The Trouble With Rehab Whether you’re a Hollywood star or hard-core junkie, treatment programs don’t always work. Here’s why. When he got out of rehab for the seventh time, Bob Forrest felt beaten down, talked out and utterly uncertain how to find his way back to a normal life. The frontman of the LA alternative band Thelonious Monster, Forrest had been an addict since high school, interrupting furious binges of booze, coke and heroin with layovers in all manner of residential treatment programs, from cushy retreats to court-ordered lockups. But even the best rehab Capital Records could buy couldn’t slow Forrest down. Four days into his most recent pit stop, he waltzed out a side door and hit the streets. Soon enough, Forrest found himself in the back of a cab heading down Sunset Boulevard, a plump mound of brown Persian heroin folded into a magazine on his lap. He remembers rolling up a dollar bill in the dull flicker of passing streetlights, crouching down in his seat and snorting as much powder as his nostrils would hold. His system relatively clean after a year of sporadic sobriety, Forrest overdosed. When he slumped over unconscious, the taxi driver pulled over, dragged him into the gutter and peeled away. The next thing Forrest remembers he was surrounded by a group of friends and drug counselors in the harsh light of Cedars Sinai emergency room. When he realized where he was, Forrest “flipped out.” After hopping off a gurney and screaming that he wouldn’t go back to rehab, he retreated to a bathroom, rummaged through his belongings and found his heroin still stashed in a shirt pocket. As a counselor pounded at the bathroom stall, he took a few deep sniffs. Again, he overdosed. For some addicts, overdosing twice in one night might constitute rock bottom – the low point that you claw your way out from, one day at a time. But Forrest continued to use, bouncing Yo-Yo-like in and out of rehabs, detoxes, jail cells and a state mental ward. When he finally did get clean in 1996 -- on his own, with help from sober friends and a neighborhood 12-step program -- Forrest had racked up 35 visits to various rehabs. From hard-core junkies like Forrest to high-profile recidivists Robert Downey Jr., Daryl Strawberry, Matthew Perry and Aaron Sorkin, rehab has not exactly been the cleansing fresh start that their loved ones, employers and publicists had hoped for. Again and again, addicts emerging from intensive, costly anti-drug programs waste little time before making their way back to the bottle, needle or pipe. At the same time, rehab has never been more popular. Hardly a month goes by without news of another strung-out rocker or hard-partying star ducking into treatment after an embarrassing flameout or encounter with the cops. Last summer saw the intake of star Ben Affleck, headbanger James Hetfield, comedienne Paula Poundstone and warbler Mariah Carey (though her publicists insisted drugs were not a factor in her plate-smashing meltdown). Whatever stigma once associated with residential treatment is now long gone -- a 28-day hiatus at a place like Promises Malibu or the Betty Ford Center is now an almost mandatory pause in the upward trajectory of stardom. Celebrities aren’t alone in reflexively looking to rehab to mop up the messes of addiction. Makers of public policy are increasingly looking to treatment as a better way to fight the drug war. In California, a 2000 ballot initiative mandated that courts direct non-violent drug offenders to treatment instead of jail. And in New York, draconian drug laws are being rewritten to ease mandatory sentences and allow judges more leeway in sending addicts to rehab. So far, however, one problem has remained unrecognized by the growing list of A-list addicts and progressive politicos: for all but the most treatable cases, rehab simply doesn’t work -- rarely on the first go-around, and often not on the first five or six. “The cycle seems to be: you do a little rehab, you go back to work, the rehab didn't take, so you go back to drugs, you do a little more rehab,” says Bruce Porter, author of Blow, which chronicled the rise and fall of the dealer who brought coke to Hollywood. “So far, no one is asking the obvious question: why isn’t rehab working?” Depending on whom you ask, relapse rates for residential treatment programs range from 60 to 90 percent. So-called success rates are famously slippery to calculate, complicated by the difficulties defining success. How do you account for the majority of addicts who bolt midway through treatment? What about the alcoholic who downs a single Martini a year later? Or the junkie who now drinks socially? Official data that does exist, however, points in the same direction. A 1994 study for the Office of National Drug Control Policy concluded that eight of every ten cocaine users relapsed within three to five years of treatment. And an authoritative 1994 study known as the California Drug and Alcohol Treatment Assessment found that while addicts who went through treatment were less