* * *
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We know a lot more about alcoholism than we did in the age of Freudian theories and racist speculation (seriously, rehabs should stop using that book). But we shouldn’t be too smug. Despite overwhelming scientific evidence that addiction is not a disease of choice, nor a purely psychological problem addicts should be able to conquer through force of will, our public policies toward addiction are based on false assumptions about what causes addiction. We still pretend alcohol and drug addiction are moral choices, to insulate ourselves from the possibility that it might happen to us, or someone we love. We still delude ourselves with myths about the “type” of people who become addicted, believing the reassuring lie that education, money, upbringing, or love can inoculate our families from a disease that strikes almost indiscriminately. We still tell ourselves that since we can stop drinking after one or two, everyone else should be able to do the same.
So where should people turn if they want help with their drinking? The years I spent cycling through the treatment industry have led me to a few conclusions. First, the treatment industry helps no one by pretending that treatment just “works,” and that if it doesn’t, it’s the alcoholic or addict who’s the problem. When I relapsed after leaving Residence XII, I felt like I had failed treatment, not the other way around, and many of the narratives I learned in treatment reinforced that belief. I hadn’t “stuck with the program” or been “willing to go to any lengths.” I forgot that “meeting makers make it” to long-term sobriety.
And what was the solution the treatment industry presented me with when I wondered how to get sober again? I had to start all over at square one, by going—where else?—back to treatment. I met people in rehab who were there for the sixth, twelfth, or nineteenth time. That’s a lot of twelve-thousand-dollar checks. (And the treatment centers I went to were among the most affordable ones in my area. Treatment can easily cost twenty, thirty, even fifty thousand dollars.) I don’t mean to be cynical about the people who dedicate their lives and careers to helping people suffering from addiction, but research backs me up here. The problem with most treatment programs isn’t that the people who are in them are lazy or don’t want to get better; the problem is that their methods aren’t evidence based, and that twenty-eight days is barely long enough to start sifting through the damage, much less to acquire a whole new set of coping mechanisms to deal with life on the outside.
The stigma associated with “failing” at treatment extends beyond the inpatient treatment world, of course; it’s prevalent in recovery circles, too. Although AA officially welcomes people back from relapse with open arms, the recitation of sobriety dates (“I’m Erica, I’m an alcoholic, and my sobriety date is August 24, 2014”) and comments like “I don’t have another drunk in me” can alienate people who are “starting over” after “going back out.” Many recovery groups and aftercare programs look askance at medication-assisted treatment (MAT) with drugs like naltrexone (which reduces the pleasurable effects of alcohol and helps heavy drinkers drink less) and acamprosate (which reduces cravings), because they see those drugs as a chemical crutch—much the same way groups like Narcotics Anonymous may consider heroin addicts who take methadone or suboxone to be active users.
Fortunately, some treatment centers (and many AA groups) are coming around. Hazelden, the largest residential treatment company in the United States, started offering medication-assisted treatment in 2012. (Gabapentin, a neurological drug I took to stave off cravings during my first six months of sobriety, is itself a kind of MAT.) Still, the stigma against chemically enhanced recovery is strong enough that fewer than one in ten alcoholics who get formal treatment use any kind of medication to help them stay sober.
What would actually help people avoid relapse, or bounce back from a “slip” without ending up far worse off than they were before? First, treatment programs need to start being honest with patients about the likelihood that they’ll relapse, and stop treating relapse like it’s an all-or-nothing proposition. Treatment taught me a single slip is the same thing as total failure (another AA maxim: “One drink, one drunk”), and as a result, I was so profoundly ashamed when I relapsed after spending so much time and money getting “fixed” that I told no one, lying about my drinking until it was obvious to everyone.
Second, they need to start teaching people how to deal with slips—not by treating them like catastrophic tragedies and running straight back to the cocoon of residential rehab but by taking immediate responsibility; reaching out to their support network, therapist, or sponsor; and making a new plan to address whatever caused them to relapse in the first place—right away, before they have an excuse to say “fuck it” and wreak more havoc.
Third, the treatment industry has to be more transparent about its methods. Most people choose a treatment center in roughly the same condition I did—desperate, terrified they’ll lose their resolve, utterly uninterested in details like what kind of program the treatment center offers, the credentials of its staff, or whether most of the patients are there involuntarily or by choice. The second time I went to treatment, the hundred-plus other patients included a large number of young men on temporary leave from jail or prison, a cliquish group of young heroin addicts who scored every chance they got, and a high percentage of people who were there against their will. This is the kind of thing that might have concerned me if I was a sober person looking for a treatment center for someone else, but I was desperate, so I didn’t care. Nor was I particularly bothered by the high number of people who had tried rehab over and over and still weren’t “cured.” Any one of those factors might be a red flag for a person who was seeking treatment in a rational manner, the way people choose schools or day cares or laundry detergents. But few people choose a treatment center in a rational manner. They do it hastily, whenever the elusive window of opportunity opens up.
