My favorite two sentences in the Alcoholics Anonymous literature are: “Alcoholics Anonymous does not demand that you believe anything. All of its twelve steps are but suggestions.” When a drunk at the end of his tether, Bill Wilson, founded Alcoholics Anonymous in the late 1930s—a spiritual program based on meeting with other addicts—there was a fundamental humility to his ideology: It might work for some.
But that sentiment is often forgotten in the rooms of AA itself, where I spent a lot of time getting sober. There I found that what are suggestions to some are fundamentalist Scripture to others. In the rooms of AA, suggestions and traditions can sometimes feel more like ironclad laws, and when I inadvertently trespassed upon those laws, I was humiliated and rebuked. The predominantly AA-based culture of rehab in America has become one of imposition and tautology: If the program doesn’t work for you, then you didn’t work the program. If you succeed in staying sober, then you did a good job working the program; ergo, the program works.
In the rooms of AA, suggestions and traditions can sometimes feel more like ironclad laws.
In Anne M. Fletcher’s excellent and exhaustive book, she finds that almost all rehabs adhere to this intransigent dogma. Some just have better views, higher thread counts, and more horses (you know, for equine therapy). There is no individualized treatment. You check in, detox, and then go to addiction-education lectures, group therapy, and AA twelve-step meetings. “I often found myself wondering, ‘Where’s the counseling?’” writes Fletcher. Patients attend these group gatherings for 28 to 90 days, and are then released back into the real world. Problem is, the real world is teeming with temptations, and most people relapse. So what do we do with them? More rehab! Because it isn’t the rehab that has failed; it is you. Fletcher’s multi-year-long dive into the realities of rehabs is deeply unsettling. “Once you’ve seen any substance abuse program, you have seen the great majority of them,” Tom McClellan, co-founder of the Treatment Research Institute, tells Fletcher.
How did this come about? Addiction was stigmatized so fervently and for so long that for decades there was no body of science to advise desperate addicts. In that vacuum, McClellan says, the field “grew its own program.” The twelve steps of AA became the template treatment for just about every compulsive behavior there is, from Narcotics Anonymous to Debtors Anonymous. Meanwhile, as AA grew, a movement was brewing in Minnesota: rehabilitation. In the 1950s, a recovering alcoholic, Austin Ripley, began a sanitarium for alcoholics based on AA principles out on a farm in Minnesota. (It became Hazelden, perhaps today’s most well-known rehab.) Soon enough, this Minnesota model attracted more people from AA, and the prototype for modern-day rehab was born, guided by, as Fletcher writes, “the folk wisdom of recovering people, particularly through the perspectives of Alcoholics Anonymous and related twelve-step programs.”
To be sure, that folk wisdom has benefitted millions, including myself. Striving for honesty, communing with people who don’t judge, admitting when you’re wrong, working on the content of your character, learning humility, being of service to others—these are deeply valuable principles, ones this alcoholic needed to find after years of boozy nonchalance. In fact, the steps could be beneficial to anyone.
But moral principles are not medical treatment. And using AA as the only rehabilitation treatment—rather than as an adjunct to treatment—defies the reality that there are many different effective treatment methods. Fletcher underscores this point with profiles of dozens of recovered addicts who quit in varied ways—through church, paid incentives for clean drug tests, psychiatry, cognitive behavioral therapy, medication, and even people who simply “matured out.”
She also profiles dozens of addicts whose rehab experiences are unconscionable. Take Jessie, an alcoholic woman who was court-ordered to attend rehab or go to jail, after a drunk-driving conviction. Three days before finishing the rehab program, the police came for her. The rehab had kicked Jessie out, claiming she’d “failed to accept a higher power” (step two). Freedom of religion was apparently not a valid excuse. Other patients faced intense confrontations (“I heard clients characterized as dishonest, narcissistic, and selfish,” writes Fletcher); were made to wear punitive signs around their necks if they broke the rules; or were forced to divulge painful secrets in a group setting. One woman who was deeply uncomfortable around men was pressured into discussing past sexual abuse in a co-ed program.
For some, sharing with a group might be valuable and—more important—validating, but for many, group therapy and meetings can be injurious and completely inappropriate. Regardless of the benefits or drawbacks, most experts agree that all addicts should have highly personalized attention from a therapist. After all, the sources of addiction are myriad: past trauma, self-medication, masking another mental illness, genetics, etc. The point is, each addict has very specific needs.
But, as Fletcher masterfully shows, rehab culture has created a deep schism between science and its twelve-step methods.1 There is now a vast body of research on addiction treatment, including groundbreaking medications that can quell urges, safely fulfill an addict’s need for dopamine, and often prevent relapse. And yet, Fletcher finds that some 80 percent of rehabs in the United States dispense no medication at all. In fact, many rehabs consider the use of opiate-replacement drugs and other medications—like naltrexone, Suboxone, and buprenorphine—as equivalent to drinking or using heroin, despite the overwhelming scientific evidence of their positive effects. In other words, you’re not truly sober if you’re “on” something. To that end, many rehabs kick addicts out for secretly using—that is, for being addicts.
Some patients were made to wear punitive signs around their necks if they broke the rules.
By the end of Chapter 5, which is called “Rehab Isn’t for Everyone: In Fact, It’s Not for Most People,” Fletcher begins to wonder if rehab is right for anyone. Mark Willenbring, a psychiatrist and the former head of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism, gives her a stark answer: “The idea of changing the life course for people with severe, recurrent forms of addiction through a time-limited intensive transformative rehab is a fatally flawed relic of ancient times. What other chronic disorder do we treat that way?”
Despite the evidence she amasses for the limitations of rehab, Fletcher does not condemn rehab and walk away, and this balanced approach is to her credit. A large portion of the book, in fact, reads like a Princeton Review Guide for Choosing Rehab: Fletcher highlights unique integrative facilities, offers nontraditional solutions, and lauds excellent traditional programs. She tells you specifically what to look for in a rehab and what to ask—like, what are you getting for the money, and do any of the staff at least have a bachelor’s degree?2
Ultimately, Fletcher’s book is less about the dismissal of rehab than the dismantling of the idea that there is one way to treat addiction. Rehab isn’t wrong—it’s just one way. She envisions a menu of options. Might heroin addicts need something different than alcoholics? Might women need something different than men? Might teens require special treatment? Fletcher addresses each of these issues and more—but the answer is always the same: Everyone needs truly individualized treatment.
This is an important argument to make. Ask someone in Alcoholics Anonymous if there are treatment options for addiction other than the twelve steps, and you’re likely to hear: “Sure, you can end up in jail, be institutionalized, or die.” But the science, Fletcher shows, tells a different story: The vast majority of people who get and remain sober, Fletcher shows, do so without AA. It’s not that the traditional model is bad or wrong; it just isn’t the only way.
Inside Rehab is an invaluable addition to addiction literature. It is fascinating, insightful, and unafraid to upset the establishment. And Anne Fletcher is a measured, detailed, and insightful reporter. Her book is also a great tool for any family struggling with an addicted loved one. Getting sober is hard. Staying sober is hard. Having more options to get clean just might mean that more people do so.
Sacha Z. Scoblic is a contributing editor at The New Republic, the author of Unwasted: My Lush Sobriety, and a Carter fellow for mental health journalism.