Rehab doesn't work

The Washington Post published an opinion piece on addiction treatment and AA by Bankole Johnson. I can’t help but think of Emerson:

Well, most men have bound their eyes with one or another handkerchief, and attached themselves to some one of these communities of opinion. This conformity makes them not false in a few particulars, authors of a few lies, but false in all particulars. Their every truth is not quite true. Their two is not the real two, their four not the real four: so that every word they say chagrins us and we know not where to begin to set them right.

Where to begin? How about the beginning?

the 12-step model pioneered by Alcoholics Anonymous that almost all facilities rely upon

Really? “almost all . . . rely”? How many is “almost all”? What constitutes “relying”? Surely, most treatment programs make referrals to 12 step programs, but I’d say relatively few “rely” on 12 step programs and owe much more to CBT based relapse prevention and motivational interviewing. Most seem to view 12 step involvement as a potentially helpful adjunct rather than something core or central to treatment. Of course, there are programs that rely on 12 step programs (Dawn Farm could be characterized this way, though we do integrate other approaches.), but to say that “almost all” “rely” on them is difficult to swallow.

We have little indication that this treatment is effective.

Just not true. (The link offers reams of evidence.)

When an alcoholic goes to rehab but does not recover, it is he who is said to have failed. But it is rehab that is failing alcoholics.

Blaming the patient for relapse is definitely a historical failing of addiction treatment providers. However, these attitudes have dramatically improved, and this problem is not unique to addiction treatment. Doctors are only beginning to look at ways to improve compliance with treatment for chronic disease and use of prescription medications? Haven’t they too historically blamed patients for failing to take their meds, exercise, follow diets, etc.? This doesn’t excuse this failure of addiction treatment providers, but it provides some important context.

And the way we attempt to treat alcoholism isn’t just ineffective, it’s ruinously expensive: Promises Treatment Centers’ Malibu facility, where Lohan reportedly went for her second round of rehab, in 2007, has stunning vistas, gourmet food, poolside lounging and acupuncture. It costs a reported $48,000 a month.

We think this is just as bad as he does. There are too many people who are cashing in on treatment. But what about nonprofits like Dawn Farm?

Even nonprofit facilities that don’t cater to Hollywood types are too costly for most people. At the 61-year-old Hazelden center in Minnesota, which bills itself as “one of the world’s largest and most respected private not-for-profit alcohol and drug addiction treatment centers,” a typical 28-day stay costs $26,000.

So these are the only 2 tiers of treatment providers? Come on. We charge around $2700 per month. Does he not know that most treatment programs programs/episodes cost nowhere near $26,000? Why would he leave uninformed readers with the impression that these programs are the norm?

And when they do report a success rate, be it 30 percent or 100, a closer look almost always reveals problems. That 100 percent rate turns out to apply only to those who “successfully completed” the program.

Fair criticism. Many programs engage in this practice. It’s, at least in part, an artifact of the acute care model where the expectation is that one time-limited treatment episode with produce full and permanent remission. I suspect that Dr. Johnson rejects the acute care model and you’d think that he’d address this fallacy in these kinds of “success rates”–that, not only are they often deceptive, but their premise is faulty.

A recent review by the Cochrane Library, a health-care research group, of studies on alcohol treatment conducted between 1966 and 2005 states its results plainly: “No experimental studies unequivocally demonstrated the effectiveness of AA or TSF [12-step facilitation] approaches for reducing alcohol dependence or problems.”

I’ve posted about Cochrane before, the most germane is a summary of a Sara Zemore presentation last year:

She very effectively rebutted the Cochrane Review from a few years ago by making the following points. (These are based on notes I took and are incomplete. Hopefully they post video so that you can see her complete rebuttal for yourself.)

• It was limited only to randomized trials and ignored the overwhelming observational evidence.
• It included one of Zemore’s studies which was NOT a randomized study of AA.
• She acknowledged that the randomized evidence is ambiguous.
• Randomized trials of AA are hard to do because some subjects in other groups end up participating in AA. This happened in Project MATCH.
• The Cochrane Review did not find Twelve-step Facilitation ineffective. It found it no more effective that CBT and MET. (The summary from the abstract says, “The available experimental studies did not demonstrate the effectiveness of AA or other 12-step approaches in reducing alcohol use and achieving abstinence compared with other treatments, but there were some limitations with these studies.”)
• Finally, she cited 4 randomized studies of Twelve-step Facilitation: The outpatient arm of Project MATCH, a study by her colleague Kaskutas, and two others that I missed.

