Addicted? Don’t Go to Rehab
Addiction treatment in America must undergo a revolution
Ian McLoone’s experience seeking treatment for his heroin addiction was so horrific that it inspired him to become a therapist himself, with the hope of changing an expensive, ineffective, and wildly outdated field from the inside.
In 2010, when he was 28 years old, McLoone sought treatment at a rehab in downtown Minneapolis. The program specialized in providing care for people whose addiction landed them in the criminal justice system. McLoone was on probation for possession of heroin and cocaine.
“I was doing whatever they told me,” he says. “I finally hit a wall, and I had to do something other than continue to lie to my wife, get kicked out of the house, and act like a fool in front of my kids.”
While out on a pass — an outing permitted by the treatment center’s staff — to attend his son’s first birthday party, McLoone received a phone call. It was the treatment center telling him to come back to the facility immediately. “What happened?” McLoone asked. “You have to come back now,” was all they said. McLoone put down his slice of birthday cake and promptly left his son’s party.
“I got back that night, and they put me on ‘the bench.’”
McLoone was condemned to sit on the bench — literally, just a wooden bench — for three consecutive days with no explanation as to why. From 9 a.m. until 5 p.m., McLoone was ordered to sit: He was not allowed to attend any group therapy sessions or interact with any of his peers, and staff had ordered them not to speak with him. When it came time to eat, McLoone had to sit alone in the cafeteria. “By day two or three, I thought, what the fuck is this? This is therapeutic? This is treatment?”
I asked McLoone why he sat without protest. He told me that at any moment the staff could cease his treatment, call his probation officer, and send him back to jail. With a second-degree felony pending against him, he had no choice but to submit.
The program McLoone attended from 2010 to 2011 was based on a model of rehabilitation called Synanon, conceived in Santa Monica in 1958 by Charles “Chuck” Dederich. The rehab, a peculiar self-help-based spin-off of Alcoholics Anonymous — which Dederich attended in 1956 — evolved into a bona fide social movement. At first, Synanon was a blueprint for clean living. But within a decade, the Dederich-designed beachside utopia devolved into a violent cult.
Despite being exposed in the 1970s as a “racket of the century” — involving child abuse, wrongful imprisonment, assault, and misappropriation of funds — Synanon, with its harsh approach, quietly remains a fixture in America’s addiction treatment. McLoone and other experts tell me this is a dirty secret among rehabs.
Using confrontation and humiliation in substance abuse counseling comes from a long history of viewing people with addiction as immature and selfish. For addiction treatment to become a healing force for Americans who are increasingly dying “deaths of despair” — from excessive alcohol use, overdose, and suicide — the field must undergo a Copernican revolution: a radical shift in the way it cares for people with addiction.
Immune to Evidence
If you look at rehab facilities’ websites today, they don’t openly advertise the use of confrontational approaches. And for good reason: Four decades of rigorous research proves they’re ineffective. Yet several experts say confrontation and other old-school methods are pervasive in contemporary treatment.
So ubiquitous, in fact, that Paula DeSanto left her post as mental health counselor after too many of her clients shared how poorly they were treated at addiction treatment facilities in Minnesota. The state even has an unofficial motto: “The Land of 10,000 Treatment Centers.” In response, DeSanto, a licensed social worker with a masters of science degree in psychiatric rehabilitation from Boston University, started her own program specializing in addiction.
Named Minnesota Alternatives, DeSanto bills it as a treatment option for people who don’t fit the conventional 12-step, abstinence-based model that dominates the industry. (Some 80 percent of rehabs in America today are based on an abstinence-only model that frown upon effective medications.)
“I heard the same story over and over again from my clients,” DeSanto says. What she heard was that her patients were being herded in and out of insurance-payout factories, where the staff talk at them, not with them. “Clients told me they were given worksheets, handed a treatment plan, and told to sign it,” she says.
DeSanto had the overwhelming sense that conventional treatment programs were not only failing their clients, but even causing further suffering.
William R. Miller, an eminent clinical psychologist in the field of addiction and emeritus professor of psychology and psychiatry at the University of New Mexico, has overseen dozens of experiments that aim to figure out which treatments for addiction work and which don’t. In 2001, Miller and his colleagues ranked treatments in order of effectiveness for a book chapter in the Handbook of Alcoholism Treatment Approaches: Effective Alternatives.
The confrontational, punishing style of treatment — like the bench — ranked 45th out of 48. As a frame of reference, psychedelic medication ranked 32nd; it turns out that tripping on hallucinogens is more effective at treating addiction than being forced to sit on a bench.
Miller, along with co-author William White, a revered historian of addiction treatment, confirmed DeSanto’s experience: In a 2008 paper, they wrote that confrontational approaches are not only ineffective but also professionally unethical and may cause true harm. Miller and White found that confrontational approaches accelerated relapse into drug using, increased DWI recidivism, and resulted in higher dropout rates.