likely to commit crimes or end up in the hospital, most continued to get high -- three out of four junkies still shot up after rehab and two of three alcoholics kept on drinking. Defenders of rehab say success cannot be judged by relapse alone. They point to research like a 1997 National Treatment Improvement Evaluation Study that concluded that addicts consumed between 45-55 percent less cocaine, crack, pot and alcohol a year after their trips to rehab. Sure, they concede, most addicts continue to get loaded after rehab -- but at least they get somewhat less loaded. That’s cold comfort to those who preach a gospel of total sobriety. Jack Bernstein, President and CEO of the Cri-Help Treatment Center in Los Angeles, says the high rates of relapse are a source of constant frustration to zero-tolerance drug counselors. The problem, of course, is that no one has come up with anything better. “Thirty years from now, people will look back at how drug addicts were treated and they’ll be appalled,” says. “They’ll look back, scratch their heads and say what a bunch of idiots we were.” While some claim miraculous results from one-on-one psychotherapy, experimental anti-craving drugs or alternative medicines like the Chinese root kudzu, there’s little hard data to suggest that any particular treatment works better than another. About the only fact everyone seems to agree on is that the longer you devote to treatment -- it doesn’t appear to matter which kind -- the better your chances of recovery. And for those with the most serious problems, the standard 28-day course of rehab covered by most insurance policies is a joke. Treatment officials say three months is a minimum, with many addicts needing a year or more to kick their habit. “Everybody’s assumption is that we ought to just send these people into rehab to focus on that drug problem,” says Dr. Lonny Shavelson, an emergency room physician who spent two years following addicts through the Byzantine San Francisco rehab system for his book Hooked: Five Addicts Challenge Our Misguided Rehab System. “But before we shift hundreds of thousands of additional addicts into rehab, we better treat the treatment system.” Critics say the most common form of residential treatment -- typically a month of intensive 12-step meetings and talk therapy in a highly structured, often militaristic setting, with lapses in abstinence met with immediate expulsion -- sets up many users for failure. Others point to the number of people whose most serious problems – everything from childhood abuse to homelessness to manic depression-- are ignored inside rehab only to crop back up again on the outside, propelling them further into addiction. “Probably a quarter of the patients who end up in rehab have some kind of dual diagnosis,” says Anne Vance, a former director at the Betty Ford Center who went on to start Crossroads Center, a Caribbean residential treatment program founded in 1998 by Eric Clapton. “In many cases, they’re treated without considering root causes. These are the people we see coming back into treatment again and again.” But perhaps the single most pernicious force working against rehab is the disease itself, which researchers have only recently begun to understand as matter of biology as well as will. Neuroscientists now say prolonged use of drugs can literally rewire the brain’s mesolimbic dopamine system -- known as the pleasure pathway -- prompting a lifetime of nonstop, bombarding impulses to relapse. “Someone who is truly dependent has gone past the point of no return with their brain chemistry,” says Dr. Carlton Erickson, professor of pharmacology at the University of Texas and the director of the Addiction Science Research and Education Center. “Their brain chemistry is going to be that way for the rest of their lives. It won’t repair itself. It will continue to tell them that they need the drug to feel normal.” From that perspective, 28 days of sobriety, group therapy and cafeteria food is more like a small start than a triumphant resolution. “People seem to think you can go somewhere, follow a program and come out fixed,” says Dr. Alan Leshner, Director of the National Institute on Drug Abuse. “The sad truth is that addiction is a chronic relapsing illness. Relapse is part of the disease. There isn’t a magic bullet and there probably never will be.” ••• No single addict has focused more attention on the rocky road of rehabilitation than Robert Downey Jr. The 36-year-old actor’s still-revolving cycle of abuse, arrest, contrition and relapse offers vivid proof of how the obsessive drive to get high can overpower even the most sophisticated treatment programs. Downey has spent much of his adult life in and out of rehab, entering his first program at the age of 20 (where he met his now-estranged wife) and returning periodically between movie and TV jobs. He managed to keep his troubles private until 1996, when he was arrested in Malibu after slipping into the bed of an 11-year-old neighbor, strung out on coke and