The Sober Truth (12 page)

What can we conclude from this? At minimum, as the researchers themselves write (with some understatement), “There appears to be a loss of treatment effect over time.” It appears that the benefits of being away from the stresses of ordinary life, in a beautiful and peaceful setting with caring people, exercise, good food, lectures, and topic-focused discussion groups, do not last long. And besides these generic supports, the single foundational treatment offered by Hazelden and most other rehab centers is the 12-step program, whose success rate we know. Rehab’s poor outcomes in light of these limitations are, therefore, not surprising.

Besides the Hazelden studies, there is little academic literature on rehab treatment outcomes. One paper cited in chapter 3 does apply, though: the 2003 study by McKellar and colleagues. In that investigation, you will recall, the subjects (all men) had been treated in a 12-step
inpatient
program before being followed up. After one year, “hazardous consumption” (the frequency of consuming more than four drinks on a drinking day) was still extremely high, at 42 percent. Even this very troubling result is certain to be an underestimate: this study suffered from the same major positive biases as the Hazelden paper, relying on self-reports and excluding those (nearly 25 percent) who had dropped out. An accurate estimate of hazardous drinking was probably at or above 50 percent at one year, consistent with the corrected Hazelden data.

It cannot be ignored that the nation’s best-known rehabs seem to continually fail their highest-profile clients as well, as most Americans with a passing familiarity with popular culture will know. Boldfaced names such as Charlie Sheen, Lindsay Lohan, Robert Downey Jr., Britney Spears, and the late Whitney Houston have, according to the media, been through rehab many times. Amy Winehouse famously wrote a song rejecting a return to rehab just a few years before she died of substance abuse. Danny Bonaduce once said about Promises Malibu: “They charged me more than $40,000 for my stay and I drank on the way home. But Malibu was beautiful. I remember thinking that if this place had a bar, it would be fantastic.”
¹⁷
With the 2013 death of Mindy McCready, the number of deaths associated with the hit show
Celebrity Rehab
reached five, leading Dr. Drew Pinsky to shutter the operation.

There is a certain halo around the rehab industry that can make its failures all the more poignant. Because many people can’t buy into AA for various reasons, including its religiosity, its rigidity, and its close-mindedness to criticism or different ideas, rehabs centered on the Twelve Steps may produce significant conflict within people as they struggle to get help. The mandatory requirement to attend 12-step meetings and the pressure to accept AA philosophy in the great majority of rehab centers have likely led many a patient to feel unheard. And when they relapse after leaving expensive and triumphantly marketed programs, the experience can lead to hopelessness. The Betty Ford Center writes on its website, “Alcoholics, addicts, and their loved ones who require alcohol treatment or drug treatment begin the exciting journey to a new life at the Betty Ford Center.” Sierra Tucson’s site says that at their “internationally-renowned alcohol treatment center, you won’t just be undergoing alcohol rehab. During your time at Sierra Tucson, you will experience innovative alcohol treatment programs that can effectively treat you completely.” Promises Malibu’s site states, “Promises drug rehab centers create the ultimate safe-haven for you or your loved one who has decided to take this important step: choosing to create an extraordinary life.” We can only imagine the pain of seeing the dream of a new life dissolve into the difficult patterns of the old.

The overwrought marketing literature of most rehab programs is intentionally designed to sell a fantasy, placing them in marked contrast to organizations whose descriptions are guided by professional standards of honesty and decorum. No respected hospital or program would claim to be able to so transform the people who enter its doors. And all of them acknowledge that if a patient isn’t better upon completion of the treatment, it’s not the patient’s fault.

