The Sober Truth
Page 9
Rehab programs thrive in this gray area.
THE DATA
Hazelden is a slight exception, having been far more forthcoming than many other rehab programs in describing and studying its own outcomes. On its website, Hazelden has reported that at one month following discharge, over 20 percent of patients said that they had resumed drinking; at six months, that number had risen to over 40 percent; and at one year, almost 50 percent of patients had resumed drinking.14 Although there is no data beyond one year, the downward slope of this outcome suggests that fewer than half of these former inpatients remained abstinent after the first year. This is a troubling result. But as it turns out, even these findings have been inflated.
Hazelden’s abstinence figures are taken from a 1998 article published in the Journal of Addictive Behaviors.15 The study involved people who had gone through the Hazelden rehab and then followed up at one, six, and twelve months. None of these patients were interviewed in person; instead, all were sent questionnaires by mail. If patients did not return the questionnaire, they were called on the telephone. All of the data was therefore captured from self-report or the reports of people whom patients had chosen to reply for them.
The limitations of this method are obvious: people who are not doing well often will not reveal the extent of their return to addictive behavior because of shame, an unwillingness to acknowledge that they have not succeeded in the caller’s program, or hostility to telling the truth to somebody they don’t know. Consequently, it is far easier to get false positive results from this sort of study design (people claiming to be doing better than they are) than false negatives (people claiming to be doing worse than they are). But even more problematic than the tendency of self-reports to underreport bad results is what the researchers did with those who failed to respond at all. Unlike Hazelden’s summary, the paper itself reveals that the authors ignored the critically large attrition rate in their subjects. They reported the results of only the people they could contact, and did not count those who dropped out. It is well known in survey-based research that those who drop out tend to be those who fared worst; indeed, the paper’s authors made this very point, even though they fell into this error:
Outcome figures may be considered to represent the upper limits of outcome . . . the self-administered mailed questionnaires were completed and returned by those individuals who could easily be contacted and who were willing to complete the questionnaire. If someone did not respond to the mailing, then the telephone follow-up method was initiated. These individuals may not have responded to the mailing because they did not want to report that they had used alcohol during the follow-up period. These results are corroborated by other studies showing that easy-to-contact subjects have better outcomes than do difficult-to-contact subjects. Therefore, those clients who were not contacted with either follow-up method are more likely to have poorer outcomes, as a group than those who were contacted.16
How many people were unaccounted for? The authors again: “The outcome figures are based on 1-month, 6-month, and 1-year follow-up response rates of 79%, 76%, and 71% of the sample, respectively. . . . About one-quarter of the sample remains unaccounted for in terms of follow-up outcome data.” The authors also found that the people who didn’t return the mailed questionnaire and had to be contacted by phone showed poorer outcomes than those who did return the questionnaire, giving further support to the notion that the people most eager to respond were those with the best outcomes.
What happens to the data if everyone is included? We cannot know whether all the dropouts resumed drinking, but as all researchers (including the authors) agree, it is likely that they did worse as a group. Let’s start by assuming that all the dropouts resumed drinking. Then, using the reported percent of dropouts at each measuring point, here are the results with everyone counted: At one month, nearly 40 percent of patients resumed drinking. At six months, about 55 percent resumed drinking. At one year, 63 percent of patients had resumed drinking.
These results paint an even grimmer picture than Hazelden’s presentation of the data. But, just as Hazelden’s numbers overestimate its success, these numbers may overstate its failure. So let’s recalculate with an optimistic assumption in Hazelden’s favor. Let us assume that, instead of all of the dropouts resuming drinking, they had only mildly worse outcomes, say 25 percent worse than the measured group. Then the numbers look like this: At one month, about 27 percent of patients had resumed drinking. At six months, the number rises to about 44 percent. By one year, 51 percent resumed drinking.
The correct numbers are probably somewhere between these two results. But even with this more optimistic reading of the data, one year after a rehabilitation treatment whose stated aim is the AA goal of abstinence, most patients had returned to drinking. Given the downward direction of the data, we can reasonably conclude that if the study were continued beyond one year, the outcome would continue to worsen. For a lifetime problem, this is a serious deficiency.
Hazelden opted to present its data another way as well, reporting findings about the percentage of days abstinent (PDA), rather than complete abstinence. This actually makes a good deal of sense from a treatment perspective, since patients can improve without being continuously abstinent. Looking at days without drinking, Hazelden’s expatients reported significant improvement at all the follow-ups within the first year, although as with continuous abstinence, the improvement declined over time. Hazelden shows a graph of these apparently excellent results on its website, though the reference for this graph is not given. Without seeing the data behind the graph, we cannot know what the PDA data mean in real terms. But we know that the numbers Hazelden used for its presentation are averages; they don’t include breakdowns of how many patients were drinking large amounts, how many were drinking medium amounts, and how many patients were abstinent. And given the way data was gathered and treated in the Journal of Addictive Behaviors paper just cited, we cannot know whether these are all self-reports by questionnaire or whether the dropouts in the study were counted.
