The Sober Truth (2 page)

There is nothing inherently wrong with apologizing to those who have been harmed, directly or indirectly, by the consequences of addiction. The problem is the echo once more of the fundamentalist religious principle: that the path to recovery is to cleanse oneself of sin. Yes, apologies can be powerful things, and there’s no question that reconciling with people can be a liberating and uplifting experience. But grounding this advice within a framework of treatment alters its timbre, transforming an elective act into one of penance.

People suffering with addictions as a rule tend to be well aware of the many “wrongs” they have committed. Awareness of this fact doesn’t help the problem.

If AA were simply presented as a religious movement dedicated to trying to comfort addicts through faith and prayer, the program would not be so problematic. What is troubling is how resolutely—and some might say disingenuously—AA has taken pains to dissociate itself from the faith-based methodology it encourages.

AA’s emphasis on proselytizing, a basic tool through which recognized religions and certain fringe religious groups spread their message, is an essential part of its worldwide success, and it’s a big reason that it has been nearly impossible to have an open national dialogue about other, potentially better ways to treat addiction.

I have been treating people suffering with addictions in public and private hospitals, in clinics, and in my private practice for more than thirty years. In that time, I have met and listened to a very large number of people who have “failed” at AA and some who continue to swear by it, despite repeated recidivism.

Dominic’s case is just one example (I have changed the names and nonessential details in the passage below and whenever I discuss patients in this book). Dominic began drinking heavily as a junior at a good college. Weekly binges soon turned to daily abuse, with predictable results: his grades plummeted; his attendance vanished. By the time he arrived home for winter break, Dominic’s family was deeply concerned about his deterioration. They advised him to seek counseling at the university health center.

Advisors there recommended that Dominic begin attending AA, which he did. He became fond of his sponsor and felt included for the first time in years—no small feat for a suffering young man. But he also found himself increasingly resentful of the “tally system” that AA uses to measure sobriety: every time he “slipped” and had a drink, he “went back to zero.” All the chips he’d earned—the tokens given by AA for milestone periods of sobriety—became meaningless. This system compounded his sense of shame and anger, leading him to wonder why he lacked the willpower or fortitude to master the incredible force of his alcoholism.

By spring, Dominic had dropped out of college. His parents turned to the family doctor for advice. She told him to double down on AA—to attend ninety meetings in ninety days, which is a common AA prescription.

It worked. Although many of the faces at the meetings kept changing and Dominic constantly felt the urge to drink, he found a few “old-timers” who believed wholly in the program and who encouraged him to dismiss the great majority of people who fell through the cracks. They just weren’t ready to stop, he was reassured. Dominic soon learned to distract himself from thinking about alcohol and to call his sponsor when the urge arose.

Four months into the program, Dominic became frustrated during a call with his bank. He bought a fifth of vodka and drank so much that he fell down the stairs, suffering three cracked vertebrae. A series of increasingly expensive stints in rehab followed throughout his twenties, with poor results. During this time, he was hospitalized twice and lost every job he held. A brief marriage ended in a bad divorce, and Dominic was deeply depressed by the time someone in his life recommended that he try something other than a 12-step program. Maybe talk therapy was worth a try.

When Dominic entered my office, he had accepted as empirical truth that he was a deeply flawed individual: amoral, narcissistic, and unable to turn himself over to a Higher Power. How else to explain the swath of destruction he had cut through his own life and the lives of those who loved him? His time in AA had also taught him that his deeper psychological life was immaterial to mastering his addiction. He had a disease; the solution was in the Twelve Steps. When he was ready to quit, he would.

It took eight months of psychotherapy before Dominic stopped drinking for good. Although he remained in therapy for several years after that, the key that unlocked his addiction was nothing more complex or ethereal than an understanding of what his addiction really was and how it really worked.

Dominic had felt enormously pressured all of his life, consumed by a suffocating need to excel in every activity. He was driven by a hunger to be “good enough”—accomplished enough, successful enough—to please his demanding father and blameful mother. Whenever he felt he was not performing up to his potential, his old sense of being trapped by implacable demands arose, and with it came a deep sense of shame and an equal fury at the awful helplessness he felt about this burden. Those were the moments he had to have a drink.

Eventually he came to realize that this odd coping mechanism made a certain kind of sense. By making a decision to drink, he was empowering himself—he no longer felt helpless. Once he understood the connection between his lifelong feelings and his urges to drink, he was able to view them with some perspective for the first time. He found that he was able to predict when his drive to drink would return, since it always tended to surface right after that old, unbearable pressure to perform. He developed enough awareness into what was beneath these urges that he could take a step back and deal with those issues more directly and appropriately. Over time, he was also able to work out the underlying narrative forces that had led him to feel so helpless throughout his life. He had, in other words, supplanted the notion of a Higher Power with something far more personally empowering: sophisticated self-awareness.

Dominic’s history follows the same contours as thousands of others. But one part of his story warrants special attention: the series of failed attempts at rehabilitation. Dominic’s family lost close to $200,000—their total retirement savings—on this string of ineffectual programs.

Rehab owns a special place in the American imagination. Our nation invented the “Cadillac” rehab, manifested in such widely celebrated brand names as Hazelden, Sierra Tucson, and the Betty Ford Center. Ask the average American about any of these institutions and you will likely hear a response tinged with reverence—these are the standard-bearers, our front line against addiction. The fact that they are all extraordinarily expensive is almost beside the point: these rehabs are fighting the good fight, and they deserve every penny we’ve got.

