The rehab don't work
Treatment that replaces drugs with therapy just makes you worse.
‘“No way could I have done this without detox and rehab” says Gale, 29. “I’d probably be dead or in jail. I’d totally lost control of my life and hit rock bottom. I’d say I was suicidal.”’ (1)
Mark Gale was one of the first residents of the Oxford Drugs Recovery Project, which provides accommodation and drug treatment for homeless drug addicts. He spent three months on a ‘maintenance’ dose of methadone, then underwent gradual withdrawal with reducing doses of methadone over the next month. During this time he attended two therapy groups a day, had one-to-one counselling and took part in social activities with other residents.
This was a ‘stepping stone’ to a six-month residential rehabilitation programme in London, followed by three-months aftercare to accompany his move into supported housing near the rehabilitation centre.
The problem identified in this article is that ‘Gale is one of the lucky ones’: services for detox and rehab are available for only a small proportion of homeless drug abusers. The author welcomes recent government proposals for a dramatic increase in the provision of treatment services of this sort.
Indeed, ‘detox’ and ‘rehab’ were the central themes of the ‘Updated Drug Strategy’ launched by home secretary David Blunkett on 30 November. Though the government has been widely criticised over some aspects of its drug policy (such as its relaxation of measures against cannabis and its endorsement of the prescription of heroin by doctors), even its staunchest critics welcome the new report’s emphasis on treatment.
The key shift signalled by the promotion of ‘detox and rehab’ is away from a ‘law and order’ approach to the drug problem towards a new therapeutic strategy, emphasising education, treatment and support. (It is not surprising that Keith Hellawell, the drug tsar, had to go: New Labour’s crusade against drugs needs a social worker or a counsellor, not a policeman, as its symbolic head.) ‘Detox and rehab’ now go together like ‘rum and coke’, but what do they mean?
The use of the term ‘detoxification’ in relation to the problems of drug addiction appears in many ways idiosyncratic. It was used in the past to refer to the process of removing some poisonous substance from the body. But the substances from which people now seek to be ‘detoxed’ - alcohol, heroin, cocaine - are not poisons. Indeed they all have therapeutic uses as well as a range of familiar beneficial effects. It is true that they may all be harmful in excessive or habitual use, but that is true of most medications.
Whereas the traditional process of detoxification was limited to the removal of the toxic substance from the system, this is only a small part of the aims of the modern detox. Drugs of abuse, such as heroin and cocaine, tend to have a short duration of action and are cleared from the body within hours (the same is true of alcohol). Indeed this rapidity of effect and clearance is linked to their tendency to induce dependency: users seek to maintain or repeat the high by further ingestion. (This is also why people tend not to get addicted to anti-depressants, which take effect over weeks rather than hours.)
Modern detox does nothing to accelerate the - already rapid - clearance of drugs from the body. The distinctive feature of contemporary detox regimes is that, rather than simply removing one drug, they tend to replace it with another. Thus alcohol is commonly replaced with a benzodiazepine (such as chlordiazepoxide) and methadone is substituted for heroin. The role of these substituted drugs is not to remove the problem drug, but to counteract symptoms which may result from its withdrawal - such as fits in alcoholics and muscle cramps in heroin addicts.
It is worth noting that both these substitute drugs are also ‘toxic’ in overdose, and both are also associated with problems of long-term dependence. The conviction on 17 December of Kathleen McCluskey, from Cambridge, for the manslaughter of two men (she was accused of killing two more and of attempting to do the same to a fifth) by administering methadone to them confirms the lethality of this drug (2).
The concept of detox is most strained when it is applied to cocaine. Cocaine produces a very rapid effect (a major part of its appeal) and it is also rapidly cleared (requiring frequently repeated doses for those habituated to its use). However, unlike heroin, it does not require increasing doses to produce the same effect, so it does not produce a characteristic physical dependency.
But whereas heroin can be replaced with methadone, no drug has been found to substitute for cocaine. Despite a vast amount of research, mainly in the USA, and experimentation with numerous drugs, including anti-depressants, anti-convulsants, opiate antagonists and beta-blockers, nothing seems to work. As one recent account by Max Daly in the UK Guardian concluded: ‘there is currently no strong evidence to support the general use of medicines as a way to ease withdrawal, reduce cocaine craving or promote abstinence.’ (3). A survey by the Royal College of Psychiatrists came to the same conclusion (4).