However, we can look at the same PDA data from the Journal of Addictive Behaviors paper just examined, since PDA results were also described there. That paper found that at one year 16 percent of the non-dropout patients drank at least one day weekly. Once again, however, the authors do not account for the 420 of the original 1,083 people who dropped out of this portion of the study. If we again assume they did less well than the people who responded and drank at least one day weekly, the percentage of patients who were weekly drinkers after one year more than triples—to 49 percent. If we recalculate with the same optimistic view of the dropout group that we used before (that the dropouts’ weekly drinking was only 25 percent more than the measured group), the weekly drinking figure rises to over 18 percent. Somewhere between 18 percent and 49 percent represents a dismaying proportion of people who were drinking every week twelve months after leaving rehab. And this number, of course, is derived from data biased toward favorable self-reports. Finally, this result doesn’t include all those (the majority, as we saw above) who are drinking, even if not every single week.
What can we conclude from this? At minimum, as the researchers themselves write (with some understatement), “There appears to be a loss of treatment effect over time.” It appears that the benefits of being away from the stresses of ordinary life, in a beautiful and peaceful setting with caring people, exercise, good food, lectures, and topic-focused discussion groups, do not last long. And besides these generic supports, the single foundational treatment offered by Hazelden and most other rehab centers is the 12-step program, whose success rate we know. Rehab’s poor outcomes in light of these limitations are, therefore, not surprising.
Besides the Hazelden studies, there is little academic literature on rehab treatment outcomes. One paper cited in chapter 3 does apply, though: the 2003 study by McKellar and colleagues. In that investigation, you will recall, the subjects (all men) had been treated in a 12-step inpatient progr
am before being followed up. After one year, “hazardous consumption” (the frequency of consuming more than four drinks on a drinking day) was still extremely high, at 42 percent. Even this very troubling result is certain to be an underestimate: this study suffered from the same major positive biases as the Hazelden paper, relying on self-reports and excluding those (nearly 25 percent) who had dropped out. An accurate estimate of hazardous drinking was probably at or above 50 percent at one year, consistent with the corrected Hazelden data.
It cannot be ignored that the nation’s best-known rehabs seem to continually fail their highest-profile clients as well, as most Americans with a passing familiarity with popular culture will know. Boldfaced names such as Charlie Sheen, Lindsay Lohan, Robert Downey Jr., Britney Spears, and the late Whitney Houston have, according to the media, been through rehab many times. Amy Winehouse famously wrote a song rejecting a return to rehab just a few years before she died of substance abuse. Danny Bonaduce once said about Promises Malibu: “They charged me more than $40,000 for my stay and I drank on the way home. But Malibu was beautiful. I remember thinking that if this place had a bar, it would be fantastic.”17 With the 2013 death of Mindy McCready, the number of deaths associated with the hit show Celebrity Rehab reached five, leading Dr. Drew Pinsky to shutter the operation.
CONSEQUENCES OF FAILURE
There is a certain halo around the rehab industry that can make its failures all the more poignant. Because many people can’t buy into AA for various reasons, including its religiosity, its rigidity, and its close-mindedness to criticism or different ideas, rehabs centered on the Twelve Steps may produce significant conflict within people as they struggle to get help. The mandatory requirement to attend 12-step meetings and the pressure to accept AA philosophy in the great majority of rehab centers have likely led many a patient to feel unheard. And when they relapse after leaving expensive and triumphantly marketed programs, the experience can lead to hopelessness. The Betty Ford Center writes on its website, “Alcoholics, addicts, and their loved ones who require alcohol treatment or drug treatment begin the exciting journey to a new life at the Betty Ford Center.” Sierra Tucson’s site says that at their “internationally-renowned alcohol treatment center, you won’t just be undergoing alcohol rehab. During your time at Sierra Tucson, you will experience innovative alcohol treatment programs that can effectively treat you completely.” Promises Malibu’s site states, “Promises drug rehab centers create the ultimate safe-haven for you or your loved one who has decided to take this important step: choosing to create an extraordinary life.” We can only imagine the pain of seeing the dream of a new life dissolve into the difficult patterns of the old.
The overwrought marketing literature of most rehab programs is intentionally designed to sell a fantasy, placing them in marked contrast to organizations whose descriptions are guided by professional standards of honesty and decorum. No respected hospital or program would claim to be able to so transform the people who enter its doors. And all of them acknowledge that if a patient isn’t better upon completion of the treatment, it’s not the patient’s fault.
For instance, here is the self-description of one of the nation’s finest medical facilities: “The mission of Dana-Farber Cancer Institute is to provide expert, compassionate care to children and adults with cancer while advancing the understanding, diagnosis, treatment, cure, and prevention of cancer and related diseases.” And here’s one of the country’s finest psychiatric facilities: “For over 90 years, the Austen Riggs Center has offered long-term residential and hospital-level psychiatric treatment based on intensive, four-times-weekly individual psychotherapy, provided by psychiatrists and psychologists who have advanced and specialized training.”18
The consequences of a post-rehab relapse are often far greater because of the enormous costs, as well. For many families who are making a major financial sacrifice based partly on the promise of metamorphic treatment, seeing a loved one return to addiction can be devastating. Patients have too often found that their support networks are not as robust following a stint at rehab; it’s not uncommon for families to direct their resentment when a patient “fails” not toward the rehab, but toward the patient: “How could he return to drinking after we put him through that wonderful/famous program at such expense?” And let us remind ourselves that this expense is usually borne without insurance.
