Families in Action
Drug Abuse Update Online
November 10, 2001 – Vogue Article on Drug Treatment Distorts Reality
Sue Thau, public policy analyst for Community Anti-Drug Coalitions of America, alerted National Families in Action to an article appearing in the November 2001 issue of Vogue magazine.
The article provides a distorted view of drug addiction treatment. Its author cites several authorities, but draws her conclusions from a few whose work is not viewed seriously by the scientific community. She ignores the large body of scientific evidence about effective treatment for drug addiction and the vast number of people who have recovered from it.
National Families in Action asked Herbert Kleber, M.D., to read and comment on the article. Dr. Kleber is director of the Division of Substance Abuse Research, Department of Psychiatry, College of Physicians and Surgeons, Columbia University. He has treated several thousand addicts during the course of his career. We have embedded his comments in the article, contained in brackets [ ], and placed his concluding comments at the end of the article.
-- In Denial
Amanda* is nervous. Her hair is nervous, a shock of curls, and smoke from her cigarette hazes her face. She has seen some things, this Amanda. She has had breast cancer, the telltale lump, the dreaded diagnosis, the cancer plucked from her body like a bean buried in fat. "I saw it," she says. "I saw the cancer, and it's not the sort of thing you forget."
Cancer is only one of Amanda's problems. She has survived a grueling divorce. She was abused as a child. She frequently gets depressed. She is so stressed out as to be virtually pickled in adrenaline. "There's no relief for me," says Amanda. "except to drink."
Which she does, now and then with great abandon. Amanda drinks just like the perfect alcoholic, jumping on the wagon only to tumble off it, in a kind of horrid debauchery, her hand shooting out for the shot glass that she fills with the burning yellow liquid. Tossed down one. Tossed down two.
Days, weeks, maybe months go by. Then, when her stomach starts to bleed, when her children, now grown, come home to find her on the floor, when the drunkenness itself is no longer relief enough and so the cocaine follows, then Amanda does what more than four million Americans do every year: She enters rehab.
The first alcoholism rehabilitation program for substance abusers was Alcoholics Anonymous, founded by Bill Wilson in 1935. Wilson opened the modest home he was living in to any number of sloshed souls in a makeshift attempt to help. Since that time, however, this grassroots movement has spread exponentially, even extravagantly. There are now rehabs with plush, shabby-chic couches; rehabs with Jacuzzis; rehabs where chefs with towering white hats serve skewered shrimp with seltzer. There are rehabs for rich people, rehabs for poor people, rehabs for people who drink too much, love too much, eat too much, starve too much; rehabs in the Utah badlands, where crafty teens confront the elements and learn, in the words of one counselor, "that you can't manipulate nature."
It is difficult, these days, to live a life that hasn't in some ways been touched by rehab culture. If you yourself haven't been in rehab, then you likely know of someone who has; if you yourself don't know of someone who has, you still can't escape rehab's ubiquitous presence in popular culture, where Ben Affleck struggles with sobriety, or Robert Downey, Jr., falls off the wagon, or Melanie Griffith sets up her own Web site while undergoing treatment. (Fans and gawkers could correspond with Griffith via the site; so yes, the rehab industry is growing even in cyberspace).
Patients, or perhaps we should call them consumers, do not go into rehab so much as go through it. Americans have come to think of drug treatment not, in fact, as rehabilitation (which means a return to the former self) but as transformation, the type that happens only when one goes through a program. To us, rehab is synonymous with enlightenment -- wayward sinners become repentant sinners, and repentant sinners eventually emerge so changed that their old life exists only as evidence of demonic possession while their newfound self shines even in its struggle.
Go into any of the myriad rehabs or detoxes in your town and you will likely find that the decor reflects the ethos of total transformation. In one house I visited, the wainscoted wood was polyurethaned to such a sheen that everywhere you turned you were reflected, a second, better self. Posters adorn the walls of most programs: praying hands suspended above a wave with the serenity prayer scripted in the sea; a white-peaked mountaintop with the imperative YOU SHALL CONQUER ALL; a man holding a brand-new brain in his hand, a brain that was green as spring and delicately rumpled. There are references to God in every corner, and LIVE AND LET LIVE twelve-step stickers attached to any available surface. How else to interpret such insistent images except as heavy-handed attempts to transmit the idea that souls, like furniture, can be stripped down and redone, long curls of leaded paint bubbling off the clotted surface, and beneath, new wood -- your shiny skin.
It is strange, therefore, that, despite the wholesale salvation message, so few rehab patients actually make it to the other side, where, indeed, the grass is green and clean. Recidivism rates for alcohol-rehabilitation programs are at a disturbing 63 percent (individuals at some programs estimate figures to be even as high as 80 percent).
