Does Rehab Work?

'Tis the season... for celebratory self-indulgence. But once you have had your fill of wassail and grog, and once your mind no longer feels like it has been invaded by dancing sugarplums, your thoughts may well turn to rehab.

Therapy may be going out of style, but rehab is all the rage. But, does it work? Is it worth the $20 billion we spend on it? According to the New York Times, the insurance companies and government agencies that are paying the bill are seriously interested in the issue. Link here.

Asking whether rehab works is easier than asking whether therapy works. At least with addiction we know what treatment success looks like: no more alcohol or drugs.

When we get to the techniques used by rehab centers, things are murkier. As with therapy, there is no clarity, no high concept that tells us what rehab is. As with therapy, it seems that rehab is as good as the individual counselor.

The medical basis for rehab is the need to detox. In many cases this requires strict medical supervision in a controlled environment.

But it does not take a month or two to detox. The rest of the stay in rehab is filled with numerous therapeutic techniques, some more valuable than others.

From group therapy to individual therapy rehab is a therapeutic cornucopia. Among the more effective is a cognitive technique that teaches addicts how to tolerate discomfort and to deal with it by doing something other than reaching for some absinthe or an eight-ball.

So far, so good.

The problem with rehab is that it takes place within a controlled environment. As such, it offers scant preparation for dealing with the temptations that will assault the recovered addict once he or she returns to the real world.

A patient named Angella explained it well to the Times. After completing rehab she remained sober for two months. Then she returned to her addiction. "After a while," she said, "you just start missing your friends."

That is why the most effective treatment programs for substance abuse are based in the twelve step programs that began as part of Alcoholics Anonymous and that have now been extended to other forms of recovery.

Rehab takes you out of your life; it gives you a temporary respite. AA reorganizes your life more constructively and more ethically.

Of course, most rehab programs involve AA-type meetings. I suspect that they all encourage their patients to continue going to meetings once they have graduated from rehab.

As everyone knows, AA works. It works for a patient population that therapy has never claimed to treat effectively. It does not always work, and it does not work for everyone. Yet, it works with sufficient consistency to allow us to say that the program, not the person of the counselor, has produced a therapeutic benefit.

AA differs from therapy because it is one thing, and only one thing. Therapy has dozens of different schools and many more different techniques. If therapy is confusion, AA is high concept. No matter where you go to meetings, no matter who your sponsor is, the program is the same.

If you say that people get better no matter what kind of therapy is being practiced, you are saying that patients are improving despite, not because of, therapy.

With AA sobriety is not the goal, as it would be with therapy. It is the price of admission. It is the basis for participation, not a goal that exists at some existential horizon.

In my view AA is not therapy. It more closely resembles coaching. It shows people how to reconstruct their lives, especially to live more ethically. It insists that they be responsible to themselves and to others, that they exercise discipline, strength of character, and good habits.

Where therapists often traffic in the rhetoric of empowerment and self-help, AA tells addicts that they must accept that they are powerless to control their habit. It adds that they can only get well when they allow a higher power to take care of them.

Therapy tells you that you are alone in the universe and that no one else really cares about you. AA tells you that you are never alone and that someone will, if you allow it, take care of you.

AA meetings are communal gatherings. They are not led by an expert, by a man or woman of science offering learned interpretations of anyone's behavior. This encourages self-discipline and respect for others.

Therapy tells people that they must gain insight into why they have problems before they can fully exorcise their demons. AA tells them to fake it till they make it. It tells them to improve their behavior now, not later.

AA works for those who follow the program. It is not about discovering why you drink. You merely have to follow the instructions laid out in the twelve steps. Recovery is something you earn for yourself by working at it in the conduct of your everyday life.

Obviously, psychotherapy has always had issues with AA. First, because it is free; second, because it does not require credentials.

Also, AA has a dubious pedigree. Psychotherapy arose from the lucubrations of great European thinkers like Freud, Jung, and Adler. AA was cobbled together in Akron, Ohio by a couple of drunks names Bill and Bob.

Psychologists and psychiatrists often learn about AA, but they do not spend their time figuring out why twelve step programs works where insights and epiphanies do not. They learn developmental psychology and advanced psychodynamics but spend precious little time studying why it is necessary to make amends for past failures and why a higher power heals something that they can only wave at.