cradling an unloaded .357 magnum. After bolting from a court-mandated rehab and missing drug tests, he was sentenced to a year of behind-bars rehab at Cocoran State Prison. When he got out, Downey flexed his prison-buff physique on the cover of Details, landed a regular gig on “Ally McBeal” and proclaimed himself clean and sober and ready to start a new life. His subsequent unraveling was just an extreme example of an all-too-common story. Once upon a time, high-profile addicts would complain of “exhaustion” and simply fall from view for a month or two. Today celebrities turn their stops at rehab into full-blown media events, alerting networks when they check in – A.J. McLean of the Backstreet Boys enlisted his bandmates last July to announce his stint in rehab on MTV – and appearing on the cover of People or US Weekly when they check out. Last April, actor Matthew Perry ducked away from the set of “Friends” for a second round of rehab to deal with a lingering addiction to Vicodin. That same month, “West Wing” creator Aaron Sorkin was caught carrying a stash of crack, magic mushrooms and marijuana on a flight to Las Vegas, five years after apparently kicking an addiction to cocaine and a few weeks after accepting an award from the rehab Phoenix House for helping increase public awareness about addiction. Then there’s Daryl Strawberry, currently committed to two years of treatment after bolting from rehab to go on a four-day crack cocaine binge. The list of rehab relapsers goes on, from rockers Scott Weiland and Anthony Kiedis to actors Tim Allen and Andy Dick. The P.R. stigma of rehab may have actually gone into full reverse, going from liability to career-booster. One story going around Hollywood last summer involved a rising starlet who reportedly feigned a heroin addiction, checked into rehab and submitted to a new detox program that begins with several days under general anaesthetic. She hoped the experience would toughen up her innocent image – and most importantly, help her effortlessly shed a few pounds for an upcoming part. If outsiders can treat rehab so casually, the attitudes of hardened addicts can be downright cavalier. Rehab counselors say many first-time patients treat rehab as a sort of crash diet, a 30-day exorcism of their cravings. “I thought I was going to rehab to get fixed,” says Chris, a former Boy Scout and surfer from Malibu who checked into rehab at 23 when his wake-and-bake pot habit became a full-blown heroin addiction. “I thought I could just take care of it and move on.” Instead, holed up in a seaside rehab that Kurt Cobain had fled before his suicide a year earlier, Chris bonded with a group of other young addicts still enamored by the outlaw glamour of junk. “It was fun,” he says. “We talked about getting high all day, romancing every detail.” With his new network of junkie friends, Chris quickly became what he calls “a nickel and dime dope fiend.” For a while he managed to keep a job pumping cappuccino at a coffee shop on the Pacific Coast Highway, shooting dope in the bathroom and supplementing his high with daily doses of methadone and whatever other pharmaceuticals he could get his hands on. When he got fired from his job, he moved into his car and scraped together money by “boosting” – scavenging receipts in the parking lots of supermarkets, then shoplifting items that appeared on the slips and collecting cash refunds. Along the way, he spent three months in jail and checked in and out of four rehabs. “I knew how to go through the motions without getting noticed,” he says. “Most of the time I genuinely believed everything I heard -- then I’d just go out and get high again.” It took eight years before Chris reached that mysterious turning point that no drug counselor or psychopharmacologist has figured out a way to induce. For Chris, anger over a girlfriend secretly making arrangements to seek help for her own drug problem finally made the difference. “She was trying to leave me behind,” he says. “I felt completely ruined and useless. I went into rehab and said, ‘fuck it, I’ll do whatever you say. Tell me what to do and I’ll do it.’” Now sober for three years and working as an operations manager for a rehab in LA, Chris says he’s still mystified why the system works for some and doesn’t for so many. “You have to be ready,” he says, repeating an oft-quoted tenet of recovery. “The tricky part is that no one – not you or anyone – can tell when you’re ready.” ••• The basic residential treatment regimen has changed remarkably little since the 1940s, when doctors at “an asylum for inebriates” in the wooded countryside outside Minneapolis developed a system called the Minnesota Model. Today, Minnesota is gospel at most of the 3,700 residential treatment programs currently operating in the U.S., from the hard-core, no-nonsense Phoenix House network to the deluxe Sierra Tucson compound in Arizona, where everyone from pill poppers to chronic gamblers spend upwards of $33,800 a month to get straight. “What do you get for your 34 