Perhaps more unsettling is the fact that, when researchers compare how those who enter typical rehab treatment -- with its focus on total abstinence and spiritual twelve-step living -- fare with those who never receive treatment, the rates of recovery are pretty much the same.
[Dr. Kleber''s comment: These are poor comparisons since they do not involve random assignment. They are probably quite different groups and one cannot assume they are equivalent. There have been better controlled studies not cited. Those who do go into treatment may be those who are sicker and who may be less likely to recover that those who can stop on their own. This has been clearly shown in smoking. Those who quit on their own are very different from those who can''t. The latter are sicker, may be clinically depressed, etc.]
Psychologist Stanton Peele, PhD., author of Diseasing of America: How We Allowed Recovery Zealots and the Treatment Industry to Convince Us We Are Out of Control, writes in his book, "It has been remarkably hard to find systematic proof that treatment for alcoholism and other addictions accomplishes anything at all." George Vaillant, M.D. professor of psychiatry at Harvard Medical School and a leading researcher in alcoholism, wrote in his groundbreaking book The Natural History of Alcoholism, "There is compelling evidence that the results of our [standard A.A.] treatment are no better than the natural history of the disease."
This raises two questions. What is the natural course of the disease of addiction? And if treatment is no better than just waiting, why do we so continuously insist on treatment?
The "natural history" of alcoholism, and by extension all other addictions, is hotly debated. The A.A./Narcotics Anonymous/rehab school believes that addiction is a disease and is inherently progressive, so to do nothing is tantamount to doing everything, waiting and watching while the person sinks lower and lower into his or her own compulsive murk. Then there are other researchers, like Peele and Bruce Alexander. Ph.D., who claim in The Meaning of Addiction: An Unconventional View that addiction is a stage in life, and one that many outgrow.
The point is, the salvation/disease model that our rehab systems so fervently embrace is only one model among many, and its performance, when scrutinized, has been pretty poor. Why, then, are Americans entering rehabs in unprecedented numbers?
"The bottom line is," says Amanda as she chain-smokes, a scarlet ring of red on each crushed butt, "the bottom line is I'm a recovery junkie." We are sitting in her Boston home. A cat slinks into the living room, wreathes around our legs, purring and butting and finally settling down to snooze on the windowsill, his ice-green eyes glinting as they close. "You know," says Amanda, "if I could be anything in this world, I'd be a cat. When a cat purrs, it's releasing endorphins into its brain, and that''s why cats purr so much. I read that as a fact."
Amanda has been out of her twenty-ninth bout of rehab for four days now, and the gloss of sobriety is wearing off. Life seems slow and boring, and she's craving the sparkle of something wet and sharp on her tongue.
"Why," I ask her, "do you keep going back to rehab? It hasn't worked for you in the past; what makes you think it will work now?"
Amanda shrugs, lights another cigarette, and gives a cough so raspy I can hear froth in her lungs. "They say you just gotta keep coming back," she replies. "You just gotta keep coming back till you finally get it."
She then goes on to tell me the story of her friend Jim*, who went to 75 bouts of rehabs before he finally "got it," and has been heroin-free now for two years. But 75! In what other branch of medicine does a patient go through 75 trials of a treatment? Imagine 75 trials of Prozac. Imagine 75 epidurals because they just won't take.
"Do your treatment providers," I ask, "ever suggest another strategy?" "Well, I've been on antidepressants, if that's what you mean. But I still relapse, on alcohol or cocaine. And when you relapse, the powers that be send you to rehab."
Apparently Amanda is not the only one addicted to addiction treatment. Rosa*, an N.A. member, says, "I see it all the time, people coming to as many meetings as they can. It takes over their lives. It becomes the new thing, the only thing." This goes not only for recovering addicts but for their treatment providers, parole officers, social workers, psychologists, and family members, as well: Treatment in its current incarnation is "the only thing,'' and, indeed, a kind of addictive thing for all of us. We watch with lurid fascination as stars like Matthew Perry struggle to their wasted knees to try and try again. Even the nonaddicts among us use the language of rehab and recovery to describe our circumstances: We are codependent, hitting bottom, in denial; we need to walk our talk. America, it sometimes seems, is one giant rehab house; and in this house we, as a society, enact the fantasy that human beings can morph into something better. We dream that the sinner can be saved. It's a profoundly American belief, formed on the frontier.