“The main problem with rehab,” says Dr. Mark Willenbring, a psychiatrist specializing in addiction, after a deep sigh, “is that most are based on the 12 steps of Alcoholics Anonymous. People who work at these places are very poorly trained; they’re not scientifically literate; and most of them are in the field because they are themselves in 12-step recovery.”
Willenbring, who founded Alltyr, an outpatient addiction specialty clinic located in downtown St. Paul, Minnesota, noted that policy at the Hazelden Betty Ford Foundation (the biggest network of rehabs in America) is to not hire counselors unless they are in 12-step recovery (either Alcoholics or Narcotics Anonymous).
“It operates like a church that way,” Willenbring said. “It’s a belief system centered on prayer and ‘God as you understand him,’ as they say.” Willenbring is referencing a phrase that frequently pops up in AA literature and the 12 steps.
Not that there’s anything inherently wrong with prayer, Willenbring says, but it’s not how we treat cancer, diabetes, or any other chronic medical condition. So why is it used in addiction treatment centers that receive insurance money?
“These places are poorly regulated,” Willenbring told me. “They don’t provide informed consent; they lie [and] aren’t held accountable for their outcomes. They tell people that 12-step programs work for opiate use disorder.”
In America’s rehabs, research takes a back seat to tradition.
My Not-So-Therapeutic Experience
In 2012, I attended the Hazelden Betty Ford facility for young people located in Plymouth, Minnesota. I was 22 years old. I was there because I had relapsed into heroin use, injecting in unsanitary, dangerous locations on Chicago’s west side. My parents, who thankfully had resources to throw at my addiction, sent me off to Hazelden.
Little did they know that, for $1,000 per day, I was treated with confrontational counseling styles. Statistically, I was better off trying psychedelics in the woods.
The most effective treatment for heroin addiction is long-term, indefinite use of medications like buprenorphine or methadone. However, while I was at Hazelden, firmly rooted in the 12 steps, it was the facility’s policy to rapidly detox me off buprenorphine, which goes against best medical practices. (Hazelden changed its policy right after my stint in 2012 because too many of its young patients were dying.)
“Not providing medication to somebody who comes in opioid-addicted is cruel and unusual punishment,” says Willenbring.
I became sick with feverish aches, diarrhea, and insomnia as result of quickly tapering off buprenorphine. Being malnourished and sleep deprived left me unable to participate in the day-to-day treatment, which involved group therapy and educational lectures. (Lectures ranked 48th out of 48 on Miller’s list of effective treatments.) Counselors mistook my sickness for defiance. The director of the treatment center berated me for being “unwilling” to receive the help I so badly needed at the time. The towering director, an intimidating bald man, called me a “lying, selfish heroin addict” in front of several counselors and staff.
I was already broken. I didn’t need more shame and guilt heaped on me. I could’ve used some medication, though.
Despite being cast out as the facility’s bench leper, McLoone “graduated” from the cult-based program in 2011.
The following fall, he enrolled in the University of Minnesota’s addiction studies program, eventually earning his master’s degree in behavioral health. Today, he’s dually trained in treating addiction and mental health and is the lead therapist at Willenbring’s Alltyr outpatient clinic in St. Paul — not far from where he was previously treated. McLoone also teaches applied psychopharmacology to graduate students in the same master’s program he graduated after rehab.
The name Alltyr comes from a story popular in Russian folklore about a stone with healing properties. However, you won’t find any folk wisdom or faith healing at Alltyr. There, therapists like McLoone combine behavioral therapies such as motivation enhancement — an approach that seeks to elicit the patient’s internal motivation for change — with medications to treat addiction. You’ll find the polar opposite of confrontations: compassion and encouragement. Gabrielle Glaser, in a New York Times profile of Willenbring, called his approach scientifically unassailable.
“I wasn’t offered anything remotely, not even close to an evidenced-based intervention,” says McLoone. Like my experience at Hazelden, McLoone was forced to taper off methadone, another drug (similar to buprenorphine) that’s used to treat opioid addiction. A slew of studies prove that these medications reduce the risk of fatal overdose, cutting the risk of death by over 50 percent. One in particular found that patients who were given only psychological treatments (if you could call what McLoone and I received treatment at all) left rehab with twice the risk of dying from a fatal overdose than patients who were treated with medication.
“Rehabs ignore decades of taxpayer-funded research,” says McLoone.
In the midst of an overdose crisis that’s killing more than 100 people every day, McLoone has become a vocal critic of his field. “If the only option is a 30-day program, where you’re going to get abstinence shoved down your throat and AA is the only theoretical orientation, then you won’t seek treatment unless you absolutely can no longer avoid it,” he says.
Until rehabs begin using medication and behavioral therapies, there’s no end in sight for the overdose crisis. Rehabs can do their part in helping those who despair, who are dying from overdoses and drinking alcohol until their livers fail. “But we need a major paradigm shift,” McLoone told me over the phone, stepping away from a family reunion with in-laws in Branson, Missouri.
A cruel tenet of confrontational “tough love” approaches asks family members to abandon their addicted loved one in the hope that it will spark motivation to change. McLoone’s family stayed by his side.