Does Rehab Work?

Two weeks ago, fresh out of yet another stint in rehab Glee star Cory Monteith killed himself with an overdose of heroin and alcohol.

Sometimes it seems as though every one of your favorite celebrities has done time in rehab. From Charlie Sheen to Lindsay Lohan to Courtney Love many celebrities have made rehab a home away from home.

Now, the mayor of San Diego, Robert Filner is going to rehab to receive intensive therapy for sexually harassing the women on his staff.

Reading between the lines, we discover that Filner is a Democrat. Were he a Republican he would long since have been drummed out of office.

As rehab’s failures accumulate many are questioning its value. After all, rehab is very expensive, so people are naturally asking whether it provides value. Last week in The Daily Beast Lizzie Crocker asked why rehab doesn’t work very often.

It’s an important point. When politicians and pundits talk about how much they want to provide mental health treatment for everyone, they rarely mention its unconscionably high failure rate.

Since Crocker overlooks the reason why people need rehab, allow me to fill in the blank. When someone is addicted to alcohol or drugs, he often needs to detox under strict medical supervision. He needs to be in a controlled medical environment in order to clean out his system.

Thus, it makes sense that rehab facilities promote abstinence. When someone is detoxing you do not offer him a drink or two.

It also makes sense that rehab would take its cues from 12 step programs. These have, by and large, been shown to be effective for those who follow the steps. Unfortunately, many people do not keep with the program and end up back on alcohol or drugs or both.

With the press keeps reporting rehab failures like Cory Monteith, the people who run these facilities are starting to ask themselves what they might be doing wrong. Surely, they are right to do so.

If Crocker is to be believed, they have decided to blame 12 step programs because these are based on abstinence. As you know, the word “abstinence” has become a buzzword designating repression.

For the record, many psychiatrists and addiction counselors are comfortable telling their patients that if they can strictly limit their alcohol consumption to, say, two drinks a day, they need not abstain totally.  Unfortunately, many alcoholics cannot do it.

Crocker reports:

… many [rehab programs] continue to be built around traditional 12-step, abstinence-only programs despite a growing body of evidence that this approach doesn’t work for everyone

That sets a very high bar. If your goal is to find a program that is going to work for everyone, you have set yourself up for failure. Even if, as Crocker suggests and as professionals seem now to believe, rehab has not been offering enough medication to patients, medication only works when an individual takes it. It doesn’t take too much imagination to understand that addicts might abuse prescription medication… when they take it.

It is inconceivable that the professionals who run these facilities are not perfectly aware of this fact. Crocker does not report it.

In the past, Crocker reports, addiction had been considered a behavioral problem. Now science believes that it is a brain disorder.

Again, this is slightly misleading. To take an example, autism is a neurological condition, but it responds to cognitive and behavioral treatment. When you say that something is a brain disorder you should not therefore assume that the only solution is a new drug. If you tell an addict that a drug is the solution, why would he not tell himself that he likes his drug more than yours?

I suspect that when clinicians say that addiction used to be considered a “behavioral problem” they are implying that addiction was taken to be a sign of weak moral character, of a lack of self-control and self-discipline. When they declare it to be a brain disease they are removing the stigma and saying that the addict bears no responsibility for his behavior.

Since 12 step programs are God-based, their approach to treatment involves humility, self-control, and character building: making amends to those you have harmed allows you to take responsibility for your behavior.

But, once you remove both the stigma associated with drug abuse and the individual’s responsibility, what do you have left?

One does understand why rehab programs offer compulsory group therapy. They are trying to inculcate the habit of going to meetings. But, AA meetings are not really group therapy. For one, participants are anonymous. For another, participation is voluntary. You can come and go as you please and you can talk or remain silent as you please.

If you tell patients that they are suffering from a brain disease, you are also saying that they, using their moral resources, are powerless to stop drinking. Doesn’t that mean that a physician has no confidence in the alcoholic’s ability stop drinking? And doesn’t it open the possibility that an alcoholic might drink because he does not want disappoint his physician's expectations?

Celebrity patients have their own special problems. A celebrity who makes a spectacle of himself for abusing alcohol or drugs gains publicity. It’s not just that he is not stigmatized for bad behavior: he is rewarded.

If celebrities, as has often been argued, are gluttons for attention, if they fear anonymity more than anything else, making fools of themselves in public serves a psychic purpose.

A non-judgmental attitude is an addict’s best friend. If you destigmatize addiction you are inevitably going to get more of it. If you convince people that there is nothing they can do, of their own volition, to control their bad habit, they are not going to try.

If no one judges an addict’s bad behavior, he might have to reach what they call “rock bottom” before it dawns on him that he is doing something wrong. Even then, nothing about hitting “rock bottom” tells him that he  can, through his own efforts overcome the problem.

The effectiveness of rehab is limited in another way. An individual in rehab has been cut off from his normal social environment. He is in a safe house where, presumably, toxic substances are not available. He is surrounded by people who are also suffering from addiction.

But this means that he will not learn how to deal with the temptations that will inevitably arise once he returns goes back to socializing the people he got drunk with or took drugs with.

As it happens, AA does address these problems. It encourages people to substitute meetings for bar hopping. It provides some new, sober friends.

If a patient gets out of rehab and is on his own, armed only with a bright new prescription, everyone in his entourage will consider him to be a challenge, like a virgin who needs to be corrupted.

12 step programs don't work for everyone. Rehab certainly doesn’t. And medication probably won’t either.

[Dr. Joy Bliss makes an important point about this post on the Maggie’s Farm blog:

Neither rehab, nor AA, nor any other program "works." The person has to "work the program," and work it as if their life depended on it. Often, it does.

The questions of whether a program or plan "works" premises a medical patient model, a passive model, as if addiction and abuse were like pneumonia, curable by the best antibiotic. They are not. You do not "go through rehab" any more than you "go through AA."]