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David Sheff's "Clean" Shines Important Light on Treatment Industry

Clean by David SheffDavid Sheff’s 2008 book, Beautiful Boy is a harrowing account of his son Nic’s drug addiction, and his own anguished attempts to understand it. A decade in the making, Sheff’s new book, Clean: Overcoming Addiction and Ending America’s Greatest Tragedy is an examination of evidence based treatment (EBT) models for addiction, as well as a comprehensive analysis of how and why we so frequently fail to use them.

Sheff, a journalist, begins with an argument that will surprise no one in the field, namely that addiction is a treatable disease, not a moral failing. However, he also elucidates how much the language with which we describe addiction reveals a judgmental bias, as if addicts were weak, selfish or immoral. Sometimes we in the substance abuse treatment field are the worst offenders. Sheff describes his visit to an inpatient treatment facility, where he witnessed a counselor dismissing a patient from treatment with these words:

 He’s not ready to be sober. His ego is in control. I’ve seen a million like him. He’s cocky, thinks he’s above the steps, thinks he knows better than all of us. He isn’t ready to do what it takes. He’ll be back when he is.  

As Sheff intelligently asks, if this counselor truly believed that addiction was an illness, why would he kick a patient out for displaying a bad attitude? Do we dismiss cancer patients who complain about chemotherapy? In Sheff’s words, addiction is the only disease for which patients are refused treatment for showing their symptoms.

Presumably, the above example does not reflect the prevailing attitude in the field, but as Sheff reports, the great majority of rehab treatment plans are based on the Twelve Steps. And while Sheff includes a description of how well AA methodologies mirror valid evidence based treatments, he also points out that in many Twelve Step-based rehabs, this can harden into orthodoxy. The Twelve Steps are viewed as the only way to get and stay sober. Patients who resist the Program are “not ready”, “haven’t hit bottom”, or are “not committed to recovery”. As Sheff points out, these are exactly the sort of judgments that stigmatize addicts in the first place.

This is old-fashioned addiction treatment and, frankly, I’m astonished that Sheff seemed to encounter so much of it. While there is no doubt that AA has helped millions of people, there are millions of others for whom it doesn’t work. The most optimistic estimate is a 30% success rate after one year, while Sheff argues that it’s more likely 18%. If the field of addiction treatment is founded on these kinds of success rates, it’s hardly surprising that addiction is more prevalent in America than cancer, stroke, HIV/AIDS, or Alzheimer’s disease.

So what is the answer? How can Sheff argue that addiction is a treatable disease? Fortunately, there are many substance abuse programs, Freedom Institute among them, that offer alternative, evidence based treatments for addiction. While we always recommend AA/NA and/or Alanon to our clients, we don’t base our treatment plan on the Twelve Steps. For one thing, as Sheff points out, AA is not designed to treat underlying psychological problems that may have contributed to addiction.  Unlike most inpatient rehab facilities, we typically retain our clients for much longer than 28 days. As a result, our focus is not only sobriety, but true emotional and psychological recovery. (It is worth pointing out that for some people, this can be achieved by actively working all Twelve Steps).

Secondly, while we consolidate a healthy respect for AA into our treatment approach, we rely on evidence based addiction treatment models that have been tested and proven to work: Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, therapeutic groups, and Motivational Interviewing. We recognize that some clients require medication, not only during detox, but also through treatment. And while we don’t yet have complete evidence to prove it (look for this in the future), we know that involving the whole family system in treatment, rather just education, offers the best outcome.

Nonetheless, Sheff’s book made me think hard about what we do, why we do it, and the language we use to describe both addiction and addicts.  It’s rare a book prompts the level of self-reflection and conversation that Clean did at Freedom Institute. I am inclined to agree with Glenn Altschuler, who described it as the best book on drug abuse and addiction to appear in years.  

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