Saturday, July 27, 2013

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."]


Lastango said...

"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."

And a business purpose. Making a name for oneself is (IMO) the single most difficult thing in entertainment and the arts. Performers who have succeeded in establishing their name are respected by others in their industry for this accomplishment alone.

(FWIW, I recall reading that when Andy Griffith found that his phone had stopped ringing, he called his agent and asked if he ought to contrive to get himself arrested.)

For politicians, it seems rehab has an entirely other purpose: washing the slate clean while eliciting public sympathy. Supporters and friendly media can then endorse without reference to addictions and criminality because rehab has magically put all that in the past.

Anonymous said...

No, no, no

Stuart Schneiderman said...

Why? why? why?

Dennis said...

I suspect that much of this stems from not believing one is worthy of the accolades they are receiving. If one gets their accolades from being a movie star then that is in playing people who really accomplished great things, fought against overwhelming odds and meet the challenges of life.
It probably is some what disheartening that when one puts the accomplishments they have garnered against that of the people played it seems unfair and lacks a certain amount of justice. Feelings of inadequacies can drive people to find ways of dealing with it that almost always leads to destructive behaviors. Without the audience one is no longer an entertainer.
I would posit that rehab does not work, given the amount of recidivism prevalent, because it does not deal with the problems that are extant. Until one can see that their life has value over and above a career then rehab, given its failures, only is a brief respite from it. It is important, especial in the Arts, to have other avenues of growth so one leads a complete life. One has to be vigilant not to let the job define them.

Anonymous said...

You gotta be in it to win it, whether its AA, rehab or whatever. I am very skeptical of the justice system requiring such "remedies," because they are so wasteful. You're not going to win a battle with addiction if you don't want to win, regardless of reasons.


Anonymous said...

When I was in rehab (the first time) I asked the chief counselor about the recidivism rate and was told quite curtly "we don't keep track of that". I replied I was somewhat confused as they had no way of monitoring the efficacy of their program. I have since learned all the mainstream rehab centers have similar programs but seem universally uninterested in improving the model. Maybe they're just churning the addicts for the bucks.

Ben David said...

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.
- - - - - - - - - -
This is a capsule summary of the gay-rights movement.

Anonymous said...

Maybe they're just churning the addicts for the bucks.

Considering many state laws require insurance companies to cover rehab treatments, then yes, this is highly possible. That is - why do you care if it works if you can get paid for it no matter what?

Gordon Scott said...

Of course the rehab industry wants to churn the patients. In Minnesota, the state will pay for rehab if you're indigent. It even has a slang name: Rule 25.

Judges like it, because when someone comes in front of them for their 10th minor drug charge, the judge can order rehab, and dismiss the case. Out of sight (for 28 days) and out of mind.

I am an addict. I have not been through rehab (when I wanted it, they said I made too much money for Rule 25). I have met other addicts who have been through rehab 25 (twenty-five, I'm not kidding) times. It's almost a bragging point.

And there are, indeed, rehab centers here which have as little therapy or programming as possible. House them, feed them, collect the check, and out the door. These joints are also utterly willing to fudge paperwork to admit people from out of state. No one verifies residency.

As Dr. Bliss wrote, rehab itself is useless without the will to stay clean (or sober). AA, NA and all the other As provide members with a set of tools. It's up to the member to take up the tools and use them.

Anonymous said...

I had a psych breakdown in the 80s. Partly from VN PTSD - an affliction I've only recently allowed myself to claim.

At the time, my health insurance paid for 6 weeks of ETOH Rehab. So that's where a shrink I'd never met before sent me for. I was Discharged (if that's the word) the very day my insurance ended.

The experience was a revelation. It was like a Chinese Re-Education Camp w/better food. Fascistic Mind Control, arrogant "counselors", tremendous peer pressure. I'm still v bitter about it.

I struck up a friendship w/a Psych Clinical Ph.D. candidate there. He told me the "success rate" was 3 to 5% - at best. Maybe less.

Upon his death, Socrates asked for a sacrifice to the god of medicine. In gratitude for releasing him from the disease of life.

We have too many Health Nazis as rulers. Many have despicable personal lives. They don't deserve the power. -- Rich Lara