The Big Idea: Sick Treatment

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Gloria Holmes didn’t need any more hassles. A working, 36-year-old mother of three, she had been in and out of drug treatment for years. Following a 2001 suicide attempt serious enough to land her in Columbia-Presbyterian Hospital for a week, doctors had given her a prescription for the antidepressant Paxil. Arrested for drug possession not long after that, she was facing prison time.

Holmes asked to be sent to a women-only treatment program. Instead, in the fall of 2001, the city Office of Special Narcotics’ Drug Treatment Alternatives to Prison Program sent her to a co-ed rehab residence run by the Veritas Therapeutic Community in Barryville, New York. There, according to Holmes, she was forced to stop taking Paxil. (Veritas says its general policy is to permit antidepressants.)

Adding to her misery, her treatment often consisted of being bullied and humiliated by her counselors. “They insult you all the time,” says Holmes. Once, she says, a staff member told her, “If I was your husband, I would put you in chains and tie you up and throw you out the window.”

The final straw came as she was sitting outside at a picnic table, enjoying the countryside. A counselor snuck up behind her and dumped a five-gallon bucket–which had been used as an ashtray and was full of cigarette butts–over her head, and banged it three or four times. “He said he did it as a joke,” she says. “He was laughing. But I was crying.”

Jurrant Middleton, the program director at Veritas in Barryville, says what happened to Holmes was no big deal. “I am familiar with this incident, and think that it was blown out of proportion,” he told City Limits. “It was inappropriate, it was dealt with and the counselor was disciplined.”

But Holmes says the incident made her feel worthless. “She felt that she was physically abused, violated tremendously and made a mockery of,” says her husband, John Holmes, a former cocaine and heroin addict now training to be an addictions counselor. “It certainly didn’t do anything for her self-esteem. She felt she could no longer take it, and she left.” Holmes dropped out of the program, violating the conditions of her sentence, and started smoking crack again. Now she is upstate, serving three to six, as a result of her failure in rehab.

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Imagine if physicians could justify being abusive, arrogant and condescending by arguing that it improves patient health. Imagine that these professionals could decide not to use chemotherapy for cancer, for example, because they “don’t believe in it,” despite overwhelming research data. That’s what addiction care has been like for the last half-century. To this day, there’s a huge gap between clinical psychiatric knowledge and the way drug treatment actually goes down.

Clinical research shows that, like anyone else, addicts–particularly women and the mentally ill–respond better to empathetic treatment than to attacks or humiliation. The University of New Mexico’s William Miller, for example, has demonstrated that patients are less likely to drop out and relapse if they have counselors who are compassionate, and not confrontational.

Yet for years, the sort of “care” Gloria Holmes received has been par for the course in addiction treatment. Many providers believe that addicts needed to be “broken down” and then re-socialized, and that insults, humiliation and degrading treatment aid this process. And while the National Institute on Drug Abuse has shown that medications like antidepressants aid recovery, a large proportion of rehab programs still routinely deny addicts standard psychiatric medications on the premise that they could lead back to addiction.

Recently, a number of federal, state and local government initiatives have begun trying to reform drug treatment, through both regulations and research. But they’ll have to overcome a deeply entrenched legacy of anti-science and even anti-addict ideology.

Until very recently, abusive treatment was almost universally praised. A 1993 book by the founder of the Daytop treatment network, Monsignor William O’Brien, calls addicts “babies” and “stupid,” and says that addiction treatment “has to be harsh,” and that “being too gentle…doesn’t do anybody any good.”

John Holmes, who works at an agency that provides housing for former addicts, doesn’t think his wife’s experience was unique. “I’ve heard about people who were made to wear dunce hats or sit in a corner for hours, about men dressed as women, or made to wear diapers,” says Holmes.

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These ideas about how addicts should be treated pervade almost every type of addiction care. But they have their roots in one specific type of treatment: therapeutic communities, often called “TCs,” like the one that Gloria Holmes attended.

Therapeutic communities began in the late 1950s, after physicians and psychiatrists essentially decided that addiction was untreatable. While some doctors continued to try, the treatment of addicts and alcoholics became a backwater of the medical profession, populated largely by profiteers and quacks with little concern about and no financial interest in determining whether their treatment actually worked.

Alcoholics Anonymous, developed by two alcoholics in the 1930’s, offered some hope to excessive drinkers. Based on the idea that one alcoholic could help another, it showed the public that alcoholism–and later other addictions via copycat 12-step programs like Narcotics Anonymous–weren’t always hopeless conditions. As “the program” grew, doctors and psychologists began to offer residential treatment to help initiate people into self-help. The first of these, Pioneer House, opened in Minnesota in 1958 and became the model for modern programs like Hazelden and Betty Ford.