Onward…

AA itself has released success rates at times, but these numbers are based only on voluntary self-reports by alcoholics who maintain their ties to AA — not exactly a representative sample.

Even taken at face value, the numbers are not impressive. In a 1990 summary of five membership surveys from 1977 through 1989, AA reported that 81 percent of alcoholics who began attending meetings stopped within one month. At any one time, only 5 percent of those still attending had been doing so for a year.

A few things. First, he acknowledges that this is not scientific survey. It’s fair to say that many AA members and allied professi
onals have little faith in the accuracy of these surveys. Second, did it really report that 81% of alcoholics stopped attending? How were they identified as alcoholics? A common concern among AA members is that courts send non-alcoholics to AA because of an alcohol related offense. Third, here’s the report on the most recent survey. It doesn’t include dropout info, but does that paint the same picture he paints?

As for his comparison to spontaneous recovery, I’ve got a few questions. The rate he cites seems very high and begs a couple of questions. First, how stable is this recovery? Second, how rigorous was the screening for DSM dependence? Did they let people slip in who were not chronic or experiencing loss of control? Finally, we’ve already cast doubt on his portrayal of AAs effectiveness.

Many proponents of AA cite Project MATCH … After eight years and $27 million, the study concluded that the techniques were equally effective.

Actually, Project MATCH found few differences in overall effectiveness, but 12 step facilitation was superior for the most severe alcoholics and people with heavy drinking social networks.

Although AA doubtless helps some people, it is not magic.

AA is not magic. It does not work for everyone. It should not be the only option available to people with alcohol problems. However, this is damning with faint praise. AA has been part of the path to recovery for millions of American alcoholics. Not to mention the drug addicts that have been helped by 12 step programs. Why is he so dismissive of this? Are there approaches that have played an important role in more recoveries?

I have seen, in my work with alcoholics, how its philosophy can be harmful to patients who chronically relapse: AA holds that, once a person starts to slip, he or she is powerless to stop.

This is known as the “Abstinence Violation Effect” theory. It’s commonly cited in criticism of the disease model, and it makes intuitive sense, but there’s little evidence to support it. Studies looking for this effect have often failed to find it.

Equally troubling, AA maintains that when an alcoholic fails, it is his fault, not the program’s. As outlined in the organization’s namesake bible, “Alcoholics Anonymous” (also known as “The Big Book”): “Those who do not recover are those who cannot or will not give themselves completely to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates . . . they seem to have been born that way.” This message can be devastating.

This is a fair criticism. It’s also fair to point out that treatment is not AA (and AA is not treatment). Treatment providers who are dropping the acute care mindset don’t hold these attitudes or allow them into the treatment milieu. It’s also worth pointing out that AA has a pretty loving and accepting toward active alcoholics and its literature humbly acknowledges the limitations of their knowledge. I also can’t help but notice Dr. Johnson’s choice of words in introducing the quote–bible. Most people refer to it as AA’s text. Why did he choose such a culturally loaded term? Does it intimate a bias?

Finally, it’s worth noting that in the AA participation fits exceptionally well with a chronic disease management approach. Medical professionals who try to help patients with diabetes and heart disease make behavioral changes would live would love a free, easily accessible, thriving community organized around supporting patients in making behavioral changes to support recovery and reduce the risk of relapse. Why doesn’t Dr. Johnson?

I asked a lot of questions in this post and one might interpret them as passive-aggressive. Let me be more clear. I believe that Dr. Johnson doesn’t like AA and I believe his piece paints treatment and AA in the worst possible light, primarily by using half-truths. Most troubling (and maybe most telling) is that he offers no alternative. AA is not magic, it does not work for everyone, there should be a menu of options, and research into other treatments should continue, but AA and treatment do work. We don’t say bypass surgery doesn’t work because some people have more blockages and heart attacks. We don’t say diet and exercise aren’t good treatment for type 2 diabetes and heart disease because too many people don’t follow through. Why hold AA and addiction treatment to another standard?