Melinda* is a 53-year-old wife and mother living in Florida. "When I was in my 20s," Melinda says, "I used my fair share of cocaine. Then I gave that up, and now I have my other little addictive ditties. Red wine. Cigarettes. When these behaviors get out of control, I go into rehab for a tune-up."
Indeed, Melinda looks remarkably tuned up. She's stalk-slender, her skin tanned to a toasty brown. Unlike Amanda, she radiates good health and wealth. Unlike Amanda's, her substance-abuse problem seems mild, because the "out-of-control behavior" she speaks of amounts to mere persistent tipsiness. "My husband starts nagging me," Melinda says. "'Melinda, you need help. Melinda, you need to go in.'' So I go."
She goes to a place in Arizona, where the mountains stand serrated against an azure sky, and every evening the sands turn pink. She goes to a place where the pool is sliced into seven lap-lanes, and twelve-step meetings are held in rooms so air-conditioned there is a rime of frost on the double panes. She goes and she returns, once or twice a year, rested and ready to begin anew, sans "the wine." "Rehab does a lot for me," says Melinda." It reminds me of where my spiritual center is. It brings me back to who I really am, or maybe"-- and here she pauses to think-- "maybe it brings me forward, to who I was meant to be. I get rid of my false self at rehab. I am altered and learn to live closer to God's will."
If this is true, we should bottle rehab's recipe and put it in the water supply. I myself am suspicious. If rehab were really truly so transformative, then recidivism rates wouldn't be so high, and people like Amanda and Melinda wouldn't need to keep going back for tune-ups. What's most interesting about rehab culture is not what it actually does for us -- meaning its raw efficacy rates -- but the way it mirrors our vexed perceptions of human nature. For instance, we cling to rehab's idea of "conversion" or "total transformation," while at the same time holding close to our hearts the idea that we are "bred in the bone." Says Jennifer Coon-Wallman, Psy.D., a psychotherapist at Brandeis University's Psychological Counseling Center, "As our world gets more and more reductive and we start to see ourselves as simply the product of this or that gene, with little hope for change, we cling to the idea of rehab as the one place where fairy tales are still possible, and paupers can become princes, despite their physiological makeup. Rehab is religion."
Melinda says, "I do think of my addictions as a disease, and I also think my daughter, who is fifteen and addicted to the Internet, has inherited my disease of addiction, which is why we need God's presence in our lives." Amanda echoes this belief. "What I have is a devilish and cunning disease, drug and alcohol addiction. It's a disease that requires prayer."
I am not by any means saying that prayer cannot be helpful in the treatment of diseases, even inherited ones, but both Melinda's and Amanda's choice of words, and the mixed metaphors within them, reveal something strange and contradictory about drug treatment. We persist in calling substance abuse a disease, and yet we treat it as a sin. In no other disease process do we tell patients a higher power is the primary medicine, or that the disease was caused by something "devilishly cunning."
Rehab culture is an interesting mix: Here Satan and the scalpel, two of our society's most captivating images, come together in a combination as potent as rum punch, as energizing as a white line on glass.
According to Melinda, her fifteen-year old-daughter Lorraine* has many addictions, the Internet only one of them. "She is addicted to food; she has an eating disorder," says her mother, and Lorraine, who is as beautiful as Mom but rounder and more wide-eyed, nods, half in agreement, half out of resignation. We are in their kitchen, the cabinets Floridian white, the pool outside a shimmer of aqua. Lorraine, with a little smirk on her mouth, spreads peanut butter on a piece of rye and takes a big bite.
"Food," says Melinda. "Porn on the Internet. Boys. She's a love addict. Addiction runs in my family: my brother was a heroin addict, my father an alcoholic. Oh, God, I just hate to think of her heritage." I eye Lorraine. Apparently this is standard conversation chez Melinda. "Lorraine," says Melinda, "you need to come to a meeting with me tonight."
Tonight they will go to a meeting. And tomorrow Lorraine -- whose Internet addiction is, according to her parents, completely out of control (she has seduced a 50-something-year-old man on-line) -- will be shipped off to an adolescent rehab program in the Southwest where she will learn, among other things, about her inherited condition, her lifelong need for medication (the antidepressant Effexor), and the importance of regular attendance at Alateen meetings. It is a strange treatment combination; in rehab, men, women, poor people, rich people, friends, lovers, movie stars, our very own children, wrestle with horned hot spirits in a particularly contemporary way, using surgeons' scalpels as their weapons, pills and prayer side by side. In a culture where there are so few places left to play out the grand drama of mythic descent and ascent, in a culture that lacks vision pits or other initiation rites, rehabs have risen to do this ancient work with a techno-twist.
