The Trouble with Rehab

whether you're a hollywood star or a hard-core junkie, treatment programs don't always work. here's why

When he got out of rehab for the seventh time, Bob Forrest felt beaten down, talked out and uncertain about how to find his way back to a normal life. Front man of the LA alternative band Thelonious Monster, Forrest had been an addict since high school, interrupting furious binges of booze, coke and heroin with layovers in all manner of residential treatment programs, from cushy retreats to court-ordered lockups.

But even the best rehab RCA could buy didn't slow down Forrest. Four days into one pit stop, he waltzed out a side door and hit the streets. Soon, he found himself in the back of a cab heading down Sunset Boulevard, a plump mound of brown Persian heroin folded into a magazine on his lap. He remembers rolling up a dollar bill in the dull flicker of passing streetlights, crouched down in his seat, snorting as much powder as his nostrils would hold.

With his system relatively clean after a year of sporadic sobriety, Forrest overdosed. When he slumped over unconscious, the taxi driver pulled over, dragged him into the gutter and peeled away. The next thing Forrest remembers, he was surrounded by a group of friends and drug counselors in the harsh light of the Cedars-Sinai emergency room.

When he realized where he was, Forrest "flipped out." After hopping off a gurney and screaming that he wouldn't go back to rehab, he retreated to a bathroom, rummaged through his belongings and found his packet of heroin stashed in a shirt pocket. As a counselor pounded on the bathroom stall, Forrest took a few deep sniffs. Again he overdosed.

For some addicts, overdosing twice in one night might signal rock bottom--the low point you claw your way out from one day at a time. But Forrest continued to use, bouncing in and out of rehabs, detoxes, jail cells and a state mental ward. When he finally got clean, in 1996--on his own, with help from sober friends and a neighborhood 12-step program--Forrest had racked up 35 visits to rehab centers.

From hard-core junkies like Forrest to high-profile recidivists Robert Downey Jr., Darryl Strawberry, Matthew Perry and Aaron Sorkin, rehab has not proved to be the cleansing fresh start that their loved ones, employers and publicists had hoped for. Again and again, addicts emerging from intensive, costly antidrug programs waste little time before making their way back to the bottle, needle or pipe.

At the same time, rehabilitation has never been more popular. Hardly a month goes by without news of another strung-out rocker or a hard-partying star ducking into treatment after an embarrassing flameout or encounter with the cops. Last summer saw the intake of actor Ben Affleck, headbanger James Hetfield, comedian Paula Poundstone and singer Mariah Carey (though her publicists insist that drugs were not a factor in her plate-smashing meltdown). The stigma once associated with residential treatment is long gone--a 28-day hiatus at Promises Malibu or the Betty Ford Center is an almost mandatory pause in the ascent to stardom.

Celebrities aren't alone in reflexively looking to rehab to mop up the messes of addiction. Makers of public policy look to treatment as a better way to fight the drug war. In California,a ballot initiative has mandated that courts direct nonviolent drug offenders to treatment instead of jail. And in New York, drug laws are being rewritten to ease mandatory sentences and allow judges more leeway in sending addicts to rehab.

While rehab has saved numerous lives, for a significant percent of addicts it simply doesn't work--rarely on the first go-around, and often not on the first five or six.

"The cycle seems to be: You do a little rehab, you go back to work, the rehab didn't take, so you go back to drugs, you do a little more rehab," says Bruce Porter, author of Blow, which chronicles the rise and fall of the smuggler who brought coke to Hollywood. "So far, no one has asked the obvious question: Why isn't rehab working?"

Depending on who you ask, relapse rates for people who enter residential treatment programs range from 60 to 90 percent. So-called success rates are slippery to calculate because of the difficulties in defining success. How do you account for the many addicts who bolt midway through the treatment? What about the alcoholic who downs a single martini a year later? Or the junkie who now drinks socially? Official data, however, points in the same direction. A 1994 study for the Office of National Drug Control Policy concluded that 87 percent of heavy cocaine users relapse after treatment. The numbers are similar for heroin. And an authoritative 1994 study known as the California Drug and Alcohol Treatment Assessment found that while addicts who went through treatment were less likely to commit crimes or end up in the hospital, most continued to get high--three out of four junkies still shot up after rehab and two of three alcoholics kept drinking.

