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"  &amp;quot;She doesn&amp;#039;t belong in here,&amp;quot; Patricia said. We were at a Missouri addiction rehab facility, where I&amp;#039;d checked in two weeks before, and Patricia was talking about Kelly, a new patient who was dominating group therapy discussions. Kelly was standing at the nurses&amp;#039; station, demanding that the laundry room be opened\u2014in full view of those of us who were lingering in &amp;quot;the fishbowl,&amp;quot; so called because it was the main area for patients to gossip, play games, and watch TV, with windows all around so staff could keep watch. &amp;quot;She just wanted to get away from her kids,&amp;quot; said Patricia, who&amp;#039;d regularly been getting electroconvulsive therapy that left her hair an upsetting color of yellow. In Patricia&amp;#039;s mind, Kelly, a science teacher and mother of three married to a real estate developer, had not experienced the real suffering that is the addict&amp;#039;s rite of passage; Kelly was just a poseur. &amp;quot;Yeah, they only got her on two meds,&amp;quot; Jimmy said. &amp;quot;I&amp;#039;m on seven, plus shots. What can be wrong with you if you&amp;#039;re only on two meeds?&amp;quot; &amp;quot;Glass of wine with dinner,&amp;quot; Patricia sneered, quoting Kelly. &amp;quot;Yeah, that sounds pretty good, Kelly. I&amp;#039;ll have a glass of wine with dinner. Then I&amp;#039;ll go huff some gas out of your Mercedes-Benz.&amp;quot; &amp;quot;You don&amp;#039;t have to be a junkie to be in here\u2014some people like to get away,&amp;quot; said an electrician who&amp;#039;d been smoking crack since the &amp;#039;80s. For a few days after payday, he and some buddies would disappear into the den. It had finally worn him out. &amp;quot;It&amp;#039;s romantic to be a fuckup,&amp;quot; he continued. &amp;quot;All her society friends are asking her to lunch the day she gets out of here. &amp;#039;Are you all better now, Kelly?&amp;#039;\u2009&amp;quot; &amp;quot;Yeah, it&amp;#039;s all BS,&amp;quot; Patricia said. &amp;quot;She can 12-step her skinny butt on outta here.&amp;quot; It&amp;#039;s an old joke, but we all laughed. Dancing the 12-step. The veteran addicts may have been &amp;quot;right&amp;quot; about Kelly, or just full of \u2028bluster\u2014who knows? Which, broadly speaking, is one of the major critiques of addiction treatment put forth in three recent books, Anne M. Fletcher&amp;#039;s Inside Rehab, Gabrielle Glaser&amp;#039;s Her Best-Kept Secret, and David Sheff&amp;#039;s Clean. It&amp;#039;s difficult to assess who belongs in rehab, Fletcher and Sheff in particular argue, because the industry has become monolithic\u2014some $13 billion a year is spent on alcohol recovery alone\u2014its effectiveness taken for granted, its practices unregulated. The basic principle behind rehab is simple and reasonable: The addict has a habit that is integrated into her daily life and relationships; removing her from the environment disrupts the &amp;quot;enabling&amp;quot; system and gives her time to get well. The vast majority of centers use some variant of the Alcoholics Anonymous 12-step program, which involves regular attendance at meetings where substance users help one another try to remain sober. But in a world where the treatment of addiction has gotten increasingly complex, the drumbeat of criticism against our current models has been growing louder. Last year, the highly respected National Center on Addiction and Substance Abuse at Columbia University (CASA) released a scathing report, concluding that &amp;quot;only a small fraction of individuals receive interventions or treatment consistent with scientific knowledge about what works.&amp;quot; Much of addiction treatment, the study went on, could possibly be described as &amp;quot;a form of medical malpractice.&amp;quot; CASA&amp;#039;s findings are echoed and elaborated on by the authors. As portrayed by Fletcher\u2014an award-winning science journalist and a former alcoholic who exhaustively surveyed the efficacy data and spent nearly five years talking with the people who go to rehab and work in the field\u2014a core problem is the one-size-fits-all approach. Alcoholics, meth addicts, cokeheads, the suicidal, anorexics, even video-game addicts are all thrown in together, the guiding philosophy being that the addiction may differ but the recovery process is the same. A. Thomas McLellan, PhD, a University of Pennsylvania psychiatry professor who has studied addiction for more than 30 years, says, &amp;quot;If you go to just about any addiction program in this country, the major treatment activity is &amp;#039;group.&amp;#039; If that doesn&amp;#039;t work, then they&amp;#039;ll try\u2026&amp;#039;group.&amp;#039; And when all else fails they&amp;#039;ll suggest\u2026&amp;#039;group!