Treatment centers take advantage of this desperation. You go in, you sit down, and they give you an assessment—a long list of questions that you’re supposed to answer to the best of your ability. Has your performance at school, work, or home been affected by your alcohol consumption? Have you ever gotten into trouble at work because of drinking? Have you ever been hospitalized because of drinking? The treatment provider takes in all this information and tells you the best course of action for your individual case—which, surprise, surprise, typically ends up being a twenty-eight-day stay in their facility. (This is why it’s important to know that you really do want to go to residential treatment before you start calling around. Outpatient treatment may be a better fit.)
The pressure doesn’t let up when you hand over your insurance card. Starting about a week before you “graduate,” the treatment provider will begin urging you to sign up to extend your time in their program through intensive outpatient treatment—by definition, a minimum of three three-hour sessions a week—followed by weekly outpatient treatment, group therapy, counseling, and follow-up visits. There are exceptions, of course—people with less severe addiction may be referred directly to intensive or regular outpatient care, and patients with severe mental disorders may be referred to dual-diagnosis programs that can address both issues simultaneously—but for the most part, treatment centers provide one-stop shopping—assessment, diagnosis, and long-term treatment, all under the same roof. When I was a patient at Residence XII, I had to take extraordinary steps to sign up for outpatient treatment with a private clinic outside the Residence XII system; my counselor warned me repeatedly against going outside the program, even though the private program I picked had meetings after hours and was in my city. Staying with Rez XII would have meant a long bus commute to the suburbs three times a week, when there were plenty of other programs less than a mile from my apartment. The upshot is that the relationship between a patient and a provider may last for two years or longer—from that first desperate, shaky phone call to the end of long-term aftercare, all billable to the same private company or
nonprofit organization. It’s a closed system that leaves little room for desperate people to argue or assess other options, especially if their insurance company will only pay for one chemical-dependency assessment.
Contrary to what you might believe, there are no nationwide standards, and few formal education or training requirements, for addiction counselors. Most states do not require addiction counselors, who make up the overwhelming majority of staff at treatment centers, to have so much as a bachelor’s degree, and fourteen states require addiction counselors to have only a high-school diploma. In my state, a chemical dependency certificate requires only a two-year associate’s degree in “human services or a related field,” or sixty semester hours of college credits from an approved school. (People who lack those credentials can acquire them while working as trainees; at Lakeside, ACs, or assistant counselors, outnumbered fully licensed counselors by a substantial margin.) One nationally representative survey found that only two of the programs surveyed were directed by a medical doctor, less than 15 percent had a single nurse on staff, and most did not employ even one psychologist or social worker. Another nationwide study found that half of all treatment centers had at least some full-time counselors on staff who had no degree; 59 percent had at least one counselor with a bachelor’s degree; 62 percent had a master’s-level counselor; and just 12 percent had a doctorate-level counselor.
In lieu of formal education, addiction counselors tend to have life experience: About half of all addiction counselors are in recovery themselves. They are, in effect, peer counselors with a couple of years of extra formal training. I don’t mean to imply that people without college degrees can’t or don’t make excellent counselors—as former alcoholics and drug addicts who managed to turn their lives around, their life experience is, one might argue, a highly relevant qualification—but it’s worth knowing what you’re paying for. Few staffers at treatment centers have the kind of medical knowledge that you might expect when you check into what looks like a hospital.
Perhaps more concerning is the fact that many treatment centers engage in practices that have been shown to be ineffective—such as requiring people whose brains are still incapable of thinking in compound sentences to take in hours of films and lectures—or counterproductive, like pitting patients against each other, teaching them that it’s their fault if they relapse, and treating a return to drinking or using drugs as a personal failure rather than the near inevitability it is. The 2012 CASA study concluded that the level of care at typical US treatment centers was so low it might constitute “a form of medical malpractice.” According to the CASA report, “Much of what passes for ‘treatment’ of addiction bears little resemblance to the treatment of other health conditions,” which typically involve testing, evidence, and proof. Imagine treating cancer, for example, with a combination of support groups and behavior modification techniques but no medication, long-term medical monitoring, or intensive follow-up. If we believe that addiction is a brain disease—and the American medical establishment does believe this—then it makes little sense that treatment centers aren’t required to follow standard protocols for treating diseases.
Both times I went to treatment, I stayed in low- to midrange facilities—several notches above your typical government-funded treatment centers for the indigent, but several worlds away from the kind of places that get covered in the tabloids when a celebrity goes off to rehab. You may think that rich people are buying better treatment, but money buys amenities, not quality care. The main difference between a rehab that costs a hundred thousand dollars (like Passages Malibu) and one that costs eleven thousand (the average of the two programs I attended) is that the former will offer equine therapy, drum circles, and coffee, while the latter will take away your cell phone and The New Yorker and force you to quit drinking coffee and eating sugar.