Defenders of rehab say success cannot be judged by relapse alone. They point to research like a 1997 National Treatment Improvement Evaluation Study that concluded addicts consumed between 45 and 55 percent less cocaine, crack or pot a year after their trips to rehab. Sure, they concede, most addicts continue to get loaded after rehab--but at least they get somewhat less loaded.

That's cold comfort to those who preach a gospel of total sobriety. Jack Bernstein, president and chief executive officer of the Cri-Help Treatment Center in Los Angeles, says the high rates of relapse frustrate zero-tolerance drug counselors. The problem, of course, is that no onehas come up with anything better. "Thirty years from now, people will look back at how drug addicts were treated and they'll be appalled," Bernstein says. "They'll look back, scratch their heads and say what a bunch of idiots we were."

While some claim miraculous results from one-on-one psychotherapy, experimental anticraving drugs or alternative medicines like the root of the Chinese kudzu, there are no data to suggest that any particular treatment works better than another. About the only fact everyone seems to agree on is that the longer you devote to treatment--it doesn't appear to matter which kind--the better your chances are of recovery. And for those with the most-serious problems, the standard 28-day course of rehab, which is covered by most insurance policies, is a joke. Treatment officials say three months is the minimum, with many addicts needing a year or more to kick their habits.

"Everybody's assumption is that we ought to just send these people into rehab to focus on their drug problem," says Dr. Lonny Shavelson, a writer and emergency room physician who spent two years following addicts through the byzantine San Francisco rehab system for his book Hooked: Five Addicts Challenge Our Misguided Drug Rehab System. "But before we shift hundreds of thousands of additional addicts into rehab, we better treat the treatment system."

Critics say the most common form of residential treatment--typically a month of intensive 12-step meetings and talk therapy in a highly structured, often militaristic setting, with lapses in abstinence met with immediate expulsion--sets up many users for failure. Others point to the number of people whose underlying psychiatric disorders, histories of childhood abuse or problems with housing and (continued on page 152)Rehab(continued from page 88) joblessness are ignored inside rehab only to crop up again on the outside, propelling them further into addiction.

"Probably a quarter of the patients who end up in rehab have some kind of dual diagnosis," says Anne Vance, a former staffer at the Betty Ford Center who went on to run Crossroads Center, a Caribbean residential treatment program founded in 1998 by Eric Clapton. "In many cases, they're treated without considering root causes. These are the people who relapse and go back into treatment again and again."

But perhaps the single most pernicious force working against rehab is the disease of addiction itself, which researchers have only recently begun to understand as a matter of biology as well as one of will. Neuroscientists now say prolonged use of drugs can rewire the brain's mesolimbic dopamine system--also known as the pleasure pathway--prompting a lifetime of nonstop, bombarding impulses to relapse.

"Someone who is truly dependent has gone past the point of no return with their brain chemistry," says Carlton Erickson, professor of pharmacology at the University of Texas and director of the Addiction Science Research and Education Center. "Their brain chemistry is going to be that way for the rest of their lives. It won't repair itself. It will continue to tell them they need the drug to feel normal."

From that perspective, 28 days of sobriety, group therapy and cafeteria food is more like a small start than a triumphant resolution. "People seem to think you can go somewhere, follow a program and come out fixed," says Alan Leshner, former director of the National Institute on Drug Abuse. "The sad truth is that addiction is a chronic relapsing illness. Relapse is part of the disease. There isn't a magic bullet, and there probably never will be."

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No one addict has focused more attention on the rocky road of rehabilitation than Robert Downey Jr. The 36-year-old actor's still-revolving cycle of abuse, arrest, contrition and relapse proves how the obsessive drive to get high can overpower even the most deluxe and apparently sophisticated treatment programs.

Downey has spent much of his adult life in and out of rehab, entering his first program in his 20s (where he met his now-estranged wife) and returning periodically between movie and TV jobs. He managed to keep his troubles private until 1996, when he was arrested after he was stopped for speeding and police found heroin, cocaine and an unloaded .357 Magnum. After bolting from a court-mandated rehab and missing drug tests, he served a year of behind-bars rehab at Corcoran State Prison. When he got out, Downey flexed his prison-buff physique on the cover of Details, landed a regular gig on Ally McBeal and proclaimed himself clean and sober and ready to start a new life.