&amp;#039;\u2009&amp;quot; According to various studies, this AA model works for about 30 percent of addicts, which is nothing to scoff at but obviously fails a large swath of people. &amp;quot;I keep coming across patient after patient who has been through rehab with either no benefit or [with] negative effects,&amp;quot; addiction psychiatrist Mark Willenbring, a former director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism (NIAAA), tells Fletcher. &amp;quot;It&amp;#039;s atrocious this is allowed to continue.&amp;quot; Rehab facilities are barely regulated compared with other medical, or even quasi-medical, institutions, the authors point out. &amp;quot;What qualifies someone to treat people with drug and alcohol problems?&amp;quot; Fletcher asks. &amp;quot;Most individuals I interviewed\u2026had no clue.&amp;quot; In some states a GED will suffice to work as a counselor; in others not even a high school degree is required. (Many in the field are themselves recovering, which can be beneficial, but I&amp;#039;d argue that this no more qualifies someone to treat addicts than having had sex would make her a good sex therapist.) In my own first experience with rehab, the MD who diagnosed me and put me on six different medications\u2014including lithium\u2014freely told me that he was a child psychiatrist who did not specialize in addiction but visited my rehab on weekends to make extra money. I saw him in his office once (he wanted to make sure I was attending a 12-step group), after which we had 15-minute &amp;quot;phone consultations&amp;quot; every other week. When I did find an addiction psychiatrist, she took me off all of the meds he&amp;#039;d prescribed except an SSRI and an antianxiety drug, informing me that my previous pharmaceutical cocktail was principally for children with bipolar disorder and likely caused a worse depression than my drinking ever did. Comparatively speaking, though, I was lucky: As Willenbring noted, rehab can actually have negative side effects. Hard-core addicts are lumped together with lesser ones, and it&amp;#039;s not uncommon for addicts to swap tips and techniques. Fletcher describes the case of Emily E., a prominent professional woman who was prescribed pain medication when she developed migraines. One legal drug led to another, and before she knew it, Emily&amp;#039;s doctor was recommending that she go to rehab to wean herself from the pharmaceuticals they&amp;#039;d prescribed. When she emerged after 64 days, now unable to get the kind of pain medication necessary for her migraines, she took heroin\u2014provided by a friend she met in rehab. Reading about Emily, I remembered a 19-year-old girl named Lisa, who attended her first AA meeting at my home group. Accompanied by her mother, who was quick to inform us that she was not an alcoholic, Lisa recounted how she&amp;#039;d gotten drunk a couple of days earlier and gone home with an older man. When she woke up in his bed, with no idea how she&amp;#039;d gotten there, she ran out of his apartment barefoot, forgetting her purse. Over the next several meetings we learned that Lisa, who always came with her mother (the group was supposed to be solely for alcoholics, but none of us protested), drank only occasionally and socially. The bad night she&amp;#039;d described was her first real drunk; yes, she&amp;#039;d blacked out, but that&amp;#039;s a warning sign, not a diagnosis. Her mother was convinced that her daughter was a drunk, however, and by the time the mother decided she no longer had to accompany Lisa, the girl was so tightly woven into the group that she &amp;quot;knew&amp;quot; she was an alcoholic. What could be the harm? you might ask. So she learns to avoid self-destructive behaviors. The issue to Fletcher is how the label may come to define people. As one psychologist told her, &amp;quot;After a lot of time in traditional rehab and twelve-step groups, they may not get exposure to other ways young people get a sense of identity\u2014for instance, being a student.&amp;quot; Also, few &amp;quot;addicts&amp;quot; manage to stay sober\u2014&amp;quot;Relapse is part of recovery,&amp;quot; the mantra goes\u2014so if Lisa has a few drinks, she&amp;#039;s apt to think she&amp;#039;s fallen off the wagon and needs more help, thereby setting up a cycle that perhaps never should&amp;#039;ve begun. Glaser, a journalist who&amp;#039;s long reported on women&amp;#039;s health, thinks the AA model is troublesome for women especially, because it exacerbates often already established feelings of weakness and dependence. (The first step of AA is to admit one is &amp;quot;powerless over alcohol.