What happens inside a large residential program?
In March 2021, I spoke with Tamra Hall, PhD, who led clinical and quality excellence nationwide for American Addiction Centers. She holds a PhD in clinical psychology and is a licensed counselor, and she visits the organization’s sites around the country to stay close to the clinical staff.
I asked her the questions many families ask before anyone goes into a program. What role does therapy play, how are other psychiatric conditions handled, what about medication, and why is insurance such a struggle? This is an archive episode, recorded when the show covered addiction and recovery broadly.
Is a program just a wrapper around meetings?
At 1:16, I described a common perception. Many people think programs have become little more than an introduction to 12-step meetings, sometimes with no psychologist or psychiatrist on site. I mentioned The Sober Truth by Dr. Lance Dodes. As I described it, the book argues that meetings may not suit everybody and that some people may benefit more from a more advanced psychotherapy.
Tamra answered that recovery is different for everybody. In her view, it is foolish to say that formal care is the only way, because some people recover on their own, with a self-help book, or in a mutual support group. Still, she said, the change has to come from within the person.
At 2:52, she described weekly counseling for everyone in her organization’s programs, with more for those who need it. She was critical of the hype in her field. In her words, it all comes down to individual care and knowing what works for the person in front of you.
How do you tell a psychiatric condition from the effects of a drug?
At 5:46, I raised a problem with diagnosis. A person may look as though they have a psychiatric condition, and then, as the drugs leave their system, it becomes clear the drugs were causing it. Of course, sometimes the underlying condition is real.
Tamra agreed that it is hard to tease apart. She called it a chicken or egg situation, where the two conditions feed each other and the question is which came first. Earlier, at 4:29, she said the brain does need to heal, yet nutrition is only one part of a picture that also includes mental health, money, and support at home.
Who counts as family in recovery?
At 7:01, Tamra made a point I thought was wise. Sometimes the family is part of the problem, so she prefers to talk about a support system. That might be a best friend, an aunt or an uncle, a community member, or a sponsor.
Her view was simple. Without support, this is not a condition a person can overcome alone.
What is cognitive behavioral therapy in plain language?
From 8:42, we talked about choice in support groups. Tamra said some people prefer SMART Recovery because they are uncomfortable with the idea of a higher power. At 9:37, I said it was good to see that option offered, because in the past people were often told that the 12 steps were the only way.
At 10:42, I asked her for a simple explanation of cognitive behavioral therapy, or CBT. She described it as becoming aware of the thoughts and ingrained patterns behind our behaviors and changing them. However, she warned against burying it in psychobabble. In her view, translating research into something real for a person in the greatest struggle of their life is an art, and it separates good therapists from the rest.
At 13:30, we turned to motivational interviewing. Tamra explained that giving people the answers is not the answer. You meet the person where they are, and you let them lead the process.
Can someone be made to stay in a program?
At 14:11, I described the Marchman Act in Florida, which allows a family to go through the courts so that a person can be placed in care against their will. Tamra said her organization does not take involuntary admissions. Everyone has to be there of their own free will, and the doors are not locked.
Interestingly, she added at 15:25 that many people who say they want to be there were really pushed by an ultimatum from a family member or a spouse. At 16:12, I said that people are often of two minds. They want help and they want to leave, both at once. So, she said, you work through that and find out where each person is.
Why does continuity matter for naltrexone?
At 18:13, I explained why a residential stay can be a good time to start naltrexone. A person has to be off opioids for at least a week first, and that is very hard at home, because the cravings a few days in are often the worst of their life. Tamra said her organization offered medication services in its facilities and was working to continue them in outpatient care.
At 19:21, I said that people who get a Vivitrol shot during a stay often struggle afterward to find a doctor who gives it, and that continuity for six months, a year, or more is really important. Fortunately, her answer was practical. Every discharge plan should include a specific follow-up appointment, so the person leaves with that appointment in hand.
Did telehealth change how people take part?
From 20:16, Tamra described her organization’s telehealth groups. When her team looked at the numbers, attendance was very high, and the therapists reported that people were actively talking rather than dozing off. She hoped to see more government support for telehealth, because it reaches people who are hesitant to walk in the door. At 22:48, I compared a video visit to the old house call, where a doctor could see how a person really lives.
Why is insurance such a battle?
At 24:15, I described insurers who delay approval of life-saving medication for days, when a person might overdose the next day. Tamra called it a daily battle. She had supported the parity law, but in her view the problem is that it is not enforced, and she described a meeting where a payer said flatly that it did not care.
At 27:47, I said that fighting an insurer on the phone usually wastes time a person may not have, and that the answers are often hidden in the fine print. Tamra also gave insurers some credit at 28:20. In her view, the industry had been like the Wild West, and pressure from payers helped push it toward common standards.
Who is Tamra Hall?
