The Rehab
Don't Work
19 December 2002
by Dr Michael
Fitzpatrick
'"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?
'Detox'
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'.
'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.
'Treatment
works'?
'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 The Tyranny of Health: Doctors and
the
Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon (UK)
or
Amazon (USA)), and a contributor to Alternative Medicine: Should We
Swallow
It? Hodder & Stoughton, 2002 (buy this book from Amazon
(UK).
Read on:
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