sick treatment

Dana Beal dana at cures-not-wars.org
Tue Jan 21 21:40:11 EST 2003


Author: Maia Szalavitz
         Bookmark: http://www.mapinc.org/rehab.htm (Treatment)

         THE BIG IDEA: SICK TREATMENT

         When Drug Counselors Attack.

         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.





         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.





         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."





         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."

         Note: 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 ).



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