Inside Rehab: The Surprising Truth About Addiction Treatment-and How to Get Help That Works Hardcover – February 7, 2013

While I agree with many of the criticisms of the treatment field in Fletcher's book, such as that most treatment is 12 step based with not enough alternative, that not enough individual therapy is provided, that many counselors are undertrained, and that 28 day residential rehab as a stand along is not enough, I don't agree with her that residential treatment is mostly unnecessary. I don't think people are being overtreated--it is the 90% of people who do not get treatment and need treatment that is the problem. Treatment absolutely needs to be much better, but that does not mean residential treatment is not needed for various reasons. Combining residential treatment with a gradual step down to outpatient treatment over a period of months is offered by many treatment centers, not just 28 days. The problem with non-12 step based treatment is one of access and affordability. If one is to go to residential treatment for a few weeks only before outpatient, and for the family to attend family groups, the center must be close to one's home. Insurance coverage would be helpful, if not a necessity. So if there is no non-12 step program near one's home or covered by one's insurance as was my case for my son, I had to work with a 12 step based program.

Under my insurance neither the HMO or PPO provided residential treatment, so I ended up paying for residential. Here is why: My son went to numerous individual counselors specializing in addiction and various outpatient treatment programs and kept getting worse because he wanted to keep using and found ways to use substances even while in treatment and went back to heavy using as soon as he stopped the treatment. When he finally got to the point of seriously trying to make treatment work for him, he had suffered many consequences and was in crisis and was totally dysfunctional. People who go to residential treatment in my experience usually need it because: they have been arrested or jailed, sometimes numerous times, for DUIs, drug possession, assault, etc., they have overdosed on opiates or alcohol and might have died (many people do) or ended up in the emergency room, they became manic or psychotic or suicidal or depressed from substance abuse and ended up on the psych ward, they flunked out of college for the second time, they lost their jobs, never had one in the first place, and their parents or spouses kicked them out of their house and they are living homeless on the street or in somebody's garage, they were told by their doctor that if they drink or use again they will suffer organ failure and die, they lost custody of their kids, etc. Fletcher sounds like my insurance company when she says people are going to have to learn to live in the real world and rehab is not the real world. That is very true--but people in crisis need to be in a calm and isolated environment to regain their health and mental faculties, take meds, and eat healthy food and develop a routine schedule before returning to the "real" world. Their lives are in shambles and taking them out of the chaos is really necessary at that point.

Now maybe this is not MOST people who need treatment and maybe MOST people can stop on their own, but since this book is about rehab, I expected the author would focus on THOSE WHO NEED IT in the book. And most people who need rehab have to be somewhat coerced or cajoled or mandated into treatment, and from what I have read, evidence shows that those who go voluntarily don't necessarily do better than those who do not.

Regarding AA based programs, I myself wanted to find a non-AA alternative, and non-AA support groups like SMART RECOVERY would be my first choice, but there is a huge advantage to AA, which is why I think it is not so bad for a treatment center to recommend and encourage AA. I don't have many SMART RECOVERY groups in my area--the nearest ones are an hour away which meets 2 or 3 times a week. But one can find an AA or NA meeting every day, several times a day, within about 10-20 minutes of my house. AA does maintain that one should "keep coming back" and stay in recovery, but at least so far, my son is finding it useful to maintain sobriety. If he can maintain sobriety without AA eventually, then no one is going to force him to go to AA meetings for the rest of his life, but there are worse things, such as the situations I mentioned above. The treatment facility I chose has an aftercare program for a year, as many do, but also recommends AA meetings and working with a sponsor to supplement that. If treatment centers don't support the idea of AA or take them to some meetings, people will not tend to use this resource which is the most available help there is. My biggest gripe with treatment and AA which Fletcher does't mention is the smoking. Compared to dying immediately of an overdose, smoking is a slower death, and some people may be further put off from treatment if not allowed to smoke, but I read that evidence shows that smokers are 25% more likely to relapse. I think more thought needs to be put into this issue.

A couple other points: Fletcher suggests it is not a good idea to mix clienta of different ages, and that grouping younger people together would be best. For adolescents, yes, but I found that older people can be helpful to younger addicts in many ways and can act as mentors. Also, centers treating about 10-20 people at a time may not have that luxury. Regarding individual therapy, I believe both group and individual therapy are necessary, and I think if the treatment center does not offer enough, after a few weeks or during outpatient treatment, there is no reason why a person cannot also see a therapist or even two on an individual basis to augment treatment. My insurance covers unlimited individual therapy if the therapist is in network, so supplementing can be done if that piece is missing for those with insurance. A Sober Livig House is another good option, but they don't usually provide food or transportation so are not a good substitute for residential treatment in the early days.

If new recovery groups arise and if treatment centers adopt more "evidence based" therapies and insurance companies don't obstruct people from getting the help they need, including residential treatment, I would be so happy, but in the "real" world, it hasn't yet happened, and as a consumer, I am not sure I want to follow the footsteps of the person Fletcher mentions who spent $500,000 and still hasn't recovered, whose advice she quoted at length. I do think that if one thing doesn't work, it is insanity to keep doing it over and over, so if there is a next time I will do something different.

Inside Rehab is the best book to date on the actual experience of people going through rehab. The fact that it is viewed as critical of the treatment industry is that the state of addiction treatment in the US today is abysmal and outmoded. So an accurate description of it simply points that out. Rehab is an approach developed in the middle of the last century, when there was not science nor real treatment. It was (and for the most part is) based on the 12 Steps of AA and an outmoded "disease concept" outlined in the Big Book of AA. It was developed basically as an introduction to AA. As Dr. Berger points out in review (I strongly disagree with his rating) 12 Step groups are not the same as treamtent programs that use some of AA principles. 12-Step groups are voluntary, anonymous and cost nothing. They provide peer support for getting and staying abstinent. They are not treatment. Treatment programs are businesses licensed by the state that charge fees for professional services. Treatment programs behave just like any other business: they have vested interests, strive to protect them, lobby, advertise, and so forth. In my opinion they have distorted the principles of AA, in the process becoming highly doctrinaire and rigid, while the founders of AA were very practical, humble, and welcoming anything that might help a suffering alcoholic. As Jung once said, "Got save me from the Jungians!" That is, followers often tend to distort and rigidify the teachings of the found (see: Christianity, Islam, Hinduism, Buddhism.)

Where Dr. Berger is wrong is his assertion that 12-step programs have been clearly shown to be the most effective way to recover. In fact, there are many routes to recovery, and only a small minority of people with addiction have long-term affiliations with 12-step groups. It is true that affiliation is correlated with better outcomes, but that does not imply causal direction. In fact the strongest predictor of affiliation is severity of dependence: the more severe it is, the more likely are people to affiliate. Severiy also predicts abstinence no matter how that's achieved. The may be because the choices between drinking and abstinence are the most stark for those the most severe addiction. For many, it's either stop or die. So, it's complex. Most people who attend 12-step groups do so for a few months or a year and then stop going. So,in my view, Dr. Berger has a strong belief in 12 step groups that is not supported by available research. At the same time, they offer a free, widely available approach that does work for many people.

What's important about Instide Rehab (in contrast to Davis Scheff's new book) is that is was thoroughly researched and thoroughly vetted with the top scientists in the field. (Disclosure: I was one of the experts consulted and I vetted the book for scientific accuracy, but did not and will not receive any payment or other financial benefit.)What the book shows is that it is time to move addiction treatment from the mid-20th century to the 21st century, that it be scientifically based and professional, and that is provided in more attractive, accessible and affordable ways. In the meantime: Buyer Beware!

Mark Willenbring, MD
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