The solution recommended by Max Daly was that cocaine addicts should be ‘placed on a residential “detox” programme’. The National Treatment Agency (NTA) is piloting 10 such schemes in the New Year. What is the nature of the detox treatment on offer? According to the NTA chief executive Paul Hayes, the key is ‘cognitive behavioural approaches, particularly around relapse prevention and consolidating people’s motivation’.
The schemes aim to provide ‘a structured series of counselling, group therapy and relapse prevention programmes’. Such is the fluidity of concepts in this therapeutic universe that ‘detox’ has metamorphosed into ‘rehab’.
‘The belief that one is powerless and that one’s actions are somehow controlled by forces other than one’s own choices is discouraging and demoralising.’ (5)
The concept of rehabilitation once meant restoring to their previous condition those whose standing in society had been impaired by injury or illness or some other misfortune (including their own deviant behaviour). In its modern form, shortened in letters, but - as the case of Mark Gale indicates - not necessarily in duration, rehab does not seek to restore the status quo ante. It aims to effect a transition from dependence on drugs to dependence on some form of professional therapeutic intervention.
Programmes of residential rehabilitation emerged out of the therapeutic community movement that flourished in the USA in the 1960s. One of the earliest therapeutic communities for drug addicts was Synanon, set up by the charismatic Charles Dederich in California (6). Synanon pioneered a confrontational, hierarchical approach that assumed that drug addicts had intrinsic - and possibly intractable - personality defects that needed to be challenged through long-term intensive therapy. Membership involved surrendering all personal rights and being treated as a child not allowed to make personal decisions. Treatment involved forceful re-education and structured humiliation.
Synanon became notorious when Dederich became obsessed with the notion that clients who left the community were betraying him. He employed a security force to coerce clients into staying and was ultimately convicted for placing a rattlesnake in the mailbox of a lawyer representing dissident clients (7). In his book The Meaning of Addiction, Stanton Peele notes that former Dederich supporters, including celebrities such as Jane Fonda, claimed that Dederich’s actions violated the Synanon philosophy. ‘In fact’, Peele comments, ‘his response was the natural consequence of the Synanon credo that membership in the community is a lifetime proposition’ (8).
A wide range of secular and religious organisations now offer residential rehab programmes on the therapeutic community model. Some are more autocratic, some more democratic; some insist on abstinence from forbidden substances, others take a more liberal approach. But they share a commitment to communal living, group and individual therapy, and shared domestic and leisure activities. A survey by the Royal College of Psychiatrists in 2000 noted that there were more than 100 centres in the UK offering residential rehab; the figure is now certainly higher (9).
Given the popularity of the therapeutic approach pioneered by Alcoholics Anonymous (AA) in contemporary rehab programmes, it merits a brief discussion. After the end of Prohibition in the USA in the 1930s, the AA movement combined the evangelical fervour of the Temperance campaign with the modern theory that alcoholism was a disease rather than a moral failing. The first two of the now-famous ‘12 steps’ through which AA guides its adherents to sobriety require that they admit ‘powerlessness’ over alcohol and submit themselves to ‘a Power’ greater than themselves (six of the steps refer to the deity).
For AA, alcoholism is a life-long illness against which only total abstinence can prevail, in an indefinite process of recovery. As Stanton Peele, a veteran campaigner against the AA approach in the USA, observes, the style of AA groups is derived from the Protestant revival meeting, ‘where the sinner seeks salvation through personal testimony, public contrition, and submission to a higher power’ (echoes of this style are apparent in the testimony of Mark Gale, quoted above) (10).
Through a combination of skilful self-promotion, endorsement by the medical and psychiatric professions and encouragement from state authorities, AA has become a major influence in the USA - and in other Western countries. Its approach has spread far beyond alcohol to other areas of addiction, including sex and gambling, and, of course, through Narcotics Anonymous (NA), to drugs.
A patient of mine was recently admitted - at the expense of the health authority - to a residential rehab programme at a clinic that describes itself as ‘one of the leading centres in Europe’. According to the clinic letter, she sought ‘treatment for chemical dependency on cannabis, cocaine and ecstasy’ (though, in pharmacological terms, none of these drugs induces chemical dependency). The centre’s prospectus outlines its theory of addiction: ‘We believe that addiction to alcohol and drugs (chemical dependency) is a chronic, progressive, primary and incurable disease, not a problem of morals or willpower. The disease, if left unchecked, will prove terminal.’
