harder to identify abandonment/attachment issues when patients believe that the issues are not there. After all, everyone else they knew was brought up in a similar fashion.
So, a therapist should never conclude that abandonment/attachment issues don’t exist. Therapists need to learn where to look for them.
What Does High-End Recovery Look Like?
Traditionally, patients completing treatment for an addictive disease would be recommended to do 90 in 90: 90 12-step meetings in 90 days. It’s likely that they would be referred to a lower level of care such as intensive outpatient, and would likely be referred to a one on one therapist as well. This certainly doesn’t describe all discharge plans, but it’s close.
Sometimes there is resistance, but options are limited by financial issues, insurance coverage, ability to be given time to blend recovery and work.
Some people just don’t like the 12 step recovery process.
I know all of the arguments. I’m a person whose life has been saved by Alcoholics Anonymous (AA). However, I can understand the resistance.
We can’t push 12-step recovery down someone’s throat.
The problem is that there is no other form of support for recovery that is as available as 12-step recovery. It’s also free. “Free” is a wonderful thing, 12 step recovery is a wonderful thing, but what about people who have more options and more resources.
Some “high-end” patients might have a therapist or team of therapists available to them 24/7. Is this as good as 90 in 90? It may be, but it’s not free. In fact, it could be incredible.
I’m aware of a patient who traveled with a personal therapist and a nurse. Sober coaches and sober companions are really good sources of support.
Fact is that patients with wealth have more options than other people. I can only wish that all of these forms of support were available to everyone, but they’re not.
What happens on some occasions is that a wealthy patient is being case managed by a person who has resentments. It may be a person who is thinking “I got sober with AA, why can’t she?”
Summary and Conclusion
At Seaside, we\’re going on our 6th year of providing care to people who are frequently referred to as “high-end,” “executive” or exclusive in some way, shape or form. BHOPB’s mission has always included the sharing of experience, strength, and hope with our professional community. “High-End” programs seem to be popping up everywhere. So we are sharing what we have learned.
One thing is to pick and train staff very carefully. If a salaried staff person tells you that they don’t have resentments toward people with extreme wealth they’re either in denial or out right lying. It’s important to recognize it.
It is also important to look for staff who can relate to, or come from wealth themselves. Believe it or not they exist. Maturity should be a sort after quality when choosing staff.
High-end people come to us with patterns of denial, issues and character traits that are not all that different than our more traditional patients. They are just displayed differently and a trained therapist needs to know where to look.
The world is not fair or equitable. It\’s not the fault of the patient. It’s important to accept that people with resources may have a path to recovery that is different than those we’ve seen in the past. The objective should be to bring everyone up, not to bring a fortunate person down.
Most of all, these are people who deserve to be cared for. Addictive diseases do not discriminate. If anything, they hit a person with wealth much harder. Being able to avoid consequences is not always a good thing.
We are also treating people who are smart, creative, and often become passionate about recovery. Sometimes they are in a position to help others.
Mostly what I’ve learned, people are people.