Tamra Hall, PhD, holds a doctorate in clinical psychology and is a licensed counselor and mental health counselor, certified in substance use. When we spoke, she led clinical and quality excellence nationwide for American Addiction Centers from Florida. She once ran for public office because of the parity bill.
What can listeners take away from this conversation?
This conversation is a view from inside a large organization in early 2021, covering how therapy, medication after discharge, voluntary admission, and insurance were handled there. Tamra’s strongest point was that care has to start from where each person actually is.
How do I approach this today?
My thinking has kept developing since this conversation was recorded. Today my practice is built on one idea that runs through all of it: when the body has adapted to a substance, the safest way off is usually gradual, with the smallest steps the person’s nervous system can tolerate. Physical dependence is not addiction.
For opioid dependence I prescribe buprenorphine, which steadies the body so a person can rebuild their life without the cycle of withdrawal. Visits are monthly, or weekly when needed. Some people stay on it for a long time, and that is a legitimate choice. Others later taper slowly, using the same gradual approach I use for every other medication.
I believe medication for opioid dependence should be available wherever people need it. I prescribe in Florida only.
This page is educational. It is not medical advice, and listening to the episode or reading this page does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
Full transcript
A note from Dr. Leeds: my guests speak from their own experience and expertise, and the terminology they use is their own. Whatever the topic, this show holds to one distinction: physical dependence on a prescribed medication is not addiction. This transcript is educational content, not medical advice, and nothing here creates a doctor-patient relationship.
Read the full transcript (38 minutes)
Announcer [00:00]
Dr. Mark Leeds [00:09] Welcome to the Rehab Podcast on the Mental Health News Radio Network. Here is your host, Dr. Mark Leeds. Tamra Hall, welcome to the Rehab Podcast.
Tamra Hall, PhD [00:12] Thank you. Glad to be here.
Dr. Mark Leeds [00:14] So you work with American Addiction Centers?
Tamra Hall, PhD [00:17] Yeah, I run the clinical and quality excellence nationwide for American Addiction Centers. I have a PhD in clinical psychology, and I’m also a licensed counselor and mental health counselor, as well as certified in substance use.
Dr. Mark Leeds [00:32] How many locations do you have?
Tamra Hall, PhD [00:34] Right now, we have approximately eight. We are always expanding. It’s a growing field, so we’re expanding with that field. But yeah, right now, we have eight specific states that we are located in. And of course, each one of those states, we have a couple of locations. I’m located down here in Florida, and we have two facilities specifically in Florida.
Dr. Mark Leeds [00:53] Do you travel around to visit each location?
Tamra Hall, PhD [00:56] I do. I do. It’s been a little bit, you know, scarce over the last year with the COVID. But overall, yeah, usually I will do a site once a month and, you know, stay in touch with the clinical staff there and stay on ground. So getting to see the people and getting on site is very, very important for what I do.
Dr. Mark Leeds [01:16] Now, you being a therapist or actually a psychologist, you’re a doctor of psychology, right? So, and that’s been a big issue and a big question that a lot of people are wondering about. How does therapy fit in rehab? And I think there’s a perception with a lot of people that rehab programs have become just kind of a thin wrapper around the 12-step program that you go to rehab to learn that you can go to AA or NA meetings. And that maybe at a lot of rehabs, they don’t even have a psychologist or psychiatrist on-site administering therapy. And there was a really good book about that. I don’t know if you’ve read it. Dr. Lance Dodes, The Sober Truth, where he talked about 12-step treatment and how, oh, not 12-step treatment, but how AA may not be the best option for everybody and how people may really benefit more from a more advanced psychotherapy. What do you think about that?
Tamra Hall, PhD [02:13] Recovery is different for everybody. There is no one size fits all. So treatment may work for some people. Doing it themselves may work for others. I think it’s rather foolish to say that treatment is the only way to go, although it is very helpful. The bottom line is you can’t recover by going to treatment. It is something you have to choose to do. You know, recovery happens within yourself, whether you reach out to treatment and that assists you in that process, or you do it through a self-help book, or you do it through AA, you have to find a modality that works best for you.
Dr. Mark Leeds [02:43] If someone goes to rehab, would you do a psychoanalysis with a person laying on the couch and you talk about their mother and childhood? What happens exactly?
Tamra Hall, PhD [02:52] Well, if somebody was laying on the couch, you know, my fear would be, are they falling asleep? You know, but you know, yeah, counseling is a big part of the treatment process. We provide counseling every single week to every individual that attends our treatment programs. It’s really, really important. There are those individuals that will request or require more therapy. It just really depends on the individual, but everybody is required to at least attend one therapy session a week because it’s very valuable to the process of healing. You know, it’s not just addiction that you’re treating. When you think of American addiction centers, you got to think of a healthcare organization that specializes in the treatment of addiction. So we’re very focused on, you know, evidence-based practices and what works and looking into the science behind it. But it’s not just that, it’s also the way you approach it. You know, I think it’s really important to get rid of all the hype associated with, you know, we do this wonderfully and we do that and we have this really unique practice or whatever it is. Really, when it comes down to it’s all individualized, you know, and you have to be willing to ebb and flow with the individual that comes into your facility and you have to know what works and how to apply diet, do the research, you know, get behind what is important to that individual and really make an impact in their life.