The clinic provides five phases of treatment based on the AA model: ‘the most important and difficult phase of the treatment is to break through the patient’s denial.’ Yet, ‘once patients have accepted they have a disease they are able to progress through the programme to begin their recovery’. During treatment, my patient ‘began to accept powerlessness and unmanageability and how this relates to the use of chemicals’. After eight weeks she was discharged home with recommendations that she maintain ‘total abstinence from alcohol and all mood-altering substances’, that she attend regular meetings of AA and NA and that she receive ‘aftercare follow-up’ at the clinic’s own ‘aftercare unit’. She relapsed shortly afterwards.
‘Many people who oppose the ‘war on drugs’ say that the ‘solution’ to the ‘problem’ is ‘treatment’. This is baloney. Addiction treatment is a scam.’ (11)
The phrase ‘treatment works’ is repeated like a mantra in the government’s ‘Updated Drug Strategy’. Everybody in the world of drug policy is desperate to believe that it is true. Indeed it is supported by evidence from research that is either carried out directly by government agencies (such as the National Treatment Outcomes Research Study) or commissioned by them. But are such studies reliable? Here the British authorities might learn from the (vast) experience of the USA in this field.
Research on the efficacy of treatment programmes for problems of addiction in the USA follows a now-familiar pattern. This begins when promoters of a new scheme or programme claim dramatic successes (often accompanied by media and celebrity endorsements). Early studies, often influenced by the enthusiasm of the promoters and the zeal of those they have cured, tend to confirm impressive results. Later, when the publicity had died down and independent researchers take a more dispassionate view of the outcomes of treatment over a longer period, the extravagant claims cannot be sustained.
Writing 25 years ago, Griffith Edwards, one of the leading British authorities on alcoholism, summed up the problem: ‘It is not only that the research literature is poor in reports which suggest that any particular treatment is advantageous; on the contrary, it is rich in reports which demonstrate that a given treatment is no better than another.’ (12) This does not mean that nobody benefits from treatment. It is simply that they do not seem to do so at any higher rate than without treatment. As Jeffrey Schaler, a trenchant critic of these methods, puts it: ‘One treatment tends to be just about as effective as any other treatment, which is just about as effective as no treatment at all.’ (13) Both Schaler and Peele provide examples that substantiate these conclusions.
In his book The Therapeutic State, another American critic, James Nolan, presents a detailed account of the drug courts in Dade County, Florida (13). These courts pioneered the diversion of drug abusers from the criminal justice system into treatment programmes, developing a model that has been taken up widely in the USA - and now features prominently in British drug policy. Nolan shows that the claims for the success of these programmes have not been borne out by independent scrutiny. He reveals how the redefinition of goals and a number of statistical scams have contributed to the impression that ‘treatment works’.
A recent British account draws together the results of a number of studies of long-term patterns of heroin use (14). These reveal that many users spontaneously give up the drug of their own accord, without benefit of detox, rehab or any other professional intervention. The authors reckon that ‘at least five to 10 percent manage this every year’ and estimate that the average length of a ‘serious heroin-using career is about 15 to 20 years’.
They emphasise that ‘this figure is independent of treatment’: ‘There is no evidence to date that any form of treatment makes any difference to length of heroin use.’ They conclude that ‘people give up when they are ready to do so. Events in their lives are much more important in making this decision than anything that occurs in the clinic’.
- The dangers of detox/rehab
‘Rehabilitation is shite; sometimes ah think ah’d rather be banged up. Rehabilitation means the surrender ay the self’, wrote Irvine Welsh in Trainspotting (15)
If the best that can be said of the detox/rehab approach is that it is ineffective, the more serious charge against it is that it reinforces a concept of addiction that is degrading to people with drug problems and results in the further diminution of their autonomy.
Behind the manifold absurdities of ‘detox’ lies a conception of drugs as an autonomous malign power over individuals and society. This tendency to make drugs a fetish pervades the government’s ‘Updated Drug Strategy’, which refers to the ‘damage caused by drugs’ to communities and to the need to ‘protect young people from drugs’.