THE AMERICAN SANITARIUM LIVES ON
In a sense, rehab centers are hardly new. They occupy a specific place in the American imagination that has thrived for more than a century: the mythology of the convalescent paradise.
Chronic diseases requiring chronic care have been with us throughout history. To take just one example, one hundred years ago, a pandemic of tuberculosis led to the rise of TB sanitaria. Often these were placed in warm, dry climates with “clean air” where breathing was easier. A close look at these lovely facilities provides a number of startling parallels to the addiction rehab industry that would follow a century later. Because TB was so widespread, many of its sufferers had enough money to choose any inpatient center they wished. This created a competitive market, and TB sanitaria marketed themselves with ever more elaborate treatment programs offering high-end luxuries sought by those who could afford them. A look at some of the marketing literature of the day feels eerily familiar:
Here is the Battle Creek Sanitarium, in 1907: “The one institution where all the most recent scientific curative measures have been assembled under one control. Many new and interesting departments have been recently installed, including Radium, Diathermy, Electrical Exercises . . . the Sanitarium offers many unique opportunities to health-seekers. The new Diet System, the physical culture classes . . . the interesting health lectures, swimming, games and drills.”19
The Sanitarium at Dansville, New York, enticed visitors with its “Beautiful Location among the hills of Genesee Valley. Pure air, pure water; climate especially mild and equable at all seasons of the year. . . . It has light, airy rooms. . . . All forms of baths, electricity, massage, etc. are scientifically administered. The apparatus for Dr. Taylor’s Swedish Movements, and a superior Holtz machine for Statical Electricity are special features. . . . An unrivalled Health Resort.”20
And so on. Moore’s Brook Sanitarium called itself a “splendid old Colonial place, over 100 acres, mature grove, grass and vine . . . 250 feet of wide veranda . . . Billiards, pool, golf, tennis, etc.” And Dr. Rogers’ Hydropathic Sanitarium and Congenial Home noted its “fine grounds and salubrious air” that could “effectually remove any disease, however chronic.”21
Despite these luxuries, none of these institutions offered any treatment for the actual cause of the illness. Indeed, while the bacterium causing TB was discovered in 1882, it would be sixty-four years before any real treatment (an effective antibiotic) was developed. It was precisely during these years when the TB sanitaria thrived. Once specific treatment did become available, the elaborate sanitaria died out, never to return.
Alcohol and drug rehabilitation centers are in just this position now, with one marked difference. Better understanding and treatment are already available; they are just not included in their programs. The addiction treatment industry is based on a model that has been unchanged since the 1930s, and because these programs are commonly staffed by people who often know little beyond AA and whose professional identities depend on the rightness of that model, there has been an enormous resistance to change. This failure in understanding and treating addiction is plainly evident in the proliferation of strange therapies and unrecognized treatments, which rehabs continue to hawk.
What might a better rehab program look like? To begin with, instead of the senseless notion of requiring exactly the same number of days of hospitalization for everyone, a rational program would be individualized. Considering that one purpose of residential care is to provide a more intensive treatment, all patients would be seen by an experienced, well-trained psychotherapist multiple times a week, if not daily. Th
erapists would have to be professionally qualified academically and up to standards of excellence for psychotherapists in the community.
Groups would be a highly valuable component, if they were designed to help patients learn about themselves and how they relate to others; that is, to find out how they are perceived and to experiment with new ways of relating. Patients themselves would bring up the ways their addiction has intertwined with their feelings about themselves and their relationships with others; no meeting would come with a set “educational” agenda.
An ideal program would also have no need for lectures about drugs or for instruction about how to use 12-step programs. Alcoholics Anonymous would be made available outside the center (free of charge, of course) for those who could make good use of it. Any decent program would also provide basic services such as adequate food and common spaces for patients to talk and learn from each other. But gourmet food and spectacular settings have nothing to do with treating addiction, so these frills would be eliminated, allowing the cost of rehabilitation to stay within reach of the common person.
I will say more about effective treatment, after first considering what really does make sense in understanding and treating addiction, in the next chapter.
CHAPTER FIVE
SO, WHAT DOES WORK TO TREAT ADDICTION?
BECAUSE THE NATURE OF addiction itself has never really been understood in human history, the phenomenon was originally associated only with its clearest form: drunkenness. The symptoms of inebriation were easy to see, leading to the conclusion that alcoholism was about the physical effects of alcohol. Because alcoholics not only couldn’t stop, but often enjoyed their drinking despite its terrible effects on others and themselves, many people also believed that alcoholism was a moral failing, even a kind of insanity. These ideas—that the problem of alcoholism lay in the power of alcohol, and that alcoholics had a moral deficit that allowed them to succumb to this power—led to a treatment that pressed alcoholics to acknowledge the power of this chemical and try to improve their morality by turning to God. This approach was, of course, Alcoholics Anonymous.