Morristown, New Jersey

Private treatment for alcoholism and drug abuse expanded greatly beginning in the late 1970s. Between 1978 and 1984, the number of beds in private alcoholism treatment centers more than quadrupled. In the '80s, hospitalization of adolescents in private psychiatric facilities mainly for drug and alcohol abuse, jumped 450 percent. Treatment centers launched advertising campaigns to compete for middle-class patients, and private hospitals sent salesmen to canvass parents, schools, and communities for business. The treatment industry also relied increasingly on coercion; a growing number of referrals are mandated either by courts or by employee assistance programs. Private insurance and federal funding have paid for all this on the assumption the drug and alcohol abuse are aspects of a disease call "chemical dependency." The high cost (on one estimate, an average of $18,000 per hospital stay) is a major burden on our health care system.

The boom has receded slightly in the last few years, as skepticism about the present system grows and insurers and employee assistance programs look for less expensive alternatives. The case of Kitty Dukakis illustrates this new questioning attitude toward private treatment. She graduated "successfully" from the well-known Edgehill-Newport treatment center, appeared on the cover of People magazine, and spoke widely about the disease of chemical dependency. Then, as she relates in her autobiography, she suffered a series of near-fatal relapses. If Betty Ford's public endorsement of alcoholism treatment embodied the enthusiasm of the 1970s, Mrs. Dukakis's story suggests the more somber assessment of the 1990s.

As a sign of the times, one prominent skeptic is Enoch Gordis, MD, the director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). After studying a large hospital program that he himself administered, Gordis concluded that "contemporary alcoholism treatment is, at best, of limited effectiveness." In 1987 he wrote that "...our whole treatment system, with its innumerable therapies, armies of therapists, large and expensive programs, endless conferences....and public relations activities is founded on a hunch, not evidence, and not on science."

Effectiveness of Treatment Methods

According to a 1986 review by William Miller and Reid Hester, many methods commonly used in the treatment of alcoholism—including AA, alcoholism education, individual counseling, group therapy, and disulfiram (Antabuse®)—"lacked scientific evidence of effectiveness." No controlled study, they added, had found that residential treatment was better than much less expensive outpatient treatment. In an editorial in the Journal of the American Medical Association, Dr. Forest Tennant wrote that "any sophisticated critic using statistical analysis to measure treatment effectiveness is appalled by the display of a media or sports star claiming cure thanks to a specific treatment center's help—which proclaims 80 to 90 percent cure rates."

The treatment industry's spokespersons often claim that all untreated alcoholics end up dead, deathly ill, or in jail. In fact, studies show so much natural remission that one investigator calls alcoholics who recover on their own "the silent majority." George Vaillant, a psychiatrist who supports the disease concept of alcoholism, worked in what he called "the most exciting alcoholism program in the world." It consisted of hospital detoxification, compulsory AA attendance, and a counseling program based on the disease concept. Yet Vaillant had to admit that his patients fared no better after eight years than alcoholics who were left to their own devices! He reflected. "Perhaps the best that can be said... is that we were certainly not interfering with the natural recovery process."

Illicit drug abuse is no different. Researchers at the Addiction Research Foundation in Toronto found that many untreated middle-class cocaine users were able to cut back or quit on their own when they found that they had begun to lose control. Cocaine addicts and alcoholics often testify that tobacco is the hardest drug of all to give up, yet more than 40 million Americans have done so. During the 1980s, according to a survey conducted by the Centers for Disease Control, 47.5 percent of smokers who tried to quit on their own succeeded—twice the success rate of those who used treatment programs.

Whether people succeed in overcoming an addiction may not be determined primarily by the treatment they receive. Vaillant notes that "the most important single prognostic variable associated with remission among alcoholics who attend alcohol clinics is having something to lose if they continue to abuse alcohol." Among Vaillant's own patients at an urban municipal hospital, many of whom had little to lose, 95 percent relapsed at some point after treatment. Another study of an inner-city hospital alcoholism ward, by John Helzer and his colleagues, found that 93 percent of the patients were either dead or still abusing alcohol five to seven years after treatment. Private treatment centers ordinarily show better outcomes, partly because their clients are more likely to have families, jobs, and incomes.

As the decisive influence of these social circumstances proves, alcoholism is not a "primary" illness whose course is determined solely by some inexorable internal mechanism. The same is true of other addictions. As clinical researcher Frank Gawin puts it, "If crack were a drug of the middle or upper classes, we would not be saying it is so impossible to treat."

Training in Life Skills

The best way to discourage addictive behavior is to show people how to meet the demands of life without drinking or drug use. Miller and Hester found that the most effective programs provided alcoholics with training in stress management and self-control, social and negotiation skills, job skills, and work habits. The most successful program for hospitalized alcoholics ever evaluated is the community reinforcement approach, which systematically trains alcoholics in job and marital skills while arranging a work and home environment that sustains and rewards sobriety.

This social and behavioral approach is more common in drug treatment. Many therapeutic communities (TCs), for example, reject the idea that drug addiction is a disease and instead inculcate positive social attitudes and skills. The National Treatment Outcomes Prospective Study found that TCs and other public drug treatment programs often succeeded (no private centers were studied). The same study, however, found that public alcoholism programs were generally unsuccessful.