When Treatment Centers Become Assembly Lines

*Image by Clker-Free-Vector-Images from Pixabay*

I’ve encountered a particular institutional condition often in my work: the drug treatment center with an “assembly line” mentality. Some of the worst behavior happens in these places, clients are rarely served quality care. But it isn’t because of poor staff (who tend to be some of the most passionate recovering people) or poor training (it extends to supervisors and clinicians as well) – it’s an organizational mentality generated by a deadly mix of too many clients and too few resources.

In the end, when staff are faced with an impossible job, they cope with it by adopting the same attitudes and behaviors of workers in similarly dismal and bureaucratic conditions.

The High Volume, Low Resourced Treatment Center

I encounter the assembly line mindset in America’s safety-net treatment centers. Beyond emergency rooms, the poor and mentally ill have increasingly ended up in publicly funded drug treatment, driven by the growth of diversionary programs that mandate attendance, and the transformation of drug treatment from something marginal into an expected community service.

These places are inundated with clients who may or may not need the level of care treatment can provide. One common challenge for staff is sniffing out who is a “real” client – someone they see as an appropriate candidate for help – versus someone who is misplaced, either because they need a higher level of care for a severe mental illness, or because they’re seen as taking advantage of the free housing, meals, and showers a residential stay provides (“We aren’t a psych ward or a shelter…”).

The churn of clients in these places feels like any other bureaucratic system; a welfare office, a jail, or a lower level court. The pressure is the same to quickly process clients and move them through the system. I’ve stood in lobbies listening to an intake interview, a facilitator leading a group, and the clicking of a counselor’s keyboard documenting a discharge – all happening simultaneously (forget confidentiality!).

But while safety-net treatment centers have inherited all of the burdens of public bureaucracy, their staff haven’t inherited the few upsides. There are no large scale unions protecting treatment staff, no pensions or other civil service benefits. Drug counselors are paid less than cops, probation officers, or public school teachers who also deal with high “case loads” in unrewarding conditions. It’s no wonder that their turnover rate is so much higher than other comparably tough professions.¹

The Assembly Line Mentality

The conditions I’m describing match what’s been written about other bureaucracies serving a high volume of the public. In Street Level Bureaucracy, Micheal Lipsky describes how conditions of mass processing shape the mindset of workers. Because work pressures make truly individualized care impossible, staff must think of clients collectively and rely on shortcuts like stereotyping to make quick judgements – an assembly line mentality.

Symptoms in safety-net treatment centers include a tendency to discuss clients as a group or cohort (“We got a tough batch right now”), rather than as individuals. Care may map onto this, with treatment delivered primarily or exclusively through groups. Staff spend considerable time thinking about and anticipating fluctuations in workload and capacity (“high census/low census”), bracing for the next surge and hunkering down when the beds are full.

Hardening is the term I use for this mentality taken to the extreme. If the dissonance of knowing few clients are helped doesn’t break someone down, the staff who remain develop a cynical attitude toward clients who they rarely see getting better. Short-term treatment gives them little opportunity to watch recovery unfold. Unfortunately, this attitude is contagious to newer staff if the hardened staff serve as supervisors or directors.

But the interesting thing in treatment centers is how this interacts with recovery experience. It’s a unique dimension here. Hospitals don’t recruit their ex-patients, nor jails their ex-inmates. But I’ve met more ‘former-clients-now-staff’ in treatment centers than anywhere else. Because pay is unlikely to be high and professional opportunities are few, these places rely on a passionate pool of former clients who feel indebted to the institution to serve as staff. This leads to all sorts of odd results on the assembly line.

Classic recovery clichés can take on double meanings, helping staff reconcile the gap between the ideal of helping every client and what they can realistically provide. That treatment “only works for those who want it” is not just a statement about hitting rock bottom; it also becomes a logic of efficiency. It helps justify investing more effort in clients who appear motivated while giving less attention to those not committed. Ultimately, it helps ration the little time staff can afford to give.

I’ve often wondered why these conditions haven’t led to a mass labor movement in the treatment workforce, like how police officers and teachers have started unions to fight for better welfare. Partially, working conditions differ so sharply between private and publicly funded treatment that solidarity and mass organizing is difficult to build. Equally important, though, is the mindset of the many recovering people who make up the workforce. I often hear that they’re “just happy to be here” – happy to be employed, happy to be given a second chance, indebted to a system that saved them and more than happy to put up with the poor conditions if the job gives them a sense of purpose.

Beyond making them blind to the exploitation they experience, it also impacts care: ex-clients often become the harshest critics of current clients.

Is There a Cure?

In future writings, I hope to illuminate some strategies which seem to bend staff attitudes back in a positive direction. But the cure ultimately lies in changing institutional conditions. If you can reduce the pressure, lengthen the time staff spend with clients, and provide adequate resources, staff will have no incentive to make shortcuts, stereotype clients, or blame them for their perceived failure.

And, broadly, we need to consider the pressures of work before blaming everything on staff. That sort of judgment is especially tempting in the treatment and recovery industry, where “stigma” is assumed to come from personal ideologies, like 12-step beliefs. Academics in this space rarely consider how a lack of resources may push staff toward hasty judgments about medications, abstinence, and motivation. These judgments serve a purpose by helping to ration limited resources and process clients more quickly. Explicitly or not, they often end up serving the goals of low-resourced institutions, a qualification that probably fits the majority of treatment and recovery settings around the country.