&amp;quot;) Glaser&amp;#039;s other objections to rehab: Women are often (unjustly) condemned for abandoning their families. Plus, women&amp;#039;s alcoholism is often hidden in the first place\u2014she attributes this to the culture&amp;#039;s acceptance in certain situations of male drunkenness but never female\u2014so what they don&amp;#039;t need is to retreat to a secret place or join a secret society. Everyone acknowledges that rehab will be appropriate for some, but, again, there are no reliable criteria for whom. Sheff talks to a researcher who compared abstinence rates for inpatient and outpatient programs and found that residential treatment benefited only those who were suicidal or who had &amp;quot;severe problems in at least four out of five areas,&amp;quot; including social isolation, employment concerns, and psychological distress. Overall, the consensus seems to be that a patient&amp;#039;s situation must be dire to warrant rehab. &amp;quot;In the end, there is simply no need to remove alcoholics from the support of relatives and friends and shut them away for the customary month in rehab,&amp;quot; wrote Bankole Johnson, MD, chairman of the department of psychiatry and neuro-behavioral sciences at the University of Virginia and one of the country&amp;#039;s leading addiction experts, in a recent Washington Post op-ed. &amp;quot;There is no need for alcoholics to be led to expect a miracle, only to be judged a failure if one does not occur. And there is no need to spend tens of thousands of dollars, again and again and again, on an approach that keeps landing people back where they started.&amp;quot; Even as we acknowledge the maxim &amp;quot;Alcoholism is a disease,&amp;quot; many people still consider the heavy drinker somehow flawed or lacking. We&amp;#039;d never judge a diabetic that way, of course, and Sheff, who nearly lost his son to crystal meth (described in his best-selling memoir Beautiful Boy), says that only by forswearing the notion that &amp;quot;drug use is a moral choice&amp;quot; will the country begin to apply the same scientific and social resources to curing addiction that we have to other diseases. (Glaser agrees: &amp;quot;Government-supported researchers have discovered hundreds of new cancer therapies over the past four decades, and there are nearly 1,000 more biopharmaceutical cancer drugs in development. Yet there are a mere six or so drugs to treat alcohol abuse.&amp;quot;) To that end, Sheff delves into the pioneering research that is being conducted into new treatments, including vaccines for addiction, genetic diagnosis, and medications tailored to individual genetic profiles or that address specific, measurable chemical imbalances in the brain. (Johnson&amp;#039;s group at UVA is on the cutting edge of this science.) Still, any revolution in treatment is at least 40 years away, Sheff says, so in the meantime, he provides a blueprint for the addict who wants to take matters into her own hands\u2014everything from how to find a well-trained doctor to different therapies to the drugs thought to prevent relapse\u2014while stressing that there&amp;#039;s no one right combination. I, for one, got sober for two years with the help of AA and a wonderful psychiatrist, went through a year of escalating relapses, and now have been sober again for about a year. My sobriety is still day-to-day work, but these are the tools I now rely on: a small daily dose of the anti-anxiety drug diazepam. My psychiatrist. The support of friends and family. Exercise. Meditation. Regular writing about my life and my addiction (my own form of journaling). Mostly avoiding other addicts, who, for me, are a trigger for relapse. Will that mix work for everyone? No, but, again, that&amp;#039;s the point. The day might come when a crystal meth addict can see her GP, get a referral to an addiction physician, then leave that doctor&amp;#039;s office with a prescription\u2014and, surely, a plan that includes lifestyle and behavioral changes. But we&amp;#039;re not there yet. And what about Kelly, the science teacher who was trying to do her laundry? I was sitting with her in the hallway of rehab on the day she checked out. &amp;quot;Are you going straight back to work?&amp;quot; I asked her. It was a Thursday morning. &amp;quot;I have to,&amp;quot; she said. &amp;quot;My husband has been home with the kids again. He&amp;#039;s practically about to lose his job because of my rehab. Honestly, I think he&amp;#039;s ready to leave me,&amp;quot; she said, and started to cry. &amp;quot;He&amp;#039;ll take the kids if he goes. I don&amp;#039;t know how I&amp;#039;ll hold it together if that happens.&amp;quot; I didn&amp;#039;t know what to say. We were sitting about six inches apart from each other on the tile floor, and we watched the nurses&amp;#039; and the orderlies&amp;#039; legs walking up and down the hallway in their scrubs. It was about time for meds, and the other residents were starting to gather outside the fishbowl. A few came around to give Kelly a hug goodbye. &amp;quot;Good luck, Kelly. Hope I don&amp;#039;t see you again.&amp;quot; That&amp;#039;s another one of the standard jokes. &amp;quot;Yeah, hope I don&amp;#039;t see you again too.&amp;quot; "^^<http://www.w3.org/2001/XMLSchema#string>
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