His subsequent unraveling was an extreme example of a story that has become as formulaic as a Lifetime special. Once upon a time, high-profile addicts would complain of "exhaustion" and simply fall from view for a month or two. But today, celebrities turn their stops at rehab into full-blown media events, alerting networks when they check in--A.J. McLean of the Backstreet Boys enlisted his bandmates in July to announce his stint in rehab on MTV--and appearing on the cover of People or US Weekly when they check out.

In February 2001, actor Matthew Perry ducked away from the set of Friends for a second round of rehab, reportedly to deal with a lingering addiction to Vicodin. In April 2001, West Wing creator Aaron Sorkin was caught carrying a stash of mushrooms and marijuana onto a flight to Las Vegas, six years after apparently kicking an addiction to cocaine and shortly after accepting an award from the rehab organization Phoenix House for personal victories over substance abuse. Then there's Darryl Strawberry, currently committed to two years of treatment after escaping rehab to go on a four-day crack binge. The list of re-lapsers goes on, from rockers Scott Weiland and Anthony Kiedis to actors Tim Allen and Andy Dick.

The PR stigma of rehab may have actually gone into full reverse, from liability to career booster. One story circulating around Hollywood last summer involved a rising starlet who reportedly feigned a heroin addiction, checked into rehab and submitted to a new detox program that begins with several days under general anesthetic. She hoped the experience would toughen up her innocent image--and, most important, help her effortlessly shed a few pounds for an upcoming part.

If outsiders can treat rehab so casually, the attitudes of hardened addicts can be downright cavalier. Rehab counselors say some first-time patients treat rehab as a sort of crash diet, a 30-day exorcism of their cravings. "I thought I was going to rehab to get fixed," says Ian (some names have been changed), a former Boy Scout and surfer from Malibu who checked into rehab when he was 23 and his wake-and-bake pot habit had become a full-blown heroin addiction. "I thought I could just take care of it and move on."

Instead, holed up in a seaside rehab that Kurt Cobain had fled before his suicide that same year, Ian bonded with a group of young addicts still enamored with the outlaw glamour of junk. "It was fun," he says. "We talked about getting high all day, romancing every detail."

With his newfound network of junkie friends, Ian quickly became what he calls "a nickel-and-dime dope fiend." For a while he managed to keep a job pumping cappuccino at various coffee shops, shooting dope in the bathroom and supplementing his high with daily doses of methadone and whatever other pharmaceuticals he could get his hands on. When he was fired from his job, he moved into his car and scraped together money by scavenging receipts in the parking lots of supermarkets, then shoplifting items that appeared on the slips and collecting cash refunds.

Along the way, he spent three months in jail and checked in and out of four rehabs. "I knew how to go through the motions without getting noticed," he says. "Most of the time I genuinely believed everything I heard--then I'd just go out and get high again."

It took five years before Ian finally reached that mysterious turning point no drug counselor or psychopharmacologist has managed to induce artificially. For Ian, anger over a girlfriend secretly making arrangements to seek help for her own drug problem finally made the difference. "She was trying to leave me behind," he says. "I felt completely ruined and useless. I went into rehab and said, 'Fuck it, I'll do whatever you say. Tell me what to do and I'll do it.'"

Now sober for three years and having worked as an operations manager for a rehab in LA, Ian says he's still mystified why the system works for some and doesn't for so many. "You have to be ready," he says, repeating an oft-quoted tenet of recovery. "The tricky part is that no one--not you or anyone--can tell when you're ready."

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The basic residential treatment regimen has changed remarkably little since the Forties, when doctors at "an asylum for inebriates" in the wooded countryside outside Minneapolis developed a system that came to be called the Minnesota model. Today, Minnesota is gospel at all but a few of the 3800 residential treatment programs currently operating in the U.S., from the no-nonsense Phoenix House network to the deluxe Sierra Tucson compound in Arizona, where everyone from pill poppers to chronic gamblers spends up to $33,800 a month to get straight.

"What do you get for your 34 grand?" asks Buddy Arnold, a 75-year-old jazz saxophonist and recovering addict who now runs the Musicians' Assistance Program with his wife, Carole Fields. "The food is pretty good and the scenery is better, but basically the treatment is the same."

In the Minnesota Model, the 12 steps are king, with addicts spending up to four hours a day in Alcoholics Anonymous or Narcotics Anonymous meetings. Trading war stories with other addicts, they're introduced to the idea they are in the throes of a lifelong disease they are powerless to cure themselves. The only way to get better, they learn, is by submitting themselves to a higher power, "working the steps" and never touching a drink or drug again.

