by Lance Dodes
One might reasonably ask: How does anyone know that thirty days is the right number of days to treat addiction? Is there any evidence to suggest that this number somehow represents the best way to achieve lasting sobriety? In fact there isn’t. Thirty days is just a round figure borrowed from our lunar cycle—one month. As I once wrote on my blog for Psychology Today, “The real question is: why would people design, and defend, a treatment based on the time it takes for the moon to revolve around the earth?”8
And yet if we dig deeper, a second reason emerges for the thirty-day rehab. Years ago, when insurance companies used to pay for inpatient rehabilitation, it was often deemed necessary for patients to stay for much longer periods of time. Once insurance carriers set the maximum on the number of days they would cover at thirty, that quickly became the proper number of days to treat alcoholism.
Another key attribute of the rehab experience is total control. Most centers have very strict policies regarding the use of banned substances and activities. Cell phones are typically prohibited, and schedules are tightly managed. The upshot is that these thirty days represent a period of time during which patients have no choice but to stop using alcohol or other drugs. The appeal of this rule cannot be overstated: the notion of being made to stop can be a relief for both addicts and their families. Of course, living without alcohol or other drugs does not eliminate the compulsion to use them in the future. Sadly, the relief many addicts experience during hospitalization is often mirrored proportionally by the despair that follows a return to using alcohol or other drugs in the real world.
Some rehab centers will only admit those who have successfully withdrawn from alcohol or other drugs, but some also offer in-house detoxification, which is the medically monitored process of helping people withdraw safely from alcohol or other drugs. This is without question a valuable service. But even for people who are infirm medically or have certain diseases, such as diabetes, that require close monitoring during withdrawal, it is rare for detox to take longer than five days. Once the detox is complete, residential treatment is elective.
Aside from the twenty-four-hour control and monitored detox facilities, it can be difficult to find features or add-ons that necessitate the residential component of rehab programs. But that hasn’t stopped these programs from creatively searching for further competitive advantages. As I described above, the nation’s most famous programs have devised extraordinary lists of classes, crafts, exercises, and adventures to differentiate themselves from one another, as well as from the free 12-step meetings. These are worth considering in some further detail, both for what they promise, and for what they lack.
EXTRA FEATURES
Sierra Tucson lists on its website “qigong therapy” among its favored treatment approaches, to take just one example. Its website describes qigong as an ancient form of Tai Chi, and states that its benefits include “enhanced immune system,” “increased energy and vitality,” “improved intuition and creativity,” “heightened spirituality,” and “improved cardiovascular, respiratory, circulatory, lymphatic, and digestive function.” The fact that there is no scientific basis for these claims is perhaps secondary to the more basic point that none of them have anything to do with the treatment of addiction.
Sierra Tucson also offers its guests “equine therapy,” noting that the process “involves establishing a relationship with a horse on the ground and then evolves into the nurturing of that relationship, which may or may not culminate in actual riding in a contained area. . . . Horses are typically non-judgmental and have no expectations or motives. Therefore, a patient can practice congruency without the perceived fear of rejection.” These claims are made without any specific reference to addiction beyond the vague intimation that being near a horse will help a person break through the “stumbling blocks to recovery.”
And I’ll leave this description of Sierra Tucson’s Reiki treatments without comment: “Reiki involves the transfer of energy from practitioner to patient and enhances the body’s natural ability to heal itself through the balancing of energy.”
Sierra Tucson is hardly alone in its pursuit of novel amenities. Promises Malibu matches Sierra Tucson horse for horse with its own equine therapy program, then ups the ante with “yoga, acupuncture and massage,” “life coaching,” and SPECT brain imaging, a medical procedure involving injecting a radioactive chemical to visualize tumors and brain damage in dementia. The American Psychiatric Association’s Psychiatric Evaluation of Adults Guideline in 2006 stated that “the use of this technique for treatment planning, diagnosis, monitoring illness or predicting prognosis has not been shown.” Nor is there any known connection with addiction.
The Betty Ford Center has remained somewhat more conservative, merely offering “aquatic aerobics” and “kickboxing” among its daily activities; Passages Malibu goes all in with its “Adventure Therapy” and “Ocean Therapy” programs, the latter of which it describes as an excursion on the center’s own private yacht (the Safe Passage), “organized to demonstrate how exciting and inspiring a sober life can be.”
Put all these elements of rehab together, and it’s a wonder there is any time left over for actual treatment. Indeed, a typical day in rehab may be surprising. Here is the daily schedule published by the Betty Ford Center:
You will notice that the day is long, running a full fifteen hours from 6 a.m. to 9 p.m. How much “treatment” is in there? There is an hour-long lecture, presumably led by a staff member; another hour-long “peer” lecture, not led by a staff member; two hour-long group meetings (a “small group” and a “relapse prevention hour”); and an hour-long 12-step meeting. Out of the fifteen-hour day, then, one can distill four actual hours of Betty Ford “treatment,” half of which involve lectures instead of therapy, plus an AA meeting.