And yet the myth that rehab offers us also blocks us from evaluating other, potentially more fruitful healing strategies, one of which may be, oddly enough, simply to watch and wait. For instance, research shows that most addicts mature out of their addiction sometime after the age of 45. In fact, interestingly enough, most emotional disorders in general decline after the age of 45, indicating that people who suffer are either burning out or growing up.
In the 1960s a researcher by the name of Charles Winick found that most adolescent and adult heroin addicts outgrew their habit by their 30s.
[Dr. Kleber's comment: There is poor data for these phenomena. The researcher relied principally on police records. A better study is a recent one from the University of California at Los Angeles (Yser and Anglan) which was a 25-year followup of heroin addicts. This found a much more grim prognosis.]
Perhaps even more intriguing are the results of a longitudinal study of obese people who lost weight. The standard wisdom is that most weight loss is temporary; the pounds inevitably creep back on, the compulsion to overeat in remission for maybe a few months or a year. In 1982, however, Stanley Schachter, Ph.D., then professor of psychology at Columbia University, did a study in which subjects were able to lose an average of 34.7 pounds without any treatment at all, and then kept it off for about eleven years. In other words, treatment, or rehab, may not be necessary for short-or long-term recovery, even for as stubborn a habit as binge eating. According to Schachter, long-term weight loss is "a relatively common event."
Smoking, perhaps, provides the most potent proof that addictions do not necessarily go into an ever-deepening spiral of destruction, and that they can remit on their own, without formal intervention. Forty million Americans have quit smoking, and 95 percent have done so on their own, despite the fact that most experts agree that smoking is one of the more addictive habits to shake, if not the most.
[Dr. Kleber's comment: Nicotine is an addicting drug, but not an intoxicating drug. Most smokers (80 to 85 percent) want to quit. Most cocaine and heroin addicts don't, a crucial difference. Also, the 40 million Americans who have quit smoking did so over a 20-year period, about 2 percent a year. This is hardly a ringing endorsement for natural recovery.]
Here is my story. From the age of fifteen to the age of 24, I smoked two packs of cigarettes a day. I smoked with a downbeat adolescent gusto, a baseball hat pulled low over my eyes, my jeans hanging off the skinny handles of my hips. I smoked in high school, hanging out in a place called The Hole, drinking bitter coffee and dragging deep on clove cigarettes until my lungs turned to tar, and crisped. I smoked in college, and then after college, waking up each day, banging the button on the snooze alarm and reaching for my matches, the strike, the spark, the smell of sulfur. By 23, I felt as though I had cotton in my lungs; by 24, when I ran across the street, gobs of spit came up in my throat, and in my hand the spit was flecked with ash. I smoked and I smoked and then-- what can I say? There is no transformation in this tale-- I stopped smoking. I got the flu, such a bad, lung-gunked flu that I couldn't touch my Marlboros for six days straight, and when the fever cleared, and when I felt my lungs fill to twice their capacity, with their linen-white lobes like new, I didn't want to go back again. I'd had six days clean, so why not seven? Then I'd had seven days clean, so why not eight? I smoked and then I stopped, and now I'm well into my 30s, and that's that. I was once a smoker.
I never hit bottom, and I never rose.
Addicts do often stop on their own, or stabilize their behavior without therapeutic intervention. However, there is no doubt that many substance abusers do need outside help. In these cases, the question becomes what kind of help and will we let our own addiction to addiction treatment that promises transformation stop us, as a society, from evaluating other choices?
In addition to "maturing out," a term coined by Winick, there is a promising set of treatment interventions called Harm Reduction. Harm Reduction recognizes and even honors an individual's complex reasons for remaining involved with drugs and alcohol and, instead of trying to "save" the individual, offers supportive therapy and psycho-education geared toward helping that person manage his/her habit as safely as possible. Harm Reduction programs might provide a heroin user with clean needles, might instruct him in purifying them with bleach, might teach CPR techniques in the event that the user is present at an overdose. Harm Reduction is about learning to live as best you can within the parameters of your particular life, with its needles and mirrors and heartbreak.
In the eighties, James Prochaska, Ph.D., a professor of psychology at the University of Rhode Island, came up with another model for treating substance abusers, which he called Stages of Change. The narrative of a user and her recovery, he argued, could be divided into six chapters: "precontemplation, contemplation, preparation, action, maintenance, termination." Prochaska said that we should cease looking at addiction as an inevitable, Dante-like descent and, instead, that a therapist should evaluate where an addict is in terms of these six stages, and then help him/her move to the next stage. In Prochaska's model, if necessary, the precontemplative addict could continue to use her drug of choice during treatment-- strictly forbidden in the all-or-nothing, Sodom and Gomorrah approach-- while the treatment provider tried to move him/her from precontemplation to contemplation, and then from contemplation to action.