grand?” asks Buddy Arnold, a 75-year-old jazz saxophonist and recovering addict who now runs the Musicians Assistance Program with wife Carole Fields. “The food is pretty good and the scenery is better, but basically the treatment is all the same.” In the Minnesota Model, the 12 steps are king, with addicts spending up to four hours a day in Alcoholics Anonymous or Narcotics Anonymous meetings. Trading war stories with other addicts, they’re introduced to the idea that they are in the throes of a lifelong disease that they are powerless to cure themselves. The only way to get better, they learn, is by submitting themselves to a higher power, “working the steps” and never touching a drink or drug again. Most rehabs also foster a strong sense of camaraderie and support. Typical is the tough love atmosphere at Cri-Help, a 130-bed facility in a rough industrial patch of the San Fernando Valley, where new patients are greeted with hugs and back-slaps and group meetings often end with participants holding hands and singing, like kids around a camp fire. But beneath the grins and hand-holding is rigid structure. Most programs enforce a strict code of conduct that covers everything from what time patients wake up to what they read and who they talk to. Rooms are inspected for cleanliness, telephone calls are monitored and men and women are often prohibited from any interaction without permission. Rules are enforced by a staff of “techs” (mostly uncertified ex-addicts who have graduated the program) and other patients, who are encouraged to “pull up” or “support” fellow addicts who they see deviating from the path. Penalties might include laps around the facility grounds, a day wearing a sign reading “asshole,” or, for severe infractions like sex or drug-taking, several days of complete silence followed by a harsh dressing-down from everyone else in rehab. The mix of boot camp-style behavior modification and family support works wonders for many addicts. “I learned how to talk to people and to share,” says Francisco, a 31-year-old cocaine addict from East LA who spent two years in the same drug treatment program at Cocoran State Prison that treated Robert Downey Jr. “On the outside, I was never been able to get my shit together. All the rules they throw at you in here forces you to start living like a normal person.” By the time most addicts wind up in rehab, their lives are often in such disarray that they desperately need guidelines and consequences, says David Carr, a New York Magazine contributing editor who went through four stints of rehab before successfully dealing with “a little problem with social crack use.” “The reason these places are so freaky about rules is that addicts are people who don’t observe any part of the social contract – they lie and scam to continue to use,” he says. “Until you create some accountability, starting with making your bed and showing up on time, you can’t get them straight.” That certainly made sense to Colette, a 28-year-old daughter of Christian missionaries who got hooked on heroin after graduating USC and ended up turning tricks for speedballs in the Mission District of San Francisco. After overdosing for the third time, she found her way to Walden House, a county-funded system that charges about $10,000 for its year-long program. At first, she welcomed the strict regimen. “In the first couple months, I needed the distraction,” she says. “It was such a constant barrage of rules and activities that by the end of the day I was so tired I couldn’t focus on using -- or anything else for that matter.” But her attitude changed after another addict “supported her” when he discovered that she had kissed one fellow patient and had sex with another. For punishment, a formal assembly was called in which she sat silently as 200 addicts were encouraged to heap insults on her. She got off relatively easy – “I saw much worse while I was there,” she says – but the experience certainly didn’t teach her anything about staying sober. If anything, she says the ritualized humiliation only stirred up old memories of childhood abuse. “Their whole idea is to strip your sense of self,” she says. “But I came away feeling I had no idea who I was – even less than when I was using.” Colette’s experience is typical of those addicts who go through rehab never really dealing with the reasons they used drugs in the first place, says author Shavelson. In Hooked, he relates the story of a junkie who spent a year in rehab and never got around to discussing the fact that his father had molested him as a child. “The majority of rehabs still focus predominantly on behavior,” he says. “They teach you ‘OK, your life has fallen apart, we’re going to teach you to come to breakfast on time, we’re going to teach you to make your bed, we’re going to teach you to come to meetings on time -- but we’re never going to deal with the fact that someone raped you for two years from the ages of seven to nine. We’re never going to deal with the fact that you can’t read or that