But drugs are inanimate material; they have no will or power of their own. As Schaler observes, ‘drugs don’t cause addiction’: people choose to use them for a variety of reasons, often to help them cope with problems of living (even though the costs may appear to exceed the benefits). Stanton Peele and Archie Brodsky insist that ‘it is important to place addictive habits in their proper context, as part of people’s lives, their personalities, their relationships, their environments, their perspectives’ (16).
The preoccupation with the supposedly objective ‘toxic’ character of drugs, and the notion of addiction as a disease, leave the subjectivity of the drug user out of the picture. Yet as Peele and Brodsky emphasise, any attempt to influence addictive behaviour must take into account the wider realities of the life of the individual in society. It is only as targets of the ‘war on drugs’ that drug users come into focus: it is of course impossible to wage war against pharmaceuticals, only against those who use them.
Though the AA’s 12-step approach has crossed the Atlantic, it is regrettable that its critics are not yet widely known in Britain: as a result, rehab clinics using these techniques have become widely established with virtually no public controversy.
Peele and Brodksy summarise the flaws of the AA model as follows: ‘it is ‘religious and dogmatic’, demanding strict adherence to the group policy and not allowing personal choices or individual variations; it ‘undermines individual confidence’ by insisting on members’ weaknesses and predicting the worst outcomes for those who violate group policies; it reinforces the ‘addict identity’ and discourages people from emerging out of it; it focuses on the addiction and the group itself, ignoring the quality of members’ lives outside the group. (17)
The authors do not deny that AA groups have proven effective for some people. But the basic premise of AA - that the individual is powerless and should seek to replace the control of one external force (drugs) with another (God, or, in the interim, the group) - can only intensify the loss of autonomy that leads to drug abuse in the first place.
No doubt some rehab programmes reject the AA model. But by their very nature, residential schemes isolate the drug user from the context in which the problem has arisen. The intensity and intimacy of relations established among members of the therapeutic group - and between clients and therapists, is likely to reinforce the client’s isolation from society. It is not surprising that residents quickly become drug-free in their communal home - or that they quickly relapse on leaving it. Though this is clearly why there is such an emphasis on ‘aftercare’ and ‘follow-up’, it also indicates the client’s continuing dependency on the therapeutic relationship forged in rehab.
The trend for drug users to be mandated to attend detox/rehab programmes, by the police, the courts, occupational health services, reflects the authoritarian dynamic behind the therapeutic face of official drug policy. The therapeutic approach is not an alternative to the criminal justice approach to drug abuse, but proceeds in tandem with it. And, whereas a prison sentence comes to an end, therapy goes on for ever.
But surely it is better to be dependent on therapy than to be hooked on heroin? Perhaps, but better still to live an independent life, free of both drugs and therapists.
Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).
spiked-issue: Drink and drugs
(1) Guardian, 11 December
(2) ‘Black Widow’ killed two with methadone, Guardian, 18 December 2002
(3) Rocky road, Guardian, 23 October 2002
(4) Royal College of Psychiatrists, Drugs: Dilemmas and Choices, Gaskell, 2000, p176
(5) Jeffrey A Schaler, Addiction is a Choice, Open Court, 2000, p40
(6) Tom Carnath and Ian Smith, Heroin Century, Routledge, 2002, p 159
(7) Stanton Peele, The Meaning of Addiction: an unconventional view, Jossey Bass, 1985, p144
(8) Stanton Peele, The Meaning of Addiction: an unconventional view, Jossey Bass, 1985
(9) Royal College of Psychiatrists, Drugs: Dilemmas and Choices, Gaskell, 2000, p162
(10) Stanton Peele, The Meaning of Addiction: an unconventional view, Jossey Bass, 1985, p31
(11) Jeffrey A Schaler, Addiction is a Choice, Open Court, 2000, p 141
(12) Quoted by Jeffrey A Schaler, Addiction is a Choice, Open Court, 2000, p44
(13) James Nolan, The Therapeutic State: justifying government at century’s end, New York University Press, 1998
(14) Tom Carnath and Ian Smith, Heroin Century, Routledge, 2002, p171
(15) Irvine Welsh, Trainspotting, Minerva 1993 , 1993, p181
(16) T Stanton Peele and Archie Brodsky, The Truth About Addiction and Recovery, Fireside, 1992; p42
(17) Stanton Peele and Archie Brodsky, The Truth About Addiction and Recovery, Fireside, 1992, p 314