So what do good treatment programs have in common? The biggest common denominator is that they include a truly personalized treatment plan—one that considers a patient’s history of trauma, past experiences in treatment, goals, risk factors, cultural background, and individual strengths and needs. A treatment plan should also take into account potential challenges—like a partner with a substance-use disorder, a stressful work environment, or a lack of transportation to get to follow-up appointments. The plan might also include help accessing services such as childcare, welfare, and sober housing. If a person isn’t religious, a good treatment center won’t shame them for not believing in God, or push them to change their beliefs; if they’ve been a victim of gender-based violence, a good treatment center won’t force them to reveal their history of trauma to a mixed-gender group (as I was at Lakeside-Milam, when one counselor didn’t show up for work and we combined two ordinarily gender-segregated groups). A good treatment center will also, in my opinion, include programs for people with co-occurring mental disorders, like anorexia, depression, and bipolar disorder—not just a single group session once a week, but one-on-one counseling to identify underlying problems and come up with a posttreatment plan to tackle them.
Treatment centers too often deliver one-size-fits-all solutions to patients whose problems are distinct and diverse—go to meetings, learn to cope with triggers, don’t isolate, call your sponsor if you want to drink. People who raise questions about one or more elements of the standard protocol, as I did, are told they suffer from “terminal uniqueness”—the (apparently fatal) flaw of thinking you’re different from everyone else. It’s a harsh and humiliating indictment—who wants to be the person who thinks she’s more special than everyone else?—and it has the effect of shutting down discussions of any differences, as if someone with bipolar disorder who drinks alone in her apartment has the exact same issues as a person who copes with abuse at home by blacking out in public every night. I don’t want to blame my treatment center, or the treatment system, for my failure to remain sober after I left, but the prevalence of relapse suggests that the problem extends beyond the patient and his or her “terminal uniqueness” to the inadequate tools we are given for surviving in the outside world. Most of what I learned at Lakeside-Milam happened between lectures and movies and writing assignments, when I was simply talking with other patients. I don’t remember my treatment plan and I certainly didn’t follow it—reading it now, I see it includes steps such as “get a job unrelated to journalism, with less stress/hours”—but I do remember talking to my roommate, Nancy, whose husband was about to leave her, about what it was like to feel isolated even when you’re surrounded by people.
Good treatment lasts as long as a person needs it. There’s little evidence that twenty-eight days is long enough for people to prepare themselves for living without alcohol or drugs in the outside world, and in fact, the twenty-eight-day limit seems to have its origins in historical accident: When the US military began sending soldiers to residential addiction treatment, four weeks was the longest they could stay away without being reassigned. Insurance companies adopted the twenty-eight-day standard, and since then, that (more or less—some insurers will only approve residential treatment in seven-day increments) has been the standard. The result is that residential treatment is essentially acute care—long enough to get a person stabilized and aware of the need to make big changes, but poorly prepared to deal with all the temptation and problems waiting for her outside the treatment center grounds. Fixing the patchwork, insurance-dictated treatment system in the United States is a trickier, longer-term project still. But as my own experience proves, even imperfect treatment can help.
For me, what “worked” to keep me sober, which was my goal, was a combination of medication, AA, cognitive behavioral therapy, self-forgiveness, and the rational-emotive tools I learned in rehab. Others might need group counseling, life-skills training, and a long-term intensive outpatient program. The point is to keep trying things until something clicks. If treatment “fails,” it isn’t because you failed the system, or even that the system failed you (although it can and, f
ar too often, it does). You just haven’t found what works yet. Relapse isn’t failure. Dropping out of treatment isn’t failure. The only failure is not trying again.
Acknowledgments
I started writing this book in my head about a year after my final stay in a detox center, in the winter of 2015, and began putting a rough outline on paper, titled “secret project,” later that year. Eventually, I wrote a fifty-page outline in a single feverish weekend, and that’s probably where it would have ended if not for the capable red pen of my agent, Daniel Greenberg, who helped me immensely throughout the writing process and talked me down from many ledges.
Josh, my bestie, was my constant through all the events of this book and remains so to this day. I’m grateful every day that he didn’t give up on me. His unconditional enthusiasm and support for this project helped me through all the days of second-guessing and self-doubt.
I’m endlessly grateful to all the friends who put up with me through the worst parts, as well as those who got fed up but never gave up hope: Lisa, Stephanie, Renee, Mark, and especially Kevin. Thanks also to my friend Sandeep, who was generous enough to let me use his home on the island as a personal writing retreat whenever I got stuck.
To my boyfriend, Daniel, thank you for your love, forbearance, and encouragement. I’m so lucky to have you in my corner.
My family—in particular, Mom, Dad, my grandparents, and Cindy—supported me when I was struggling and have been my champions during the writing of this book. I hope they read it despite all the swears.
I’m grateful to Allison Lorentzen, my editor at Viking, for whipping this memoir into shape. She saw the big picture when I could not, and challenged me to rewrite, rethink, and reimagine this book. I am so grateful to her for pushing me to open myself up and for helping me tell my story with clarity and integrity.
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