Rehab Reality Check

The time is coming-- perhaps even within the decade--when doctors will treat alcoholism with a pill. As they improve their understanding of the biochemistry of addiction, researchers will find new ways to interrupt the neurological sequence that begins with pulling the tab on a can of beer and ends with sobbing on the phone to someone you dated twice in 1987. It will be a paradigm shift as profound as the one wrought by Prozac in the treatment of depression, says Dr. Mark Willenbring of the National Institute on Alcohol Abuse and Alcoholism: people with drinking problems will get a modicum of counseling and prescriptions from their family doctors. This will be a great boon to most people except for athletes, congressmen and movie stars, who will lose one of the defining rites of passage of modern celebrity: the all-absolving, career-rejuvenating, Barbara Walters-placating ritual of checking into rehab.

It has been a fixture of our culture since as far back as 1983, when Elizabeth Taylor checked her aura of tragic, tawdry glamour into the Betty Ford Center, setting an example of courageous humility for future generations of troubled divas, wild-man comics and hard-partying rockers. Since that time, residential treatment programs for the middle and upper classes have proliferated across both the geographic and the therapeutic maps. Heated disputes have erupted between proponents of different treatment models. This is exacerbated by a growing rivalry between old-guard institutions like the Ford Center, with its comparatively austere campuslike ambience, and the new class of superluxury rehab centers in ocean-view mansions that supplement the traditional 12-step approach with acupuncture, massage, equine therapy and Native American Talking Circles. Charging from $40,000 to $100,000 for a 30-day stay, the deluxe centers approach rehab from the point of view that the dark night of the soul is a little less dreary if it's preceded by a sunset over the Pacific, viewed from the Malibu hills.

It's easy to mock the idea that these places rehabilitate anything other than the images of high-profile clients who appear to have chosen "addict" as a less embarrassing label than "sexual predator" or "bigot." But simple math suggests that, with as many as 26 residential treatment centers in Malibu, Calif., alone, there aren't enough celebrities to fill all the beds; the rest, presumably, are occupied by people--lawyers, executives, housewives--sincerely trying to overcome addiction, but who don't see themselves fitting in the "highly structured" environment of Phoenix House down the coast in Venice. (An exception appears to be San Francisco Mayor Gavin Newsom, who said he would do his rehab at his city's Delancey Street Foundation, where about 400 residents, many of them ex-convicts, spend up to two years learning "life skills" and staffing the foundation's restaurant and other businesses. How he would do that in practice was unclear last week.) "People feel more supported in an environment that mimics their real life," says Richard Rogg, founder and CEO of Promises Residential Center in Malibu. Rogg won't name clients, but among those who reportedly sought serenity on its lush grounds were Ben Affleck, Kelly Osbourne and Diana Ross. Daniel Gatlin, executive director of Renaissance Malibu, asserts that the ocean views aren't just an amenity, but serve a positive therapeutic function: "When you go out and overlook the ocean, you can take yourself out of yourself." At Sierra Tucson, in whose adobe casitas former congressman Mark Foley sought refuge, patients can work out their "relationship issues" by learning to bond with horses, animals that, unlike voters or studio executives, are considered nonjudgmental.

To John Schwarzlose, president and CEO of the Betty Ford Center in Rancho Mirage, Calif., the blurring of lines between "spa" and "treatment center" is disheartening. "They say, 'We have 500-count sheets.' It trivializes what we do." Schwarzlose may be sensitive in part because some of the Malibu places have been known to spread the rumor--which he denies--that Elizabeth Taylor had to clean the bathrooms when she was at Betty Ford. But Willenbring agrees that gourmet chefs and riding stables run counter to the spirit of treatment. "The best thing for you in rehab," he says, "is to sit next to a guy from skid row and realize, you're just as much an alcoholic as he is. Learning humility is part of the recovery process."