For instance, here is the self-description of one of the nation’s finest medical facilities: “The mission of Dana-Farber Cancer Institute is to provide expert, compassionate care to children and adults with cancer while advancing the understanding, diagnosis, treatment, cure, and prevention of cancer and related diseases.” And here’s one of the country’s finest psychiatric facilities: “For over 90 years, the Austen Riggs Center has offered long-term residential and hospital-level psychiatric treatment based on intensive, four-times-weekly individual psychotherapy, provided by psychiatrists and psychologists who have advanced and specialized training.”
¹⁸

The consequences of a post-rehab relapse are often far greater because of the enormous costs, as well. For many families who are making a major financial sacrifice based partly on the promise of metamorphic treatment, seeing a loved one return to addiction can be devastating. Patients have too often found that their support networks are not as robust following a stint at rehab; it’s not uncommon for families to direct their resentment when a patient “fails” not toward the rehab, but toward the patient: “How could he return to drinking after we put him through that wonderful/famous program at such expense?” And let us remind ourselves that this expense is usually borne without insurance.

In a sense, rehab centers are hardly new. They occupy a specific place in the American imagination that has thrived for more than a century: the mythology of the convalescent paradise.

Chronic diseases requiring chronic care have been with us throughout history. To take just one example, one hundred years ago, a pandemic of tuberculosis led to the rise of TB sanitaria. Often these were placed in warm, dry climates with “clean air” where breathing was easier. A close look at these lovely facilities provides a number of startling parallels to the addiction rehab industry that would follow a century later. Because TB was so widespread, many of its sufferers had enough money to choose any inpatient center they wished. This created a competitive market, and TB sanitaria marketed themselves with ever more elaborate treatment programs offering high-end luxuries sought by those who could afford them. A look at some of the marketing literature of the day feels eerily familiar:

Here is the Battle Creek Sanitarium, in 1907: “The one institution where all the most recent scientific curative measures have been assembled under one control. Many new and interesting departments have been recently installed, including Radium, Diathermy, Electrical Exercises . . . the Sanitarium offers many unique opportunities to health-seekers. The new Diet System, the physical culture classes . . . the interesting health lectures, swimming, games and drills.”
¹⁹

The Sanitarium at Dansville, New York, enticed visitors with its “Beautiful Location among the hills of Genesee Valley. Pure air, pure water; climate especially mild and equable at all seasons of the year. . . . It has light, airy rooms. . . . All forms of baths, electricity, massage, etc. are scientifically administered. The apparatus for Dr. Taylor’s Swedish Movements, and a superior Holtz machine for Statical Electricity are special features. . . . An unrivalled Health Resort.”
²⁰

And so on. Moore’s Brook Sanitarium called itself a “splendid old Colonial place, over 100 acres, mature grove, grass and vine . . . 250 feet of wide veranda . . . Billiards, pool, golf, tennis, etc.” And Dr. Rogers’ Hydropathic Sanitarium and Congenial Home noted its “fine grounds and salubrious air” that could “effectually remove any disease, however chronic.”
²¹

Despite these luxuries, none of these institutions offered any treatment for the actual cause of the illness. Indeed, while the bacterium causing TB was discovered in 1882, it would be sixty-four years before any real treatment (an effective antibiotic) was developed. It was precisely during these years when the TB sanitaria thrived. Once specific treatment did become available, the elaborate sanitaria died out, never to return.

Alcohol and drug rehabilitation centers are in just this position now, with one marked difference. Better understanding and treatment are already available; they are just not included in their programs. The addiction treatment industry is based on a model that has been unchanged since the 1930s, and because these programs are commonly staffed by people who often know little beyond AA and whose professional identities depend on the rightness of that model, there has been an enormous resistance to change. This failure in understanding and treating addiction is plainly evident in the proliferation of strange therapies and unrecognized treatments, which rehabs continue to hawk.

What might a better rehab program look like? To begin with, instead of the senseless notion of requiring exactly the same number of days of hospitalization for everyone, a rational program would be individualized. Considering that one purpose of residential care is to provide a more intensive treatment, all patients would be seen by an experienced, well-trained psychotherapist multiple times a week, if not daily. Therapists would have to be professionally qualified academically and up to standards of excellence for psychotherapists in the community.