What is the rest of the day filled with? Eating, fitness, “work assignments” (“circling chairs in the group room, making community announcements, setting up tables in the dining room . . .”), and free time. There is also an hour during breakfast for “nicotine support” and a newcomer meeting when people first arrive (otherwise, patients attend the 12-step meeting).
With the possible exception of one hour (“small group”), what is notably missing from this schedule is bona fide therapy. Although there are presumably individual meetings with counselors of some sort at the Betty Ford Center—the center lists a consulting medical staff that includes physicians and psychiatrists—it apparently did not deem these critical enough to their program to be included, or even to show time for, in their daily schedule. The website confirms this in their FAQ:
Will I get individual sessions with my counselor?
The majority of the counseling is done in a group setting. Individual sessions occur regularly with your counselor and/or various members of the interdisciplinary treatment team, depending on your needs. [Emphasis added].
How typical is Betty Ford? Here is the published daily schedule from Hazelden:
Patients experience a full day of therapy, education and fellowship.
The day typically starts at 7 a.m. and ends at 8:30 p.m. and may include the following activities:
• Morning meditation followed by mealtime and fellowship
• Educational lectures followed by a group meeting for processing the lecture
• Usage history
• Twelve Step groups
• Special group meetings tailored to the needs of the individual. Groups could include:
– Leisure skills group
– Anger group
– Stress management
– Mental health group
– Grief group
• Rational Emotive Therapy group
• Relaxation, exercise and recreational activities
• Individual appointments as needed with physician, psychiatrist, psychologist or other professional from the multidisciplinary team.
• Wellness activities such as biofeedback
• Personal time for r
eflection including reading and individual treatment assignments
This appears to be another long day. Yet as with Betty Ford, the “full day of therapy” promised by Hazelden actually consists largely of non-therapies such as meditation, education, relaxation, exercise, recreation, “wellness” (for example, biofeedback, for which there is no evidence of effectiveness in treating addiction), and personal time for reflection.
Most of the therapies listed consist of groups that are designated to work on certain areas or skills, and not to freely explore the individual issues for each person. Two of these are groups for “leisure skills” and “stress management,” which are not directly or specifically related to the treatment of addiction. The “anger,” “mental health,” and grief groups may be useful for certain people but seem to be topic-focused rather than individual-focused.
The Rational Emotive Therapy group deserves special mention. RET was developed in the 1950s as an effort to look at emotional life as a problem with rationality. It is intended to help people see their irrational thoughts and learn from them. While this makes some sense, most modern frameworks of human psychology have recognized that learning one has irrational thoughts rarely solves emotional problems; indeed, many people begin therapy knowing full well that they have irrational ideas and make poor choices, yet they cannot stop.
The Hazelden program does list individual meetings yet, like Betty Ford, describes them occurring “as needed.” The explicit de-emphasis on individual therapy is common among the nation’s most popular rehab programs. Even those that pay lip service to the notion of “individualized” care rarely seem to mean what most people would expect from the term. For instance, Sierra Tucson’s description of its own “Individualized Treatment Plans” states: “Patients are . . . provided an individualized treatment plan, which may include disease and recovery education, relapse prevention, 12-Step meetings, Equine-Assisted Therapy, Adventure Therapy, and Grief and Spirituality therapy sessions.” Individualized in this context seems to mean choosing different programs à la carte based on the patient. But the programs themselves are not individualized: 12-step meetings are not “individualized treatment.” Educational lectures are neither individualized nor treatment. Equine therapy and adventure therapy are not recognized treatments for addiction (or anything else). And spirituality sessions are neither individual nor medical or psychological treatment. Grief counseling may be individualized if it is psychologically oriented to help people with their specific difficulties in dealing with loss, but not if it is simply generic support. Relapse prevention is a laudable goal, but if it takes place in a group setting, it is less likely to explore in any depth individual emotional factors that lead to relapse.
In sharp contrast, a good psychiatric center provides frequent individual psychotherapy for every patient. This is administered by trained psychological professionals (rather than people recovering from psychiatric problems) and is unique to the specific issues of the patient. Good psychiatric hospitals also provide psychodynamic groups whose purpose is to explore the way people interact with others in a way that is designed to bring out the singular attitudes, concerns, and difficulties unique to each person. They are not formulaic groups organized around predetermined topics. Psychiatric centers also offer sophisticated psychological testing to better understand complex or covert psychological problems and to ferret out neurobiological issues such as learning or attention disorders.
How did standardized, education-like group therapy become the predominant mode of treatment at rehab centers, despite their having ample room and money to employ a higher standard of professional care? One clue might be to examine the credentials and expertise of the staff.