Dr. Mark Leeds [04:14] How about nutrition? I think that’s one concern that if a person goes into rehab and just eats like an all carb diet or something, if they don’t eat well enough, that their brain isn’t going to heal and recover as quickly. Do you focus on nutrition?
Tamra Hall, PhD [04:29] Well, we do have nutrition components for sure. I mean, nutrition is absolutely important, but it’s not the only important thing. I think it has to be multifaceted. You know, we have to look at it from, you know, nutrition and health and exercise, as well as, you know, are you mentally, you know, healthy? You know, are you stable? Are you, do you have your resources that you need at home? Are you able to pay your bills? I mean, there’s so many contributing factors, but yeah, the brain does need to heal and eating healthy is certainly one of those ways that you can address it has to be not just one thing, but a multitude of different avenues based on what the person actually went through. And the drug of choice, of course, because you look at people that may have been using for, I don’t know, 30 years drinking and their body is very, very deprived versus somebody who’s maybe new to the substance use disorder population and they’re really struggling. But they may have different areas where they are strong, and one of them may be their physical health. So it depends. And what is the comorbidity of the person? So all factors need to be considered. And it’s really hard to pinpoint that down and even have a discussion about it sometimes, because you’re like, wow, the magnitude of this disease is all-encompassing, you know?
Dr. Mark Leeds [05:46] Definitely. And speaking of comorbidities, you know, like when a person has another psychiatric condition, and sometimes you don’t even know if they have it because maybe it’s the drugs causing them to look like they, you know, maybe someone looks like they have a certain psychiatric condition and you might diagnose them with something. And then as the drugs get out of their system, you might look at them again and say, well, they don’t really have that was the drugs that were causing that. Or they may very well have an underlying psychiatric condition. Do patients get to see a psychiatrist to get evaluated for that?
Tamra Hall, PhD [06:19] Oh, absolutely. Absolutely. And it really depends on what level of care they’re seeking and the intensity of services needed to treat what’s going on. But absolutely, we need to rule that out. And it’s hard. You’re right. It’s hard to tease it out because it’s sort of a chicken or the egg situation where what came first and which one is sort of causing the other one to trigger and how do they coexist and how do they ping off each other. There’s, you know, you’ve got to be able to tease out, is there an underlying mental health condition that may be driving some of these addictive patterns?
Dr. Mark Leeds [06:57] How about family therapy or did families get involved in rehab?
Tamra Hall, PhD [07:01] Oh, yes. Well, you know, that would be foolish for me to say, yeah, everybody gets involved. We certainly reach out to family members, but there are times when the individual who’s coming in, maybe the family is a source of the problem. You know, maybe family isn’t necessarily a part of their healthy recovery. So, you know, reaching out to family support systems is important. But I like the word, I like using, you know, a support system because a support system says maybe it’s a community member. Maybe it’s a best friend. Maybe it’s an aunt or an uncle because parents are just not healthy or siblings are not healthy or maybe your partner is not healthy. I think we have to look at finding a support person for the individual in treatment and making sure that supportive individual is involved in that treatment process. I mean, but we certainly have family days. Our facility in Tampa has, you know, every Saturday or certain Saturdays are, you know, sort of a family picnic type day where they come in and they monitor and work with the family members, work on communication skills, and then, you know, they break off into individual family therapy sessions. So, you know, and it’s not always just the family that shows up, you know, maybe the only person, you know, somebody has is somebody from AA or maybe it’s their sponsor. You got to bring in what you can because without support, this is just not a disorder you can do or overcome on your own.
Dr. Mark Leeds [08:30] That’s a good point. Definitely. To the patients, they do get exposed to the 12 steps. Do you have like a 12 step facilitator at each location that helps introduce that to people if they might be uncomfortable with the idea of it?
Tamra Hall, PhD [08:42] Yeah, I mean, we definitely have that available at every single site. You know, people can join 12-step or they can specifically do AA or they can do NA. There’s a lot of different types of modalities that we offer. You know, just over the years, we’ve learned that people may really, really like AA. And then there are some people that, you know, may like smart recovery because they don’t like sort of the component of a higher being, you know, involved in it. So, yeah, you have to have those modalities offered. And it’s important to create that diversity so that people feel comfortable because they may not gravitate to the individuals. Maybe they like that approach, but they may not gravitate towards the individuals in that recovery group because there’s a lot of healing that goes on just between the individuals communicating in the group and sharing. So, you know, they may want to try something new.
