Firm Steps to Rehab

What Families Need to Know About the Addiction Treatment Industrial Complex

After a golden run as a Wall Street stockbroker, Bill Wilson found himself a broken man, approaching age 40 and hopelessly enslaved to the bottle. On a bleak November day in 1934, he sat drinking alone in his kitchen when the phone rang. It was an old drinking buddy he hadn't heard from in years. Great! he thought; I can drink openly with him. But when Edwin "Ebby" arrived, he refused the glass Bill pushed across the table.

Bill was shocked. "What's all this about?"

"I've got religion," Ebby said simply, and he'd come to pass his experience along, if Bill cared to have it.

As it turned out, Bill did care to have it, and over the ensuing months he got sober with the help of his friend Ebby and the Oxford Group, a quasi-religious fellowship that combined self-improvement ideals with biblical principles about admitting wrong, making amends, and looking to a higher power for help.

Once sober, Wilson found that a key to staying sober was helping others overcome their addictions, and so the following year, he and Dr. Bob Smith, also a former alcoholic, founded Alcoholics Anonymous (AA). Wilson subsequently wrote a textbook for AA. Commonly known as The Big Book, it outlined twelve guiding principles for alcoholics seeking long-term sobriety. The AA -structure and Wilson's principles served early AA members well, and today some two million members meet regularly in more than 100,000 independent groups across 170 countries.

From its humble beginnings, 12-Step has spread to become the standard method of treatment in nearly all addiction treatment facilities in the U.S. And while it has worked well in traditional AA settings, where members voluntarily come together for mutual support in pursuit of a common goal, the rehab industry, which has exploded in recent decades, may be another matter.

Navigating a Cash Cow Industry

In 1986, there were about 4,000 addiction treatment centers in the U.S. Today, there are more than 14,000, and they make up a $35 billion industry. Conditions "treated" run the gamut: substance abuse—primarily drug and alcohol addictions; compulsive behavior patterns, such as gambling, sex addictions, workaholism, and relationship dependencies; emotional trauma syndromes, such as PTSD and abuse survival; and the panoply of DSM-based mental health diagnoses including (but by no means limited to) depression, generalized anxiety, and bipolar disorders.

Given the size and scope of this industry, as well as the life-and-death nature of its stock in trade, we are justified in asking how well it serves its clients. After getting an inside look from working as a sober companion, filmmaker and recovered alcoholic Greg Horvath took a lens to it, and the best thing he has to say about it is that the system is now more harmful than it is helpful. The results of his investigation are evenhandedly chronicled in his 2016 film, The Business of Recovery. Here are some things families should know before they reach the point of crisis:

• 12-Step was not designed for institutional use. AA was founded on the simple idea of people in recovery helping people in recovery. But with the introduction of court-ordered rehab and staged "volun-told" interventions, the voluntary support group dynamic is, at best, diluted.

No one seems to know how 12-Step came to occupy such a privileged role in systematized care. Dr. William Miller, Professor of Psychology and Psychiatry at the University of New Mexico, compared treatment using 12-Step with cognitive behavior coping skill therapy (CBT) and Motivational Enhancement Therapy (MET—a form of counseling designed to encourage personal motivation for change) and found that all three performed equally well. And addiction specialist Dr. Lance Dodes, author of The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, says that over the long term, good psychotherapy is the better model. Nonetheless, some 90-95 percent of recovery programs are 12-Step based.

• The medicalization of addiction undermines the therapeutic model. When the AMA designated alcoholism a disease in the 1960s, the AA central office followed suit. But this shifted status of the individual from addict to patient allowed for a parallel (and arguably dehumanizing) shift in personal responsibility. In fact, the very terms "treatment" and "patient" imply that a formulated regimen is being administered to a passive recipient in the same way that chemotherapy is administered to a cancer patient. But everyone, save for those in deepest denial, knows that this is not how emotional and behavior-based conditions work.

The medical model also paved the way for the institutional trappings, systematized record-keeping, and layers of insurance-related technicalities that now accompany health care. The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 may have been passed with good intentions, but it also further removed the individual in need from the successful fellowship-based culture of AA.

Returning to 12-Step, all twelve of the steps involve matters of the will. Six of them refer to God, either directly or indirectly, and Step 12 explicitly presupposes that the individual has experienced a "spiritual awakening." But thinking people know that steps of the will, especially when they involve one's relationship to God, cannot be induced or coerced. What this means, then, is that the entire rehab industry rests on a foundational incoherency: the 12-Step approach and the medical model of addiction are, from their very philosophical cores, incompatible.