Kathryn Davis, LICSW, a clinical social worker who works at AfterCare Services in East Boston and who specializes in Harm Reduction programs for addicts, says. "I utilize Prochaska's model in my practice. I do not require or expect addicts to be clean in treatment. That's like saying to a cancer patient, 'I'm sorry, I can't treat you until you're in remission.' It's ridiculous."
Davis tells of a young woman she is treating, a college student, a musician, an artist, "quite possibly a genius," who is also a heroin addict. "This young woman's just not ready to give it up, and that's OK. She sees heroin as part of her creative inspiration, which I highly doubt. But I'm not going to say to this person what so many other providers have said, which is 'Don't come back until you're clean.' For the first time, with me, she's making a commitment to treatment; she's starting to recognize what her triggers are. She's moving from precontemplation to contemplation, and it's tremendously exciting to watch."
Of course, Prochaska gets little airtime in the jammed wires that transmit treatment information. He certainly does not get the press of A.A. or N.A. or Hazelden or the Betty Ford Center, where the stars go to get cured, or exorcised. In Prochaska's model, and in the Harm Reduction model, there are no exorcisms, and, in fact, there really is no cure, so to what can we hold?
[Dr. Kleber's comment: If "cure" means return to controlled use, this statement usually would be correct (although some can-- probably less than 10 percent). If "cure" means no longer taking addictive substances, many have achieved that. It all depends on how you define cure. A substantial number of addicts no longer continue to use drugs. Harm reduction has the problem that the mortality rate remains high, e.g. needle exchange users tend to continue to practice unsafe sex and, thus, contract AIDS that way. While using clean needles, they die of overdoses.]
If, as a society, we came to accept these strategies as treatment alternatives, we would be taking a step bigger than all the twelve steps combined; we would be saying, "All right. We cannot be saved. We have to release rehabs from the redemptive roles we have forced them to play. What exists in life, in culture, is not total transformation but a daily struggle and modest, often melting increments."
And so we come to the end, where no one is really better. Lorraine is off in the Southwest, but, because that program doesn't seem to be working, her parents are thinking of one of those Outward Bound-style desert deals in Utah, where maybe, like Jacob, she will finally wrestle with God. Melinda is back to "sipping some wine," which means, according to her, she''s due for a tune-up sometime soon. Ben Affleck has recently been on the cover of People, where he tells us why he decided to check himself into some posh rehab house. And then there's Amanda. She's been clean for seven days outside rehab when I go back, once again, to visit her. "It's been one week. Do you think you're going to make it this time?" I ask. "Can you tell yet?"
"Look," says Amanda, and she leads me into her kitchen, where there is a birdcage hanging from a hook in the ceiling, and inside the cage, what must be a parrot of some sort, tropical green, with a red ruff. "I just got him," she says, and she takes him out, sets him on her shoulder. The bird turns its head this way and that.
"Is he a part of your recovery?" I ask.
"Recovery, recovery," the parrot squawks. Amanda laughs. "I taught him that," she says.
"What else does he know?" I say. And then the bird says, "You have a devilish and cunning disease, 90 meetings in 90 days, one drink, one drug, and you're done," all in the strange, raspy voice of a winged thing.
I stare at Amanda.
"He's here to help," she says.
I nod. Such strange help, this fairy-tale creature. So bright and beautiful, with wings that are not ours.
* Names have been changed to protect privacy.
-----END OF ARTICLE -------
Dr. Kleber concludes with these summary comments:
1. Addicts are a heterogeneous group. Some may, indeed, be able to stop on their own. Most, however, cannot and need some form of intervention.
2. There is no one treatment for addiction. The 12-step approach the article attacks is but one approach. Other methods, for example, medication such as methadone or naltrexone and psychosocial therapies such as cognitive behavioral relapse prevention, are other treatments that are in common use and may help.
3. Therapeutic communities such as Phoenix House can help still others.
4. The McLellan et al. paper in the Journal of the American Medical Association (McLellan At, Lewis DC, O''Brien CP, Kleber HG: Drug Dependence, A Chronic Medical Illness: Implications for Treatment, Insurance, and Outcomes Evaluation. JAMA 284: 1689-1695, 2000) views addiction as a chronic relapsing disease and fits the data about the course of the disorder much better than Peele's argument that addiction is a bad habit.
5. The author cites only studies that support her position and ignores a wealth of other data.
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