The Sober Truth (10 page)

Of course there are some treatment centers that are explicitly non-disease-model and non-12-step. New York’s St. Jude Retreats describes itself this way:

However, St. Jude’s is an outlier in this regard (and the program is unfortunately limited by employing a purely educational model, staffed by teachers rather than therapists).

Nearly all other rehab programs have some allegiance to the 12-step method. Even somewhat more psychologically sophisticated programs, such as Promises in California and the Fernside Center in Massachusetts, still incorporate the Twelve Steps into their philosophy.

All this begs the question: given that virtually every rehab is an elaborate expansion of 12-step meetings, why do people spend a fortune for programs that aren’t fundamentally different from what they could find for free in a church basement?

The biggest difference between rehabs and AA meetings on the outside is, of course, the element of institutionalization itself: being away from one’s ordinary life while receiving constant care and support is a qualitatively separate experience from attending meetings from home.

Yet hospitalization isn’t necessarily an unqualified good, nor is it considered “better” than outpatient treatment for many problems. In medicine, hospitalization is usually indicated only according to a specific set of criteria: patients are either unable to care for themselves, in precarious health, or in need of significant further treatment unavailable on the outside. No such criteria are applied at most of the biggest rehab centers, where admission decisions are generally made according to subjective and opaque processes, including, predominantly, the desire to be admitted and, of course, the ability to pay.

The duration of residence is treated differently in rehab than it is in either psychiatry or the rest of medicine as well. Nearly all credentialed medical facilities determine the length of a patient’s stay according to that patient’s diagnosis, history, and medical needs. Yet virtually every major rehabilitation center requires a lump-sum stay of twenty-eight, or sometimes thirty, days. (Promises Malibu opts for thirty, because “we want our clients to leave here with 30 days of sobriety,” according to CEO David Sack.)
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This number is applied without any special consideration of the health or prognosis of the patient. One size fits all.

One might reasonably ask: How does anyone know that thirty days is the right number of days to treat addiction? Is there any evidence to suggest that this number somehow represents the best way to achieve lasting sobriety? In fact there isn’t. Thirty days is just a round figure borrowed from our lunar cycle—one month. As I once wrote on my blog for
Psychology Today
, “The real question is: why would people design, and defend, a treatment based on the time it takes for the moon to revolve around the earth?”
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And yet if we dig deeper, a second reason emerges for the thirty-day rehab. Years ago, when insurance companies used to pay for inpatient rehabilitation, it was often deemed necessary for patients to stay for much longer periods of time. Once insurance carriers set the maximum on the number of days they would cover at thirty, that quickly became the proper number of days to treat alcoholism.

Another key attribute of the rehab experience is total control. Most centers have very strict policies regarding the use of banned substances and activities. Cell phones are typically prohibited, and schedules are tightly managed. The upshot is that these thirty days represent a period of time during which patients have no choice but to stop using alcohol or other drugs. The appeal of this rule cannot be overstated: the notion of being made to stop can be a relief for both addicts and their families. Of course, living without alcohol or other drugs does not eliminate the compulsion to use them in the future. Sadly, the relief many addicts experience during hospitalization is often mirrored proportionally by the despair that follows a return to using alcohol or other drugs in the real world.

Some rehab centers will only admit those who have successfully withdrawn from alcohol or other drugs, but some also offer in-house detoxification, which is the medically monitored process of helping people withdraw safely from alcohol or other drugs. This is without question a valuable service. But even for people who are infirm medically or have certain diseases, such as diabetes, that require close monitoring during withdrawal, it is rare for detox to take longer than five days. Once the detox is complete, residential treatment is elective.

Aside from the twenty-four-hour control and monitored detox facilities, it can be difficult to find features or add-ons that necessitate the residential component of rehab programs. But that hasn’t stopped these programs from creatively searching for further competitive advantages. As I described above, the nation’s most famous programs have devised extraordinary lists of classes, crafts, exercises, and adventures to differentiate themselves from one another, as well as from the free 12-step meetings. These are worth considering in some further detail, both for what they promise, and for what they lack.

Sierra Tucson lists on its website “qigong therapy” among its favored treatment approaches, to take just one example. Its website describes qigong as an ancient form of Tai Chi, and states that its benefits include “enhanced immune system,” “increased energy and vitality,” “improved intuition and creativity,” “heightened spirituality,” and “improved cardiovascular, respiratory, circulatory, lymphatic, and digestive function.” The fact that there is no scientific basis for these claims is perhaps secondary to the more basic point that none of them have anything to do with the treatment of addiction.

Sierra Tucson also offers its guests “equine therapy,” noting that the process “involves establishing a relationship with a horse on the ground and then evolves into the nurturing of that relationship, which may or may not culminate in actual riding in a contained area. . . . Horses are typically non-judgmental and have no expectations or motives. Therefore, a patient can practice congruency without the perceived fear of rejection.” These claims are made without any specific reference to addiction beyond the vague intimation that being near a horse will help a person break through the “stumbling blocks to recovery.”