• Treatment centers market themselves. Buyers should beware. Treatment centers usually offer managed care that includes counseling and behavioral therapy, and in many cases on-site psychiatric care. Most also offer suites of added services and features that range from the sophisticated EMDR (Eye-Movement Desensitization and Reprocessing for overcoming trauma) to the nice-but-arguably-superfluous pet therapy to the luxurious accommodations that have earned some centers the nickname "Rehab Riviera."

How does a family in crisis know what to think? Facilities usually market their treatment approaches as "evidence-based," but what does that really mean? As it turns out, not very much. Dr. Miller said that when centers were asked about their success rates, all reported upwards of 80 percent. But when asked how that rate was arrived at, "no one had any data. They were simply making up the figure." If a single study shows that a treatment has worked, he said, then it can be designated as evidence-based. This is an inexcusably low bar. Few do follow-up evaluations, and of those who do, most are based on self-reporting. One former patient said he just lies when they call.

• Sober living homes: proceed with extreme caution. While Horvath acknowledges that thetreatment centers can have some benefit, in his view, the follow-up sober living homes (what used to be called halfway houses) are the most dangerous aspect of addiction treatment today. "At the very, very best, nothing bad will happen," he says, while "at the very worst, there is relapse, sexual assault, and death by overdose."

The Business of Recovery includes an interview with a man who can only be described as a sober home slumlord. Rick Schoonover had a record of multiple felony convictions yet was collecting $24,000 per month to house an untold number of renters (he couldn't recall how many), dormitory-style, in three California homes. He was president of the Sober Living Home Coalition at the time when a young man died of overdose in one of his homes. The horror stories go on and on, Horvath says, but you won't hear much about them because families rarely go public.

• Bureaucratization is metastatic. Blend all this together, and you have the makings of a cash-cow industrial complex. The fact that its customer base consists of people in crisis only heightens the potential for predatory practices.

The Primary Importance of Family

Rick Van Warner and his wife Mary had lost all hope that their son Tommy would ever be free of his opioid addiction. After shepherding him through many cycles of "the expensive recovery machine" to little avail, Rick took a step back from everything the experts had been telling him.

Ever since his deliberate overdose and the despair that led up to it, I'd begun looking at our son's addiction from a different perspective. No program, residential or outpatient, series of meetings or halfway houses had worked. The only thing that kept him alive was the love of his family and the fact that we wouldn't give up on him.

By the tender age of 22, Tommy was destitute, frail, and emotionally shattered. For some time, Mary had been saying that Tommy needed his father, and with some trepidation, they decided to let him come back home, a move that would also involve facilitating detox in the home. A major breakthrough came later, when Rick invited Tommy to come along with him to a local Irish pub where he played on a darts team. He introduced Tommy to several of his friends, and, for the first time ever, father and son had a drink together.

This was definitely a breach of the 12-Step all-or-nothing doctrine of recovery, but Rick had begun to believe that, more than anything, Tommy needed his unconditional acceptance. On the way home, they picked up some cigars and sat out back and talked for hours—"the most honest and open dialogue we'd ever shared."

From that point on, Tommy began to recover. He later confirmed that it was the tenacious love of his family that brought him through. Rick relates the whole harrowing yet ultimately hopeful story in his book, On Pills and Needles: The Relentless Fight to Save My Son from Opioid Addiction.

Love: The Supreme Rule of Engagement

With AA freely available to anyone anywhere, Horvath asks, what does an expensive 12-Step center offer that a motivated person can't get from reading The Big Book and joining a local group? It's a point worth pondering, and this leads to the biggest aspect of addiction that gets lost in the medicalized model.

AA was founded on the simple idea that meaningful relationships between ordinary people can have a symbiotic effect. Certainly, everyone should think carefully before diverting from the advice of experts in their field, but the point to take from this is that relationships may well be a bigger factor in recovery than the experts' rules of engagement.

The Business of Recovery is an eye-opening look into the industry, and On Pills and Needles is an eye-opening look into one family's ordeal. Here are some takeaways from both: Relationships matter a lot, and families do well to think outside the rehab box. If you have a close relationship with someone whose life is spinning out of control, you may be just the ordinary person your loved one needs most. Don't check your brains at any rehab door, and never underestimate the power of your love in that relationship.