Groups would be a highly valuable component, if they were designed to help patients learn about themselves and how they relate to others; that is, to find out how they are perceived and to experiment with new ways of relating. Patients themselves would bring up the ways their addiction has intertwined with their feelings about themselves and their relationships with others; no meeting would come with a set “educational” agenda.

An ideal program would also have no need for lectures about drugs or for instruction about how to use 12-step programs. Alcoholics Anonymous would be made available outside the center (free of charge, of course) for those who could make good use of it. Any decent program would also provide basic services such as adequate food and common spaces for patients to talk and learn from each other. But gourmet food and spectacular settings have nothing to do with treating addiction, so these frills would be eliminated, allowing the cost of rehabilitation to stay within reach of the common person.

I will say more about effective treatment, after first considering what really does make sense in understanding and treating addiction, in the next chapter.

BECAUSE THE NATURE OF
addiction
itself has never really been understood in human history, the phenomenon was originally associated only with its clearest form: drunkenness. The symptoms of inebriation were easy to see, leading to the conclusion that alcoholism was about the physical effects of alcohol. Because alcoholics not only couldn’t stop, but often enjoyed their drinking despite its terrible effects on others and themselves, many people also believed that alcoholism was a moral failing, even a kind of insanity. These ideas—that the problem of alcoholism lay in the power of alcohol, and that alcoholics had a moral deficit that allowed them to succumb to this power—led to a treatment that pressed alcoholics to acknowledge the power of this chemical and try to improve their morality by turning to God. This approach was, of course, Alcoholics Anonymous.

One of the principal sources of confusion was that people mixed up
physical addiction
with the underlying
nature
of addiction. Even though both may be present in the same person at the same time, they actually have nothing to do with each other. Physical addiction is a simple physiological phenomenon that can happen to anybody. Our bodies react to certain drugs by adapting to them, changing to accommodate their presence. This phenomenon is called
tolerance
. Dramatic things can happen when people stop taking a drug to which they have become tolerant. Because the body is “prepared” to deal with the drug, when the drug is removed, a reaction occurs. The body pushes back, compensating for a drug that isn’t there.

This is known as a
withdrawal syndrome
—a set of physiological symptoms that are always expressed in the exact opposite direction from the effects of the drug. Since nearly every drug capable of producing physical addiction is a sedative (also known as a central nervous system depressant, or “downer”), the withdrawal syndrome is physiological overexcitement. In the case of alcohol, this starts with shaking (“the shakes”), but can proceed to full-blown seizures. Withdrawal from other drugs looks different. Narcotic withdrawal, for instance, commonly involves goose bumps and severe gastrointestinal discomfort. Interestingly, since seizures aren’t present for narcotic withdrawal, it’s actually medically safer to withdraw from heroin than from alcohol.

How do we know that this physical addiction has nothing to do with the true nature of addiction? One clue is that many addictions have no physical component at all. Examples include the addictive use of marijuana or LSD, which don’t produce a tolerance response, and all the non-drug addictions such as compulsive gambling, eating, shopping, and sex. A second clue is that it’s common to develop a
physical addiction
but never have a true addiction. Everyone who is hospitalized and given high enough doses of morphine over a period of enough time to treat pain—for example as part of treatment for cancer—will become physically addicted. But when these people are discharged, they generally don’t run out and find the local drug pusher. One more way to be sure that physical addiction and true addiction are separate things: we know from vast experience that, even after detoxification, when there is no more physical addiction, true addicts are not “cured” of their need to use alcohol or other drugs. Many return to use months or even years after detox.

Starting in the 1960s, experts in human psychology began to take an interest in addiction for the first time. Rather than viewing the behavior as a form of pleasure seeking, they theorized that taking drugs was something people did to manage intolerable feelings, almost like self-prescribing a medication. Thus was born the now-famous “self-medication hypothesis” of drug use.