And I’ll leave this description of Sierra Tucson’s Reiki treatments without comment: “Reiki involves the transfer of energy from practitioner to patient and enhances the body’s natural ability to heal itself through the balancing of energy.”

Sierra Tucson is hardly alone in its pursuit of novel amenities. Promises Malibu matches Sierra Tucson horse for horse with its own equine therapy program, then ups the ante with “yoga, acupuncture and massage,” “life coaching,” and SPECT brain imaging, a medical procedure involving injecting a radioactive chemical to visualize tumors and brain damage in dementia. The American Psychiatric Association’s Psychiatric Evaluation of Adults Guideline in 2006 stated that “the use of this technique for treatment planning, diagnosis, monitoring illness or predicting prognosis has not been shown.” Nor is there any known connection with addiction.

The Betty Ford Center has remained somewhat more conservative, merely offering “aquatic aerobics” and “kickboxing” among its daily activities; Passages Malibu goes all in with its “Adventure Therapy” and “Ocean Therapy” programs, the latter of which it describes as an excursion on the center’s own private yacht (the
Safe Passage
), “organized to demonstrate how exciting and inspiring a sober life can be.”

Put all these elements of rehab together, and it’s a wonder there is any time left over for actual treatment. Indeed, a typical day in rehab may be surprising. Here is the daily schedule published by the Betty Ford Center:

You will notice that the day is long, running a full fifteen hours from 6 a.m. to 9 p.m. How much “treatment” is in there? There is an hour-long lecture, presumably led by a staff member; another hour-long “peer” lecture, not led by a staff member; two hour-long group meetings (a “small group” and a “relapse prevention hour”); and an hour-long 12-step meeting. Out of the fifteen-hour day, then, one can distill four actual hours of Betty Ford “treatment,” half of which involve lectures instead of therapy, plus an AA meeting.

What is the rest of the day filled with? Eating, fitness, “work assignments” (“circling chairs in the group room, making community announcements, setting up tables in the dining room . . .”), and free time. There is also an hour during breakfast for “nicotine support” and a newcomer meeting when people first arrive (otherwise, patients attend the 12-step meeting).

With the possible exception of one hour (“small group”), what is notably missing from this schedule is bona fide therapy. Although there are presumably individual meetings with counselors of some sort at the Betty Ford Center—the center lists a consulting medical staff that includes physicians and psychiatrists—it apparently did not deem these critical enough to their program to be included, or even to show time for, in their daily schedule. The website confirms this in their FAQ:

How typical is Betty Ford? Here is the published daily schedule from Hazelden:

This appears to be another long day. Yet as with Betty Ford, the “full day of therapy” promised by Hazelden actually consists largely of non-therapies such as meditation, education, relaxation, exercise, recreation, “wellness” (for example, biofeedback, for which there is no evidence of effectiveness in treating addiction), and personal time for reflection.

Most of the therapies listed consist of groups that are designated to work on certain areas or skills, and not to freely explore the individual issues for each person. Two of these are groups for “leisure skills” and “stress management,” which are not directly or specifically related to the treatment of addiction. The “anger,” “mental health,” and grief groups may be useful for certain people but seem to be topic-focused rather than individual-focused.

The Rational Emotive Therapy group deserves special mention. RET was developed in the 1950s as an effort to look at emotional life as a problem with rationality. It is intended to help people see their irrational thoughts and learn from them. While this makes some sense, most modern frameworks of human psychology have recognized that learning one has irrational thoughts rarely solves emotional problems; indeed, many people begin therapy knowing full well that they have irrational ideas and make poor choices, yet they cannot stop.

The Hazelden program does list individual meetings yet, like Betty Ford, describes them occurring “as needed.” The explicit de-emphasis on individual therapy is common among the nation’s most popular rehab programs. Even those that pay lip service to the notion of “individualized” care rarely seem to mean what most people would expect from the term. For instance, Sierra Tucson’s description of its own “Individualized Treatment Plans” states: “Patients are . . . provided an individualized treatment plan, which may include disease and recovery education, relapse prevention, 12-Step meetings, Equine-Assisted Therapy, Adventure Therapy, and Grief and Spirituality therapy sessions.”
Individualized
in this context seems to mean choosing different programs à la carte based on the patient. But the programs themselves are not individualized: 12-step meetings are not “individualized treatment.” Educational lectures are neither individualized nor treatment. Equine therapy and adventure therapy are not recognized treatments for addiction (or anything else). And spirituality sessions are neither individual nor medical or psychological treatment. Grief counseling may be individualized if it is psychologically oriented to help people with their specific difficulties in dealing with loss, but not if it is simply generic support. Relapse prevention is a laudable goal, but if it takes place in a group setting, it is less likely to explore in any depth individual emotional factors that lead to relapse.