Dr. Mark Leeds [09:37] That’s really good that you offer access to smart recovery because I think maybe other rehabs are in the past, it was all 12 steps or nothing. People would go into rehab and they would be told that the 12 steps are the way and the only way. And now you have smart recovery, which offers a whole different way of looking at things. And I know that they use cognitive behavioral therapy as part of their program. Do you implement that in your rehab program also?
Tamra Hall, PhD [10:05] Oh, absolutely. It is a big part of it. We have to incorporate that. I mean, because you really want to look at what are the thoughts, you know, sort of driving these behaviors and getting at that thought process. It’s a big part of what we do along with motivational interviewing because it’s proven. It’s proven to work. It sort of raises the person’s awareness, makes them cognitive of what is going on behind the scenes, what is driving their behaviors. Personally, I love cognitive behavioral therapy and I like seeing it on ground. Some people just really want to get to a more spiritual part of that, and we offer that as well.
Dr. Mark Leeds [10:42] If you had to explain cognitive behavioral therapy or CBT, just a really straightforward, easy-to-understand explanation. I thought I understood that it helps people identify triggers. I heard a commercial on the radio for it yesterday. Apparently, they’re advertising CBT on the radio. And they said it was about becoming aware of the bad thoughts and replacing them with good thoughts or something like that. How would you explain it just in a straightforward way? What exactly is CBT?
Tamra Hall, PhD [11:11] Well, CBT is obviously huge. It’s much bigger than that. It’s about the entire process of thought and behaviors that pre-exist are ingrained in what we do and sort of changing those and being aware of those. I think it’s helpful sometimes to shrink it down because it’s more digestible, especially when you’re solely focused on your recovery. You go into this little pocket, if you will, and you need to focus on the things that are going to work for you. So I think sometimes we break it down into more digestible pieces for the individuals and then sort of step it up as they go. I don’t like to bury a lot of treatment in psychobabble. I don’t think it works. I don’t think it resonates with people. Overall, when I look at the way people react to it in a treatment setting or when they’re working on recovery, the more psychobabble that you put on things, the more they disconnect with it. So you’ve got to consider the practical application of a lot of these modalities or these evidence based treatments, because they can be as great as they want on paper and they can say all these fancy things and all this research around it, which is great. It definitely is. But now how are you going to translate that to somebody who is actually in the midst of the greatest struggle of their life? How is that going to become real for them? And that’s a really different story. And that really comes down to an art. And that really separates the good therapists from people who are maybe not as great at providing therapy. You’ve got to be able to translate that into something that actually is going to help that patient.
Dr. Mark Leeds [12:44] Yeah. Yeah. That reminds me of a show we were just watching where it was that show with Hugh Grant, The Undoing, where he asked the lawyer, what’s our strategy? And she said, our strategy is fluid. It’s based on whatever they throw at us.
Tamra Hall, PhD [12:57] Which is true. I mean, life is fluid. And isn’t that what we’re teaching people anyways? You know, it’s that rigidity sometimes that gets them in trouble. So, you know, we got to be able to account for whatever is going to be thrown at us in life. And sometimes, you know, people who can’t or they don’t have that resiliency makes it really hard to do that. So, you know, you got to teach them how to be flexible when somebody throws it this way or that way. You know, do you duck? Do you swerve? Do you know, what do you do? So people have to be able to move in any situation.
Dr. Mark Leeds [13:30] And you also mentioned motivational interviewing, which is interesting as far as, you know, not, I guess it’s not attacking a person or saying you need to do this. Or you need to do that, but maybe getting them to come to the right conclusion.
Tamra Hall, PhD [13:44] Right. Recovery is a personal thing. You have to meet the person where they’re at, and you have to let them guide that process. And you’re really there just to make sure things are going the right way or that they’re going down the right path. Giving people the answers all the time is not the answer, and it really is not the answer. So you have to have people sort of lead that journey, lead that process, and then meet them where they’re at.
Dr. Mark Leeds [14:11] Yeah, that makes sense. You know, in Florida, they have the Marchman Act, which I think scares a lot of people. That’s the thing where a person could be put in a treatment against their will. Their family can go to a lawyer, and they can go to the judge, and they can be put in treatment for three months or even up to six months. And in some cases, it’s not a bad thing. In some cases, it’s a protective thing. I believe it protects a patient from other legal issues, you know, like where the state might take over their case and they might get sent to a place where they don’t want to be sent, maybe jail or maybe like a state-run rehab that’s not very pleasant. Do you work with attorneys or with those kind of situations where patients need to be put in rehab for maybe an extended period of time and maybe compulsory rehab?
Tamra Hall, PhD [14:54] Actually, we don’t. I do know of a lot of facilities in Florida that do provide that. We do not. Everybody that comes to any of the American addiction facilities has to be there of their own free will.
Dr. Mark Leeds [15:07] Okay, yeah, and that’s also, I mean, it must make things easier and, you know, not easier, but it must make things, you know, as far as like if you’re sitting next to someone who doesn’t want to be there and they’re in lockdown and, you know, might make it harder for the other people that want to recover. So that, yeah.