you don’t have anywhere to live when you get out of here.” ••• Rehab counselors often talk about the crucial difference between “program sobriety” and “street sobriety.” The difference may explain why so many addicts drilled in the rehab routine get loaded the first chance they get on the outside. Few addicts understand the difference better than a burly ex-Marine named Pat. Fifty-three years old with a thinning crew cut and a vocabulary brimming with buzzwords from the Big Book of AA, Pat knows all about “program sobriety.” He checked into his first rehab in 1972 after returning from Viet Nam hooked on speed, opium and pot. He got clean nine years and a few more rehabs later in a VA program modeled after Synanon, a cultish “therapeutic commune” run out of a seaside hotel in Santa Monica that advocated a brand of “attack therapy” that used equal parts of hippie love and harsh ridicule to break through addicts’ defenses. He remembers nights scrubbing the floors with a toothbrush and days wearing a toilet seat around his neck. “That’s because I was full of shit,” he explains. “It was humiliating as all hell, but it worked.” (Synanon eventually disbanded after its founder was named in a corruption scandal that peaked when an opposing lawyer was nearly killed by a four-and-a-half foot rattlesnake left in his mailbox.) Pat went on to become a drug counselor himself. Working for and later running hospital anti-drug programs, he ended up adopting some of the aggressive techniques that had helped him get sober. He remembers one patient in particular, a “big ol’ thug” named Dave who was clearly, Pat thought, going through the motions before he could get out and get high again. One day the rehab staff caught two detoxing junkies stealing cake from the kitchen and a group meeting was called to decide the appropriate punishment. When it came time for Dave to weigh in, he leaned back in his chair, smiled and said, “I think I’ll turn it over” – AA-speak for allowing a higher power to decide the fate of a problem. This struck Pat as manipulative cop-out, a sly attempt to mask his own passivity in the language of recovery. “I jumped up and yelled, ‘if you want to turn something over, grab a shovel and turn over that yard,’” he says. As the group looked on, Dave was made to march outside and dig up a muddy lawn until Pat was satisfied he was properly humbled. When he came back inside and began “bitching and complaining,” Pat had another exercise for him. “I called him a big fucking baby, threw him a pacifier and told him to suck it for the rest of the day,” he says, laughing. “It was priceless.” Pat says there are two important points about the story. The first is that he genuinely believes the exercise helped snap Dave out of his temporary, surface “program recovery,” and move closer to a lasting, meaningful “street sobriety.” The second point is harder for Pat to explain: that he managed to orchestrate this breakthrough while he himself was high as a kite. The truth was that Pat had been secretly dosing himself with fistfuls of pharmaceuticals for more than five years. It began when he discovered that mixing the painkillers Vicodin and Soma produced a high remarkably similar to heroin. At one point, he was visiting three or four doctors a week to maintain a habit of between 20-50 pills a day. “I beat myself up about it all the time, but it made no difference,” he says. “I was in the grip.” Back in rehab as a patient, Pat says he hopes to reemerge after ten weeks and reclaim his old job. “Even when I was loaded, I was a great counselor,” he says. ••• Critics of rehab fall into two main camps: clinical researchers who argue that the disease of addiction will be cured with scientific scrutiny not spiritual platitudes, and a growing movement of activists who advocate a flexible approach that doesn’t require addicts to quit cold turkey. Think of them as the doctors and the dopers. Until quite recently, physicians had precious little to offer addicts other than sage words of sympathy and referrals to the local chapter of AA. But as researchers have learned more about the genetics and neurobiology of addiction, medical interest has intensified, culminating in a landmark 1995 meeting in Virginia in which substance-abuse experts declared addiction a disease of the brain. Their research has yielded a new crop of treatments – including drugs that ease cravings and therapies designed to reduce relapse. But according to National Institute on Drug Abuse Director Alan Leshner, rehabs have not exactly thrown open their doors to the boys in the lab coats. “Let’s just say that not every rehab uses state-of-the-art, science-based principles,” he says. “Many of these programs are based more in tradition than in clinical depth. We’ve had to work hard to bring science to bear on what they do.” But to those who run rehabs, clinical research offers little more than impractical theories and drugs for people trying to become drug-free. “If there’s a pill that inactivates whatever it is physiologically