Unfortunately, nearly all these programs use an adaptation of the same AA approach that has been shown repeatedly to be highly ineffective. Where they deviate from traditional AA dogma is actually more alarming: many top rehab programs include extra features such as horseback riding, Reiki massage, and “adventure therapy” to help their clients exorcise the demons of addiction. Some renowned programs even have “equine therapists” available to treat addiction—a fairly novel credential in this context, to put it kindly. Sadly, there is no evidence that these additional “treatments” serve any purpose other than to provide momentary comfort to their clientele—and cover for the programs’ astronomical fees, which can exceed $90,000 a month.

Why do we tolerate this industry? One reason may sound familiar: in rehab, one feels that one is
doing
something, taking on a life-changing intervention whose exorbitant expense ironically reinforces the impression that epochal changes must be just around the corner. It is marketed as the sort of cleansing experience that can herald the dawn of a new era. How many of us have not indulged this fantasy at one time or another—the daydream that if we could just put our lives “on pause” for a while and retreat somewhere pastoral and lovely, we could finally make sense of all our problems?

Alas, the effect is temporary at best. Many patients begin using again soon after they emerge from rehab, often suffering repeated relapses. The discouragement that follows these failures can magnify the desperation that originally brought them to help’s door.

What’s especially shocking is how the rehab industry responds to these individuals: they simply repeat their failed treatments, sometimes dozens of times. Repeat stays in rehab are very common, and readmission is almost always granted without any special consideration or review. On second and subsequent stays, the same program is offered, including lectures previously attended.

Any serious treatment center would study its own outcomes to modify and improve its approach. But rehabs generally don’t do this. For example, only one of the three best-known facilities has ever published outcome studies (Hazelden); neither Betty Ford nor Sierra Tucson has checked to see if their treatment is producing any results for at least the past decade. Hazelden’s follow-up studies looked at just the first year following discharge and showed disappointing results, as we will see later.

Efforts by journalists to solicit data from rehabs have also been met with resistance, making an independent audit of their results almost impossible and leading to the inevitable conclusion that the rest of the programs either don’t study their own outcomes or refuse to publish what they find.
⁵

AA IS UNDENIABLY AN international phenomenon, but its rise to world consciousness was neither easy nor inevitable. The story of AA’s ascendance and ability to beat out so many competing ideas is a tale of tremendous will and effort that rests largely on the shoulders of its tireless messengers—none more so than AA founder Bill Wilson, known in recovery circles simply as “Bill W.”

Bill Wilson was a lifelong alcoholic with a string of business failures under his belt before he managed to marshal America’s most august institutions to the cause of AA. These included such household names as the Rockefeller family, the
Saturday Evening Post
, Yale University, and later, the American Medical Association. Some of this lobbying occurred in the open, in the form of public testimony and press, but a greater portion took the form of private navigation among the power players of America’s medical elite.

To tell the story of AA’s ascendancy properly, we must begin at the beginning and ask a simple question: What did people
do
about alcoholism before the advent of AA?

Alcoholism has almost certainly been with us for as long as alcohol itself. Fermented fruits, primitive spirits, and home-brewed wine feature broadly in indigenous rituals, and some of the earliest writings in Eastern and Western literature make reference to prodigious drinking.

A landmark essay in 1774, “Mighty Destroyer Destroyed,” discussed alcoholism for the first time in American letters.
¹
This was followed a decade later by Dr. Benjamin Rush’s “Inquiry into the Effects of Ardent Spirits on the Human Mind and Body,” a widely circulated monograph that sought to describe “chronic drunkenness” from a scientific perspective, and to redefine the problem as a disease worth treating. This second essay became something of a foundational document for one of the more powerful political moments in American culture: the temperance movement.
²

The term
temperance
was shorthand for a religiously inflected approach to the problem of “chronic drunkenness,” one that held that alcohol itself was dangerous and addictive. More focused on drinking than on drinkers, the temperance movement gained momentum as a mass effort to rid homes and taverns of alcohol and, expressly, to restore morality to America. Protestants and Catholics alike endorsed different versions of the platform, and more than a million people had signed on with the movement by 1837.

None of these advocates seems to have spent much time seeking to lighten the burden of the “incurable drunk.” The era’s prevailing treatments consisted of detoxification, hospitalization, institutionalization, and prayer. But Americans wouldn’t have long to wait for an innovation that might serve the “drunks” themselves; a major breakthrough was just around the corner.

In 1879, an Irish émigré named Dr. Leslie Keeley made a startling announcement: “Drunkenness is a disease, and I can cure it.” The statement electrified the nation. Keeley had a secret sauce, a “tonic” of chemicals administered via injection, which he claimed had the ability to eradicate the craving for alcohol. Not much is known about these injections today, but some historians have speculated that they contained a mixture of “atropine, strychnine, cinchona [basically quinine], glycerin, and gold and sodium chloride.” This was a tonic that, as one modern historian noted, required one “to possess a strong constitution to withstand the treatment.”
³
Keeley was nonetheless famously bullish on his eponymous cure, telling anyone who would listen that it had no injurious effects, and that it worked 95 percent of the time.
⁴

The Keeley method spawned a cottage industry of Keeley Institutes—some 120 nationwide—that would eventually “treat” as many as 500,000 alcoholics between 1880 and 1920. Alas, despite the storied fortitude required to withstand Keeley’s needle, alcoholism itself was more than up to the task. Keeley’s method fell out of favor as the public eventually recognized it as a scam. His branded network of rehab centers was completely shut down by the end of World War I.