Tamra Hall, PhD [15:25] Well, they don’t all, now let me say this. Not everybody wants to be there. Some of them, you know, are given an ultimatum by their family or maybe this is the last chance to save a marriage or whatever it is. A lot of times people say they want to be there, but they really were forced there. But as far as legal restrictions around it, yeah, we don’t have that. We don’t lock our facilities. People are not forced to stay.
Dr. Mark Leeds [15:51] Yeah, that was in a movie also. I don’t remember that. There was a movie about, I think it was a true story. It was a guy that was heavily addicted to methamphetamine and the father was trying to do everything possible to help him. And he was in shock when he found out that the rehab didn’t lock people up in rehab, that someone can actually get up and walk away if they want to.
Tamra Hall, PhD [16:08] Yeah. Yeah, they can.
Dr. Mark Leeds [16:12] But I think a lot of people are conflicted that they kind of secretly, they do want help. And then they don’t, at the same time, I mean, you know, brain doesn’t always all work together at once. You can think two different things that are opposing at the same time where you want to stay and get better. And at the same time, you don’t want to stay.
Tamra Hall, PhD [16:29] Right. That’s exactly right. You know, You’ve got to work through that with people and find out where they’re at. That’s why meeting them where they’re at is so important because everybody’s at a different place in their recovery process. You need to identify that early on so that you’re not speaking basically over their head because they’ll just shut it out. They don’t want to hear it. That’s not where they’re at. That’s not the steps that they’re ready to make. It is important.
Dr. Mark Leeds [16:53] Do you use contingency management in your treatment as far as rewarding people for when they do the right thing?
Tamra Hall, PhD [17:00] I don’t know if I would call it rewarding people. I mean, we certainly have, it depends on what level of care they’re at. You know, people that are more in our community-based care levels. You know, there’s a lot of outdoor activities and things that they can do when they come during the day that really make the groups fun. But, you know, when you’re in our residential type programs and if you’re doing, you know, really good in those programs, we do have things that are enjoyable for people to participate paid in, you know, but it’s not necessarily just for those individuals that, you know, did a great job or achieved something. I think we try to encourage everybody equally to achieve greatness, and so we really try to avoid a specific bonus or award or whatever it is. I think the ultimate reward is that, you know, recovery, and we certainly have, you know, things that we do to reward the steps along the way. Sometimes it’s a coining ceremony or it’s a certificate of achievement. There are those types of things that we use throughout the treatment process, depending on what the person or what program the person is engaged in.
Dr. Mark Leeds [18:13] Also in rehab, when a person is in a residential program for a period of four weeks or even a couple of weeks, it creates a great opportunity to start a medication like naltrexone. For example, if a person is on opioids and they go to a doctor’s office, you really can’t give them naltrexone because they need to be opioid free for at least a week, which is almost impossible for a lot of people to go home and be opioid free for a week because three days in quitting opioids, they get the worst cravings of their life. They just say, forget this, I’m going to go back to opiates again. But when a person is in rehab, that’s a great opportunity. Do you offer that like Vivitrol or Naltrexone?
Tamra Hall, PhD [18:54] Absolutely. Yes, we do. We have MAT services. Right now, they’re specifically in the facilities, but we’re looking at setting up programs to continue that so that they can continue with outpatient services as well as receiving those MAT services. We’re looking to expand that because it’s very, very important. There are a lot of people that need that sort of step down to help them and to suppress those cravings. So absolutely, we believe in that.
Dr. Mark Leeds [19:21] Yeah, that’s great. Yeah, because especially if a person gets their Vivitrol shot, like towards the end of their stay or during their stay, and then they leave, that happens to some people, they try to find a doctor, and it’s hard to find a doctor that gives Vivitrol. And so yeah, continuity where a person can get it for at least six months or more, or a year or more is really important.
Tamra Hall, PhD [19:41] Absolutely, absolutely. And even if they are leaving your program, and they decide not to stay, and even if we do have a MAT program, they’re like, yeah, you know, I want to stay with your MAT program. We have to be vigilant about including in their discharge plan a specific appointment with a specific facility or setting up that doctor’s appointment for follow-up. So when they leave, they’re actually leaving with an appointment in hand for their next MAT service, whether it’s with us or somebody else.
Dr. Mark Leeds [20:07] How would somebody find your program? I mean, would they just basically, would the best way be if, you know, if they’re typing on Google or?