That same year, AA member Chuck Dederich opened a small storefront in Santa Monica and began treating heroin addicts. He found that living in a dedicated community, where addicts forced each other to look at their problems, could help some stay away from drugs. Synanon–named after the way one resident mispronounced “seminar”–became the first American therapeutic community, spawning countless imitators. Two of them, Phoenix House and Daytop (both based in New York), are now the country’s largest providers of addiction treatment.

Unfortunately, Synanon’s program became increasingly bizarre over time, eventually devolving into a violent cult. After putting a rattlesnake in the mailbox of an attorney who was suing Synanon, Dederich and several other members were ultimately convicted of conspiracy to commit murder.

Synanon is gone now, but its methods live on. Before Synanon imploded, mainstream programs picked up many of its methods, including “marathon” therapy sessions lasting days without breaks for sleep or food, brutal emotional confrontation, humiliating punishments–such as being dressed as a bum and wearing a sign saying “I am an asshole”–and other techniques aimed at dehumanizing and degrading participants.

Like fraternity initiations, this “tough love” tradition is highly resistant to change, often because many TC staffers are graduates themselves. A large proportion of graduates believe that what was done to them was necessary to their recovery. They come into the field with an evangelical urge to spread the word–and some, unfortunately, relish the chance to do unto others as others had done unto them.

As a result, they often not only disregard science as being irrelevant to what they do, but also tend to view medications and more humane treatments as inimical to recovery. “Remember that Synanon and TCs started as an anti-psychiatry, anti-medication movement, because those things weren’t doing anybody any good,” says Jim Dahl, director of program planning for Phoenix House. “To have the same people embrace research, it’s a total culture clash.”

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In the last few years, state and federal governments have tried to bring research into practice. The National Institute on Drug Abuse’s Clinical Trials Network, which has outposts at NYU and Columbia, runs trials of research-based treatments in community programs, in the hope that such collaboration will encourage providers to adopt effective new methods.

Similar work is also being done by the federal Center for Substance Abuse Treatment. New York State’s Office of Alcohol and Substance Abuse Services uses a federally funded network to bring together local providers and researchers for meetings and networking.

Kevin Wadalavage, vice president of the Outreach Project, which runs a variety of treatment programs as well as New York State’s largest training program for addiction counselors, thinks that ideological barriers are starting to fall. “The new generation is more open,” he says. “I think as we start to understand the disease of addiction as a brain-based phenomenon, we are getting there. Sometimes people will have a ‘drug-free’ philosophy, but I don’t think it’s as pervasive as people think.”

Nonetheless, even Wadalavage recognizes numerous obstacles to change. The research projects and collaborations can only exhort providers to improve care, not force change. As courts sentence more and more people to rehab as an alternative to prison, patients have little choice about which program they enter–but they are blamed for it and incarcerated if they “fail” treatment. And since drug courts provide a steady stream of patients–at least 50 percent of clients, in some residential drug programs–providers have few incentives to improve their practices.

There are also practical problems. Addiction counseling pays little and has high turnover, and many programs don’t require much training beyond having graduated from a therapeutic community or being a member of a 12-step program. “The problem is that therapeutic communities are the only modality which really grooms its recovering people to work in the field,” says Ira Marion, executive director of the Division of Substance Abuse at Albert Einstein College of Medicine, which runs a methadone program for 4,400 patients. “TCs now integrate Narcotics Anonymous, which is totally against medication. Even if you train such people up the wazoo–and one big issue in the field still is training–they still have their experience and the NA credo in their gut and in their soul.”

Despite the obstacles, there is definitely a shift underway. “We try to create an environment where if someone says, ‘AA was the only way for me,’ someone else can say, ‘Well, that didn’t work for me,'” explains Wadalavage. “Or if someone says, ‘I’m opposed to methadone’ [someone else can reply], ‘Well, methadone saved my life.'”

Dahl, too, is adamant about abandoning infantilizing techniques. “That reduces self-esteem, and the self-esteem of most of our clients is already quite low,” he says. “We have a manual for operating a TC, and we try to hold [staff] accountable if they do things like making someone wear bum clothes, put on a dunce hat, etc.”

He acknowledges that the change is not yet complete, however. “Here and there you still do find that old tradition rearing its ugly head,” Dahl admits. “A lot of people still carry those toxic methods with them. It’s very hard to change. But we’re trying desperately.”

Maia Szalavitz is a co-author of Recovery Options: The Complete Guide: How You and Your Loved Ones Can Understand and Treat Alcohol and Other Drug Problems (Wiley 2000).