Rehab, Relapse, Repeat (Lindsay Lohan, Take Note!)
Reading in the supermarket checkout line that the latest troubled starlet has gone into rehab—yet again—may inspire cynicism and eye-rolling. But on the front lines of addiction treatment, figuring out why rehab works, and why it often doesn't, is a serious matter. Just one fourth of drug and alcohol addicts get treatment, according to the nonprofit Network for the Improvement of Addiction Treatment (NIATx). And as many as half of people who do get help don't complete the full program.
Celebrity relapses notwithstanding, treatment for substance abuse can indeed work, say experts. In fact, research has homed in on methods and practices that increase the odds of success. But pitfalls can lurk in the expectations many people bring to treatment, what happens after they finish a program—and even in how "success" is defined.
First, what works? Whether it's at a fancy inpatient facility or through a publicly funded outpatient center, almost all programs are based to some extent on the 12-step approach of Alcoholics Anonymous. Those steps include the admission that a life involving alcohol (or other addictive substances) has become unmanageable. Other therapeutic techniques often get layered on top of these principles, including cognitive-behavioral therapy—which monitors and then modifies everyday thinking and behavior—and an approach called motivational interviewing, which consists of asking questions intended to help the patient recognize his need for help, says Thomas Irwin, program director for the McLean Center at Fernside, an inpatient alcohol and drug treatment center in Princeton, Mass.
As for the length of a program, he says, there's nothing magic about 21 or 28 days, the two most common terms of treatment. It takes about a week to get through detox and wean the body off a substance, and that's when people can really begin to focus on the psychological and behavioral aspects of addiction. After that, treatment length depends on the severity and duration of the addiction—at least in theory. In practice, it's often limited by what insurance will cover. When it comes to outpatient programs, attending at least four treatment sessions within the first month seems to be a key predictor of success, says David Gustafson, national program office director of NIATx. His organization is a partnership of government and nonprofit groups aimed at improving access to and retention in addiction treatment.
Whatever the type of program, it's important to have the right expectations about treatment. Addiction "is a lifelong chronic illness," says Deni Carise of the nonprofit Treatment Research Institute in Philadelphia. "The public thinks people will go away for 21 or 28 days, something called 'treatment' will happen behind a closed door, and they will come out a non-substance abuser. But it's a lifestyle change, just like managing obesity or diabetes."
That's why follow-up is hugely important, and it's here that efforts often fail. "Research shows that the environment that people go back to is the most critical element and the most predictive of success," says Irwin. In other words, if after rehab you return to the same old friends and same old situations, expecting willpower alone to carry you through, relapse is more likely. And in addition to having a supportive network of family, friends, or others in recovery, one needs some kind of aftercare plan: The Betty Ford Center, for example, makes regular phone calls to patients after they're discharged to make sure that they're attending meetings and maintaining contact with a sponsor.
Gustafson says there also should be a seamless transition between different stages of care—from detox into a residential program, for example. And people need access to various services during and after treatment, such as protection from an abusive boyfriend or transportation to and from a group meeting.
Carise has developed a computer program that gives counselors easy access to those needed "wrap-around" services. Entering a few keywords and a ZIP code might yield info on where to take the GED in Spanish. One patient couldn't make it to a regular family support group because he had to watch his Alzheimer's-stricken mother; the software identified three local groups dedicated to caring for Alzheimer's patients while their caregivers were getting other human services. A study published in 2005 found that patients counseled with Carise's program had better matches for the services they needed, and were more likely to finish treatment, than patients counseled using standard methods.
Addiction researchers are also struggling with how to define "success" or "recovery" in the context of rehab. Historically, the benchmark has been total abstinence from drugs and alcohol, says Carise, a definition that doesn't take all factors into account. Consider a former heroin addict and alcoholic who is HIV positive and doesn't have a job. After treatment, perhaps, he has stopped using heroin, has a job, has his infection under control, and occasionally drinks a beer when watching a football game. "While I hope that he doesn't drink," says Carise, "I don't see that guy as a failure."