Most rehabs also foster a strong sense of camaraderie and support. Typical is the tough-love atmosphere at Cri-Help, a 135-bed facility in a rough industrial patch of the San Fernando Valley, where new patients are greeted with hugs and backslaps and group meetings can end with the participants' holding hands and singing, like kids around a campfire.

But beneath the grins and hand-holding is rigid structure--most programs enforce a strict code of conduct that covers everything from what time patients wake up to what they read and who they talk to. Rooms are inspected for cleanliness, telephone calls are monitored and men and women are often prohibited from any interaction without permission. Rules are enforced by a staff of "techs" (mostly uncertified ex-addicts who have graduated from the program) and other patients, who are encouraged to "pull up" or "support" fellow addicts who they see deviating from the path. Penalties might include laps around the facility grounds or, for severe infractions like sex or drug taking, several days of complete silence followed by a harsh dressing-down from everyone else in rehab.

The mix of boot camp--style behavior modification and family support works wonders for many addicts. "I learned how to talk to people and to share," says Francisco, a 31-year-old cocaine addict from East LA who spent two years in the drug treatment program at Corcoran State Prison that treated Robert Downey Jr. "On the outside, I was never able to get my shit together. All the rules they throw at you in here force you to start living like a normal person."

By the time many addicts wind up in rehab, their lives are in such disarray that they desperately need guidelines and consequences, says David Carr, a writer at New York magazine and The Atlantic Monthly who went through four stints of rehab before successfully dealing with "a little problem with social crack use." "The reason these places are so freaky about rules is that addicts are people who don't observe any part of the social contract--they lie and scam to continue to use," he says. "Until you create some accountability, starting with making your bed and showing up on time, you can't get them straight."

That certainly made sense to Colette, a 28-year-old daughter of Christian missionaries who got hooked on heroin while attending USC and ultimately turned tricks for speedballs in the Mission District of San Francisco. After overdosing for the third time, she found her way to Walden House, a nonprofit government-funded service that charges about $23,000 for its yearlong program.

At first, Colette welcomed the strict regimen. "In the first couple months, I needed the distraction," she says. "It was such a constant barrage of rules and activities that by the end of the day I was so tired I couldn't focus on using--or anything else, for that matter."

But her attitude changed after another addict "supported her" when he discovered that she had kissed a fellow patient and had sex with another. For punishment, a formal assembly was called in which she sat silently as 200 addicts were encouraged to heap insults on her. She got off relatively easy--"I saw much worse while I was there," she says--but the experience certainly didn't teach her anything about staying sober. If anything, she says, the ritualized humiliation only stirred up old memories of childhood abuse.

"Their whole idea is to strip your sense of self," she says. "But I came away feeling I had no idea who I was--even less than when I was using."

Colette's experience is typical of addicts who go through rehab without confronting the reasons they used drugs in the first place. In Hooked, Dr. Shavelson relates the story of a junkie who spent half a year in rehab and never got around to discussing the fact that his father had molested him as a child. "It's common for rehabs to focus predominantly on behavior," he says. "They teach you 'OK, your life has fallen apart, we're going to teach you to come to breakfast on time, we're going to teach you to make your bed, we're going to teach you to come to meetings on time--but we're never going to deal with the fact that someone raped you for two years starting when you were seven. We are not going to deal with the fact that you can't read or that you don't have anywhere to live when you get out of here.'"

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Critics of rehab fall into two main camps: clinical researchers who argue that the disease of addiction will be cured with scientific scrutiny, not spiritual platitudes, and a growing movement of activists who advocate a flexible approach that doesn't require addicts to quit cold turkey. Think of them as the doctors and the dopers.

Until recently, physicians have had precious little to offer addicts other than sage words of sympathy and referrals to the local chapter of Alcoholics Anonymous. But as researchers have learned more about the genetics and neurobiology of addiction, medical interest has intensified, culminating in a landmark 1995 meeting in Virginia at which substance-abuse experts declared addiction a disease of the brain.

Their research has yielded a new crop of treatments--including drugs that ease cravings and therapies designed to reduce relapse. But according to Leshner, formerly of the National Institute on Drug Abuse, rehabs have not thrown open their doors to the people in lab coats.