Tamra Hall, PhD [20:16] Well, you know, there’s several different ways. You know, we have a really strong online presence, so we get a lot of calls from our websites. But also, you know, American Addiction Centers is a well-known name. And so we get a lot of people that will just call directly and, you know, say this is what’s going on. And then we sort of, based on the needs and, you know, what specific centers specialize in, you know, or whatever the payer may be, we will send them to the appropriate site that’s going to address those issues. So, but it’s mostly from our websites, from word of mouth. We get a lot of word of mouth referrals. We’re starting to get more and more community referrals as our centers become, you know, more involved in their local communities. We get a lot of people that’ll just show up at the site and we can actually do a quick screening and assessment there to bring them in the program. So we really want to make our doors as open as possible. The other cool thing that I think a lot of providers are going into that AAC definitely has a big presence in is the telehealth services. So just in the state of the world is right now, having those telehealth options is really, really important. We have a totally secure patient portal, and they can go in through that. They can sign all of their documents. They could see live group therapy with their doctors. It’s basically face-to-face. Like if you and I were sitting right in front of each other, in fact, we were discussing the other day, you know, how big of an impact this telehealth really has become. And we were, I do a lot of stats and research behind what we do. We crunched all the numbers and found that we had a 94% attendance rate for those individuals participating in our telehealth programs, which is really, really good. I don’t know if it’s people being comfortable in their own homes and being able to receive treatment in an environment that is just more conducive or relaxing to them, you know, whatever it is. But they are actively involved and they can’t just, you know, doze off or sleep while they’re doing it, you know, because the therapist can see them and the group members can see them. So it’s really, really great that AAC is sort of embarked down this road very, very early and that we have the technology to support it correctly. Because it is an important part of treatment. So that is another venue in which they can come in and receive those services. So, you know, you got to keep those doors very, very wide open, because you never know when the next person is going to come in for need and what their need is.
Dr. Mark Leeds [22:48] Yeah, and telehealth is definitely really important. That’s great that you’re way ahead on that. And it’s true. I think you’re right. I was just seeing a patient yesterday and who was apologizing for, you know, being in the middle of her busy household. I said, well, no, that’s perfect. That’s just like the old fashioned house call where a doctor got to get insight into how the family was interacting together. I mean, that’s important to see how a person is really living at home and not just how they present themselves when they come in.
Tamra Hall, PhD [23:14] Absolutely. Yeah, absolutely. You get to see them in their own, you know, environment. And I think it makes them feel better. There’s a lot of opening up, you know, and when we found that number, you know, when we saw how high the attendance was, we reached out to the facilities and the therapists that are actually providing and we’re like, well, is that just because they’re logging in and, you know, dozing off or, you know, what’s going on? And all the therapists pretty much across the board were saying, no, no, they’re active. You know, they’re talking, you know, we have to make sure that people are trying to, you know, mute while others are talking because so many people are engaged in talking. So, you know, we keep those groups small so we don’t have a big problem with that, but there’s a lot of activity in that area. And I really, really hope that, you know, as things progress into 2021, we keep that going. I’d like to see more government involvement in pushing that as being the mainstay for mental health, for substance use services, because it gives us that broader reach into people who may be a little more apprehensive to physically go on site.
Dr. Mark Leeds [24:15] As far as insurance, in 2008, I think with Obamacare, part of that law, the Affordable Care Act. There was the Parity Act, which made access to mental health equal to everything else, where an insurance company couldn’t deny a person getting care. And I’ve come up against this where insurance companies don’t want to pay for life-saving medication, and a person might not get access to it when they need it right then. It’s either they’re going to take it now, or they could overdose the next day because they didn’t have access to it. And the insurance company says, well, we need three to five days to review it. And things have gotten better. But I mean, do you take insurance and do you really fight on behalf of the person to make sure the insurance company does what they’re supposed to do and covers addiction treatment?
Tamra Hall, PhD [25:02] Oh, gosh. Yeah. You know, you are speaking to, I mean, you’re just speaking about something that is a daily constant battle for us. Yes, we take private insurance. In fact, predominantly certainly private insurance and or private pay. So that’s majority of our patients coming in, you know, working with larger payers can be very difficult. You know, parity was great. It was back in the day, I actually ran for public office because of the parity bill. And I was very, very supportive and wanting to see it go through. And like you said, you know, we got the parity bill through. The problem is we don’t have enforcement. And so it looks great on paper, but unless you can enforce something, it’s not going to go very far. So our biggest problem a lot of times is working with the payers and not necessarily that it’s all bad, but yeah, it’s a definite struggle because getting authorization for that care. And meanwhile, we’re providing that life-saving care to make sure these individuals are getting what they need and their insurance company is behind the scenes going, eh, you know, well, we’re going to think about it. Or, well, you know, we think, even though they’ve never seen the patient, we think they deserve this level of care. Really, the doctor doesn’t need to be that involved. You’re over-providing care. And you’re just like, and you saw the patient win? So it becomes a struggle. It’s a daily battle. I mean, there’s a whole department dedicated to working with the insurance companies and talking to them every day about the medical necessity of each patient. It’s a lot of work, but at the same time, individuals need us to do that. People need us to talk to that insurance company and get that pushed through so that they can get the services that they’re actually paying for when they’re paying these premiums every month. They’re paying for this. So it really is, it’s a difficult battle. I’d love to see more enforcement of parity. I’ve had, without naming the payer specifically, I’ve had a payer in a meeting. We’ve gone to the table and dispute with them actually you know we’ll say well this is where you didn’t follow parity law and they said we don’t care flat out we don’t care oh well they absolutely know they’re doing it so it’s struggle
Dr. Mark Leeds [27:18] Yeah yeah I don’t know I don’t think I’ve ever had anyone say I don’t care but I’ve seen some these crazy things where it’s essentially the same thing where they just refuse to do what they know they’re supposed to do
Tamra Hall, PhD [27:29] It’s scary I don’t know how they sleep at night. There’s sometimes I’m thinking, who is behind the curtain? You know, I want to pull back Oz’s curtain and say, like, are you human? Are you a robot? What’s back there? But, yeah, I’ve literally sat at a table with a bunch of lawyers and had that flat out said to me.