Many staff members at rehabilitation centers have extremely limited training. Although every program boasts of the presence of psychologists and psychiatrists in a consulting capacity, many of those who provide direct treatment are qualified mainly by being “in recovery.” This is not a terribly difficult credential to attain: Hazelden’s own website invites visitors to “Become an addiction counselor in as little as one year.” Training to be a clinical social worker, psychologist, or psychiatrist, by contrast, requires from three to eight years, and to be an excellent therapist takes years beyond the end of formal training.
Also noteworthy is that although many rehab programs have psychiatrists or psychologists on speed dial, these people virtually never become the primary therapists for patients, instead serving in supervisory or consultative roles. To this day there are no academic requirements for becoming a counselor or “therapist” in a drug-rehabilitation facility.
A 2007 exposé in the Los Angeles Times noted: “Promises and fierce rival Passages Addiction Cure Center make sweeping claims on their websites about their clinical successes and reputations, purporting to have few or no equals in the world. Addiction researchers say the boasts are virtually impossible to substantiate. In addition, Promises, Passages, and other Malibu rehab firms have identified on their websites a number of psychiatrists and other physicians as staff members, even though the centers are not licensed to provide medical care.”9
The issue here goes deeper than the value of good training. There is considerable evidence to support the idea that counselors without professional backgrounds develop their own personal ideas about what constitutes appropriate treatment and philosophy. For example, non-professionally trained “recovering” addicts in AA, who often provide treatment for addiction in this country, tend to tell patients to do what they themselves did, since they have neither training nor experience with anything else.
Untrained counselors may do more harm than good. One study surveyed 317 staff members of hospital-based residential detoxification and rehabilitation programs, nonhospital detoxification and rehabilitation centers, outpatient and intensive outpatient drug-free clinics, methadone maintenance clinics, freestanding recovery houses, and several specialized inpatient and outpatient programs for adolescents, women, and women with children.10 The authors found that “[i]ndividuals with more formal training tended to be less supportive of confrontation. . . . Support for the increased use of confrontation was strongest among staff members with the least formal education.” The significance of this is that confrontation is basically a nonprofessional stance, in contrast with understanding, or often even trying to understand, what drives people to behaviors they themselves wish they could stop. Too often, it is also an enactment of these untrained counselors’ frustration with patients. The authors appropriately deplored this finding, writing, “Perhaps staff rely upon confrontational approaches because they are unfamiliar with alternatives . . . beliefs about the utility of confrontation may be subject to change based on education . . . senior clinicians might be most easily enlisted to implement, and possibly help transfer, these less confrontational approaches.”
Another recent paper examined 592 treatment providers in the United States and United Kingdom and found that the belief that addiction is a disease was stronger among those who provide for-profit treatment, have stronger spiritual beliefs, and have had a past addiction problem.11 One would hope that what treaters believe about addiction would arise not from these factors but from knowledge—just the thing professional training provides.
MONEY AND EFFECTIVENESS
Of course, there is one more difference between rehab and traditional 12-step programs: money. Most rehabilitation centers are extraordinary financial enterprises, charging more in a few months than the most expensive universities charge for a full year of tuition. Even those that are legally nonprofits seem somehow to justify large monthly rates. Hazelden charges around $28,300 a month and notes that “additional services such as counseling for other issues, prescriptions, etc. are charged separately when needed.” The Betty Ford Center charges $32,000 for thirty days, not counting detoxification. Sierra Tucson starts its residential program at $39,000 for thirty days, but the price leaps to $2,300 a day ($69,000 a month) for residents in the “Medical Assessment a
nd Stabilization Unit.” Promises Malibu’s prices range from $55,000 for a shared room and up to $90,000 a month for a private suite. Passages Malibu starts at $88,500 for a twenty-eight-day stay.
One of the principal ways that these facilities justify their price tags is with outsized claims of effectiveness. Yet, the industry regularly does not provide this data. I made a direct inquiry to Dr. A. Thomas McClellan, the chief executive officer of the Treatment Research Center that has for years done research for Betty Ford. He replied: “We have done work for them for quite a while but there is to my knowledge no follow up study—at least in the past ten years.” The response to the same inquiry put to a different rehab, Sierra Tucson, was that they had no outcome data at all. As one addiction researcher put it in the Los Angeles Times, “Anybody can make any claim they want and get away with it. It’s essentially an unregulated industry.”12 McClellan told the New York Times, “It doesn’t really matter if you’re a movie star going to some resort by the sea or a homeless person. The system doesn’t work well for what for many people is a chronic, recurring problem.” The New York Times put it this way in 2008:
Very few rehabilitation programs have the evidence to show that they are effective. The resort-and-spa private clinics generally do not allow outside researchers to verify their published success rates. The publicly supported programs spend their scarce resources on patient care, not costly studies.
And the field has no standard guidelines. Each program has its own philosophy; so, for that matter, do individual counselors. No one knows which approach is best for which patient, because these programs rarely if ever track clients closely after they graduate. Even Alcoholics Anonymous, the best known of all the substance-abuse programs, does not publish data on its participants’ success rate.13
