Friday, December 26, 2008

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.

1 comment:

Dan B. said...

Even as a therapist, I know we have to help people stop drinking before we can talk about why they became an alcoholic. But as a therapist, I also know we can ask the same questions of rehab as we do of therapy: “What is rehab anyway?” “And what do we mean by work?” Even though it may seem clear that the ultimate outcome of addictions treatment is absolute abstinence and sobriety, we must ask if we mean over the short or long-term. We can and must ask treatment programs how well they do keeping people clean at 30 days, at 90 days, at 6 months, at one year? Since everyone, even in AA, knows addiction is a chronic and relapsing condition, it seems quite a lofty goal to expect that rehab or AA “working” means that someone stays clean forever. AA does not even allow that one is ever really “recovered”: one is always only “in recovery,” which may make some uncomfortable who are looking for clarity about what “works” means. Generally, a good outcome for any addictions treatment program, even AA, is shorter and more infrequent relapses, and some “harm reduction” for individuals (ie., less dangerous and unhealthy and illegal behaviors) and for society (ie., less crime to support drug habits) while building toward longer-term sobriety and rebuilding a productive life and virtuous character. The outcome data on addictions treatment programs, while less impressive than the outcome data about the general effectiveness of psychotherapy, does reinforce the sense that the best predictor of long term outcome (whether it’s measured as abstinence at 3,6,9, or 12 months, less legal involvement, better health, better school or work performance, or the like) is a patient’s alliance with one’s therapist/rehab counselor. Again we see proximal outcomes predicting distal outcomes – early change in treatment and a positive alliance with a counselor predicts longer term success. This pattern is not to suggest that patients improve despite treatment. On the contrary, when patients improve in therapy and in rehab, it is precisely BECAUSE of the treatment, just not the specific technical and theoretical elements of the treatment. It is the non-specific, contextual factors of treatment that contribute the most to outcome. Treatment works better than no treatment, but the specific factors of the treatment contribute very little to outcome. AA works for this reason as well – it creates a hopeful expectation of change, it offers a community of support, it provides crucial and necessary remoralization, and it amplifies the common factors of all successful treatments and treaters – relationship, hope, and a plan.
Thanks again. A big toast to you, and to one of the best, and certainly the most wide-ranging, new Blogs of 2008!! Dan B.