Dr. Mark Leeds [27:47] That’s good that you have experts, you know, billing experts and legal experts and people, you know, looking at these things and advocating for the patient. Because there are ways. There’s tricks, you know, in the long, you know, when a person calls and fights on the phone with their insurance company, company, I always tell people don’t bother because they’re just wasting your time and using up the time that you might need. You know, you might only have a short window of time to fight this and you need to be reading all the fine print on the many pages of documents they might have sent you in the mail. And, you know, the answers are all in there of like the secret fax number you have to send something to and the wording.
Tamra Hall, PhD [28:20] The secret. Yeah, that’s so true. And it’s hard for them because they’re supposed to be focused on the recovery or getting healthy. You know, they don’t need to be focused on all this fine print at the bottom that you have to sign in blood or give your firstborn. I mean, it is amazing to see what some of this requires. But, you know, the industry has really improved. I agree with you. I mean, there are some things that insurance companies stand behind that I agree with. I think we do need to improve the services that we give. I think the industry was very much like the wild, wild west in the past. And it’s improved greatly, mostly because the payers were the first ones to stand up and say, hey, no, this needs to be up to the standards. So I do agree with that is a very, very important transition that I think a lot of places have had to make. You know, when I say AAC is a healthcare organization, I think that’s really important for individuals and payers to know that we are a healthcare organization first and we provide the healthcare that is absolutely medically necessary for individuals. So, you know, we had to improve, everybody had to improve. And now I think that sort of forced us all into a better place. We’ve got ASAM that’s really been a big part of, you know, adopting that and PEAR’s coming along forward with that. So we all agree on some baseline standards. It’s an evolving industry. It’s an evolving part of healthcare. Medicine had to go through this eons ago. You know, behavioral health had to go through this in the 90s. Substance abuse is now going through growing pains. And hopefully we’re coming to a place where, you know, we’re settling into, you know, we all agree upon standards and we all agree upon certain thresholds. And so patients can get the services they need.
Dr. Mark Leeds [30:03] Are you guys involved in harm reduction at any level as far as like if a person just isn’t ready at all, like they’re just not going to come into treatment? As far as maybe community services with things like naloxone or any other things that might involve harm reduction. I’m just keeping a person safe and healthy and alive until they are ready to come into treatment.
Tamra Hall, PhD [30:24] Well, we’re connected with other facilities for sure that provide that. So if a person isn’t ready to come in to our facilities upon the first call or when they’re calling into our call center, the navigators there will certainly point them in the direction that they need to be in so that they’re not floundering out there. You know, if our services don’t fit for you right away, we want to make sure that you’re getting services that you’re being taken care of. So AAC itself does not do harm reduction, but we do make sure that we’re involved with other industry providers that do. And so if a person calls, they’re going to get services regardless.
Dr. Mark Leeds [30:58] Are you providing any of the new high-tech things as far as like they have apps that do therapy of some sort? You know, there’s Pear Therapeutics, they have an app that does cognitive behavioral therapy and rewards and that kind of thing. And it keeps the person connected. Well, I know you said you do have your own technology that connects people online, but also like biofeedback technology. There was a thing I saw years ago where they connect patients to a, they put electrodes on their head to pick up their brainwaves and they can actually help people to get into like a different state of mind, I guess, like a alpha or beta or theta state or whatever, you know, something more relaxing and to help them deal with cravings. Are you providing any kind of those novel new technology-based therapies?
Tamra Hall, PhD [31:42] Yeah, we definitely provide those kinds of therapies. We do have biofeedback at some of our facilities, which is great. A lot of patients really like that’s something they can do on their own time. It’s something we have. We also have some apps. We’re working towards introducing them earlier in the therapeutic process so that people are more familiar by the time they get out, but most of them right now, like what we’re working with is like an aftercare app. So individuals being able to have sort of a social community, much like Facebook, but for sobriety. And it’s specific to the AAC family, if you will. So we even have employees that are living in recovery that post, you know, when they hit certain milestones and all kinds of stuff. And there’s a lot of fun activities that are involved in that app, but there’s, you know, we’re always following what the science is saying and where the industry is going. But at the same time, we don’t want to let go of the fundamentals. You know, the fundamentals are very, very important. And I think sometimes you can get at least fancy add-ons, but when push comes to shove, you know, you really got to work on the core issues that need to be addressed for people to recover. So, you know, yes, those things are great. And we have some of them, but we never, ever lose sight of what we’re doing and the core fundamental elements that people have to work on while they’re in recovery.