that makes an addict different from a normal person – that’s great, that’s a cure,” says Cri-Help’s Bernstein. “But so far all we’ve gotten are drugs like Methadone, which doesn’t even necessarily help addicts. They’re still strung out – except now they’re strung out on a different drug.” And while those who run rehabs are happy that the medical establishment has begun to treat addiction more seriously, many believe doctors with stethoscopes can only offer so much assistance in what is essentially a spiritual struggle. Sitting in the grassy yard of the Promises center in Los Angeles – the $1,000-a-day treatment center where Charlie Sheen, Christian Slater, Tim Allen, Andy Dick, Paula Poundstone and Ben Affleck have all dried out – founder Richard Rogg says recovery is a deeply intimate experience that falls outside the realm of science. “This is not an area where you can watch mice in a box,” he says. “Miracles happen here in strange little places. They can happen at three in the morning, slipping outside to smoke a cigarette and finding yourself sharing things with someone you never told anybody in your life. The next morning you wake up and feel a weight lifted. That’s not something doctors know how to fit into their models.” Others who work with addicts, meanwhile, have more direct criticisms of the standard rehab regimen. The so-called harm reduction movement is based on the idea that some addicts simply can’t give up their dependency all at once. Rehab’s demand that they do, the theory goes, only drives them deeper into dependency. “You don’t wake up one day with your life in shambles and a crack pipe in your hand,” says Maria Chavez King, regional director for the national Harm Reduction Coalition. “That’s not the way addiction happens -- it happens slowly over time. And that’s the way it should un-happen. We allow addicts room to improve themselves at their pace, not ours.” Lifelong heroin addict Evelyn Milan became a believer after two years of traditional treatment failed to make a dent in her 10-gram-a-day habit. “I’d sit there in their meetings listening to all these horror stories -- about how people lost their jobs, how they ruined their lives,” she says. “All it made me want to do is go out and use again.” Milan finally did get with help from counselors in New York’s Lower East Side trained in harm reduction. They urged her to taper off drugs while helping get her life in order, setting up doctor appointments, housing assistance and help with her three kids. “I couldn’t let my drug go overnight,” she says. “I had to fill in the gaps left by my drug little by little.” Followers of the 12-steps, however, insist that anything less than total abstinence is destructive self-delusion. “If someone is capable of slowly tapering off, they weren’t an addict to begin with,” says Carr. “Addicts are fundamentally different -- they can’t be tweaked or gradually amended.” While Milan and others may have been able to modify their habits into submission, others have failed spectacularly. Audrey Kishline, founder of an organization that advocates “controlled drinking” over outright abstinence, pled guilty two years ago of vehicular homicide after driving her pickup truck head-on into opposing traffic and killing a father and daughter. Her blood alcohol level was three times the legal limit. ••• It may be imperfect, but rehab is still the treatment of choice for hard core addiction. What other choice is there? Prison has proven to be a spectacularly ineffective option, one that voters have grown weary of paying the hefty bill for. In California, Proposition 36 has directed some 20,000 addicts into treatment in its first year alone. And in New York, the easing of Rockefeller-era drug laws is expected to redirect tens of thousands of addicts away from jail cells and into treatment. With public policy – and the spotlight of celebrity – now pointing toward rehab, observers say the time for reform is ripe. While some rehabs (ranging from the hoity-toity Betty Ford to the hard-core Cri-Help) offer patients more than the standard course of talk therapy and tough love, too many treat their programs as sacrosanct systems that must be protected at all costs from the influence of outsiders. Any meaningful reform, says Shavelson, would force rehabs to work more closely with psychotherapists, social workers, clinical researchers and others equipped to spot and deal with underlying causes of addiction. “Drug abuse is not just about drugs – therefore rehab can’t just be about drug rehab,” he says. Until then, even the most intensive rehab will help the easiest cases while leaving others little more than high expectations and hollow catchphrases. Take the case of Pam, a 43-year-old mother of two who has been and out of 31 rehabs. After all that treatment, she says she’s traded one dependency for another. “I’m not leaving rehab until the SWAT team blows me out,” she says flatly. “I know how to get along in here, but I have no idea how to function outside. I never have.”