In fact, with a few exceptions most residential programs run along broadly similar lines. The typical stay is a month, which might not be optimal but is as much as most insurance plans covered back in the 1980s when the programs were designed. Now most plans barely pay for residential treatment at all. The reigning paradigm is the 12-step program pioneered by the Hazelden Foundation in the 1960s. Its advantage is that it provides a model and a ready-made, worldwide network for post-rehab support at Alcoholics Anonymous and its spinoffs. Most experts believe this is essential to recovery. "When people are released from their 28-day rehabs, relapse rates are pretty high without consistent after-care," says G. Alan Marlatt, director of the Addictive Behaviors Research Center at the University of Washington. "One of our expectations is that patients will go to AA and get a sponsor after they leave us," says Dr. Shari Corbitt, clinical director of Sierra Tucson. The disadvantage of the 12-step program, according to Chris Prentiss, cofounder of Passages Addiction Cure Center in Malibu, is that its emphasis on helplessness in the face of addiction makes people feel stupid and ashamed. Prentiss, whose background was in real estate before he got interested in rehab as a way to rescue his own son from addiction, is almost alone in rejecting the 12-step model, and in advertising his own program of intensive one-on-one therapy and personal empowerment as a "cure." "We don't send people to meetings," he boasts. "When they leave, they're cured"--which flies in the face of what virtually the entire drug-treatment community believes about the possibility of "curing" addiction.

Some programs supplant, or supplement, 12-step programs with newer therapies. Cognitive Behavioral Therapy focuses on overcoming poor self-esteem and defeatist thinking. ("I'll be an alcoholic all my life and I'll never amount to anything.") Motivational therapy aims to encourage and reinforce the desire for change. ("What don't you like about drinking? How much do you want to stop?") In a study involving alcoholics, according to Willenbring, these were each about equally successful, and no better nor worse than 12-step programs. The exact form of therapy, he says, is less important than just the fact of seeking treatment. A year after completing a rehab program, about a third of alcoholics are sober, an additional 40 percent are substantially improved but still drink heavily on occasion, and a quarter have completely relapsed.

There is an ongoing debate in the field between the hermetic model of places like Sierra Tucson, which bans cell phones and magazines as distractions from therapy, and the secular approach that attempts to integrate sober behavior into clients' ordinary lives. Wonderland Center, which has undertaken the Sisyphean challenge of treating Lindsay Lohan, sends its patients out into the world of temptation--it's located in West Hollywood, so they don't have to travel far for it--with a "Sober Companion" to utter for them the life-giving phrase, "mineral water with a twist." Individuals respond better to one program or another, but overall, the most important variable is simple motivation. Schwarzlose, whose facility has treated 76,000 people over the years, some more than once, points out that licensed health-care professionals and commercial pilots who go through rehab at Betty Ford usually stay clean afterward, because they know they'll be out of work for life if they fail another drug test. If movie studios treated actors the same way, he muses, gossip columns would have a lot less to write about.

But the real breakthrough, the paradigm shift, will come when safe, reliable drug treatments are available for addiction. Although they are no more likely to end addiction forever than Prozac ended depression, such drugs could make a big difference in the lives of people struggling with addiction. Their eventual likelihood got a big boost when researchers made the astonishing claim last month that people with injuries to a specific region of the brain instantly lost the desire to smoke. "There are probably 10 new drugs in development for alcoholism," says Willenbring, "and some are very exciting." Of course, people were very excited in the 1990s about using antidepressants to treat addiction, but that approach hasn't lived up to its promise. (Another disappointment was Antabuse, which reacts with alcohol to make you throw up; naltrexone, a more sophisticated drug, blocks the brain's opiate receptors--you can still drink, but it won't make you feel good. It can reduce relapse rates in the three months after treatment by 20 to 40 percent.)

But as researchers learn more about how addiction works, even more ingenious and effective drugs are possible. One, Topamax, an existing epilepsy drug (which means it has a leg up on safety testing), affects the balance between two brain chemicals, glutamate and GABA. Addicts have an excess of glutamate, which enhances the desire for drugs or alcohol; GABA inhibits it, so restoring the balance reduces cravings. You could call it willpower in a pill. A second class of drugs, nearing clinical trials, dampens the stress response, which researchers believe is crucial to preventing relapses after treatment. Willenbring cautions, though, that even the most effective drugs will undoubtedly have to be combined with some form of behavioral support.

But the paradigm shift goes deeper, because research will almost certainly also show that, under the $500 haircuts, celebrity brains are a lot like everyone else's. The advent of these drugs may also portend an end to that peculiar medical specialty, celebrity addiction, with its ego-soothing trappings and Pacific sunsets. One authority on this is William Moyers, 47, the son of TV journalist Bill Moyers, and himself a recovering alcoholic and crack addict. After four rounds of treatment he finally achieved sobriety in 1994. He is now vice president of external affairs of the Hazelden Foundation, which runs the highly respected treatment center in Minnesota. Hazelden, like Betty Ford, takes celebrities, but also many ordinary people struggling with addiction. "The best way to recover," he says, "is to level the playing field, so that people understand they're not alone. Whether they're actresses or waitresses."

Join the Discussion