"Let's just say that not every rehab uses state-of-the-art, science-based principles," he says. "Many of these programs are based more in tradition than in clinical depth. We've had to work hard to bring science to bear on what they do."

But to those who run rehabs, clinical research offers little more than impractical theories and drugs for people trying to become drug-free. "If there's a pill that inactivates whatever it is physiologically that makes an addict different from a normal person--that's great, that's a cure," says Cri-Help's Bernstein. "But so far all we've gotten are drugs like methadone, which doesn't necessarily help addicts. They're still strung out--except now they're strung out on a different drug."

And while those who run rehabs are happy that the medical establishment has begun to treat addiction more seriously, many believe doctors with stethoscopes can only offer so much assistance in what is essentially a spiritual struggle.

Sitting in the grassy yard of the Promises Malibu center just north of Los Angeles--the $1000-a-day treatment center where Charlie Sheen, Christian Slater, Tim Allen, Andy Dick, Paula Poundstone and Ben Affleck have all dried out--founder Richard Rogg says recovery is a deeply intimate experience that falls outside the realm of science. "This is not an area where you can watch mice in a box," he says. "Miracles happen here in strange little places. They can happen at three in the morning, slipping outside to smoke a cigarette and finding yourself sharing with someone things you never told anybody in your life. The next morning you wake up and feel a weight lifted. That's not something that doctors know how to fit into their models."

Others who work with addicts believe the standard rehab regimen is fundamentally flawed. The so-called harm reduction movement is based on the idea that some addicts simply can't give up their dependency all at once. Rehab's demand that they do, the theory goes, only drives them deeper into dependency.

"You don't wake up one day with your life in shambles and a crack pipe in your hand," says Maria Chavez, regional director for the national Harm Reduction Coalition. "That's not the way addiction happens--it happens slowly over time. And that's the way it should unhappen. We allow addicts room to improve themselves at their pace, not ours."

Longtime heroin addict Evelyn Milan became a believer after two years of traditional treatment failed to make a dent in her 10-gram-a-day habit. "I'd sit there in their meetings listening to all these horror stories--about how people had lost their jobs, how they'd ruined their lives," she says. "All it made me want to do is go out and use again."

Milan finally got help on New York's Lower East Side from counselors trained in harm reduction. They urged her to taper off drugs while helping her get her life in order, setting up doctor appointments, housing assistance and help with her three kids. "I couldn't let my drug go overnight," she says. "I had to fill in the gaps left by my drug little by little."

Followers of the 12 steps, however, insist that anything less than total abstinence is destructive self-delusion. "If someone is capable of slowly tapering off, he wasn't an addict to begin with," says Carr. "Addicts are fundamentally different--they can't be tweaked or gradually amended."

While Milan and others may have been able to modify their habits and live more normal lives, others have failed miserably. Audrey Kishline, founder of an organization that advocates "moderate drinking" over outright abstinence, pleaded guilty in June 2000 to vehicular homicide after driving her pickup head-on into traffic and killing a father and daughter. Her blood alcohol level was three times the legal limit.

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It may be imperfect, but rehab is still the treatment of choice for hard-core addiction. What other choice is there? Prison has proved to be an ineffective option, and voters have finally grown weary of paying its hefty bill. In California, the recently enacted Proposition 36 will direct at least 20,000 addicts into treatment in its first year alone. And in New York, the easing of Rockefeller-era drug laws is expected to redirect tens of thousands of addicts from jail cells into treatment.

With public policy--and the spotlight of celebrity--now pointing toward rehab, observers say the time for reform is ripe. While some rehabs (including Cri-Help, Promises and Betty Ford) offer patients more than the standard course of talk therapy and rigid codes of conduct, too many treat their programs as sacrosanct systems that must be protected at all costs from the influence of outsiders. Any meaningful reform, says Shavelson, would force rehabs to work more closely with psychotherapists, social workers, clinical researchers and anyone else equipped to spot and deal with underlying causes of addiction.

"Drug abuse is not just about drugs--therefore rehab can't just be about drug rehab," he says. Until then, even the most intensive rehab will help a minority while leaving other addicts with little more than high expectations and hollow catchphrases. Take the case of Pam, a 43-year-old mother of three who has been in 31 rehabs. After all that treatment, she says, she's traded one dependency for another. "I'm not leaving rehab until the SWAT team blows me out," she says flatly. "I know how to get along in here, but I have no idea how to function outside. I never have."