Dr. Mark Leeds [33:06] That’s actually really important that what you mentioned of having like a social connection of patients that may have gone through and people may form a really close bond with the other people that they’re in treatment with.
Tamra Hall, PhD [33:18] Yeah, community is extraordinarily important, you know, especially when you’re new in your recovery, you know, who do you talk to? Who else has gone through this? You know, you don’t want to go back to your community and basically lose all connection to that recovery community. And so this is, this is a real easy way, you know, you can be sitting on your phone and or taking a break at work and you could just scroll up and see, you know, how people are doing. It’s something we monitor though, strictly to make sure that it stays, you know, very positive and that it’s helpful, but people have a way, you know, on there to reach out. So when people identify that there may be struggling, we reach out to them, we will call them and make sure they’re doing okay and offer services if they need them or, you know, a referral if they need it to make sure that people are actually working in their recovery and doing well. Because you can’t just abandon people and say, oh, good luck. You know, hey, nice pat on the back. Thank you. And hopefully you do great in life. That’s just not how recovery works. We know this is a lifelong struggle. This is a challenge. It’s an, you know, you get up in the morning, it’s as normal as putting on your pants and your shoes. You know, you got to put on your recovery every single day. So, you know, we want to make sure we’re a part of that and having that sort of community. It’s not just us, it’s bigger than us. It’s, you know, yeah, the people you connected with in treatment, the people that you shared, you know, your life story with in group, that’s important. You opened up that book and it’s really, really important to be able to stay connected to those individuals in a positive way. So technology is just great in that way because it would have been harder in the 1990s or the 80s, you know, to have that sort of social community, but now you can live all the way across the world and still stay in connection with people like they’re right there. So it’s a very, very positive thing to include in our aftercare services. But yeah, you’re right. Bring it in early so people understand what it is instead of when they’re walking out the door, it’s not like we’re just going to hand you and this is how you do it. And hopefully you join. You know, we want to make sure they’re aware of it and they can make a choice if they want to be involved or not.
Dr. Mark Leeds [35:18] Are you guys involved in any of the new up and coming therapies that are being researched, everyone now has interest in things like psychedelic therapy, psilocybin, ketamine, and even cannabis for treating addiction. And some countries are already using various kinds of psychoactive drugs to treat addiction and in some way reset the central nervous system. And there’s some risk to those things and questions of if they even work or if it’s a good idea. Are you guys looking into any of those new treatments or are you using some of them now?
Tamra Hall, PhD [35:52] We are not using any of those right now. We are not involved in any of those. We want to make sure something is very evidence-based before we engage in it or subject anybody to it. But I think it’s important as an industry leader to always be aware of it. I mean, we certainly know what’s going on. Myself and the chief medical, you know, we’re always reading the research behind what’s new in the industry. And it’s fascinating to see things that are going on in other countries and some of the results they’re getting. But I like to err on the side of safety and make sure that it is something that is well practiced before, you know, you introduce it to somebody who is, like I said, in the midst of the largest struggle of their life. You don’t want something that’s, well, this is, you know, up and coming or new. And that’s not what I think everybody needs at that particular point in their life. So they want to know it’s going to work. I mean, this is this is their life you’re talking about. So they want to know it’s going to work.
Dr. Mark Leeds [36:47] Is detox part of your program? Can people that are just coming off of alcohol or heroin or fentanyl come right into your program, or would they have to go to a detox facility first?
Tamra Hall, PhD [36:58] Oh, yeah. We certainly have detox. We have all levels of care. So we provide the detoxification and the withdrawal management, residential services. We provide partial hospitalization or day programs, if you will, here in Florida. That’s what we call them, day-night programs. We have intensive out. We have outpatient. So, and then now, of course, the telehealth services that are available. So we have all levels. So it’s a very, very involved process. You know, we make sure that we cover all spectrums for individuals and people come in at different levels. It depends on where they’re at. You know, we assess for that medical necessity coming right in off the bat and make sure we match them up where they need to be. Because not everybody needs withdrawal management and some people need a lot more withdrawal management. It just really depends. But yeah we make sure we offer all of those for our patients and I believe all of our sites actually let me think yeah all of our sites have withdrawal management in one form or another yeah
Dr. Mark Leeds [37:57] Tamra Hall thank you for joining me today on the rehab podcast
Tamra Hall, PhD [38:00] Yeah thank you for having me Thank you.
