In the contentious world of drug and alcohol treatment, dissent is never tolerated, and all apostates are ruthlessly cast out. After a recent 20/20 episode described the debate over the new "controlled drinking" trend among some recovering alcoholics, the Betty Ford Center was quick to respond with letters to ABC charging that the show was "sensationalistic, simplistic, and unbalanced," and that people would die as a result.
But now, in a move tantamount to the Catholic Church's reversing its position on abortion, the legendarily hard-line Smithers Addiction Treatment and Research Center on Manhattan's West Side, best known for treating troubled Met Daryl Strawberry and Pulitzer Prize winner Nan Robertson, has decided to break with the two other treatment pioneers -- the Hazelden Foundation and the Betty Ford Center -- and abandon the lifetime-abstinence approach.
In the fifties, Smithers was one of the first to adopt the Minnesota Model, in which total abstinence is compulsory from day one -- anything else, even if accompanied by major life improvements, is failure. Attending twelve-step meetings is considered the only route to recovery. Acceptance of "powerlessness" over drugs and surrender to a "Higher Power" (generally God) are vigorously promoted. Resistance is confronted. Patients who don't comply are said to be "in denial" and are often expelled.
In the old days, counselors told patients that prayer and AA meetings were their only hope for avoiding jail, institutionalization, or addiction-related death. But under the new dispensation, they let patients decide for themselves how to recover. Cut down rather than quit? No problem: Moderation Management meets on-site. Need medications? We've got everything from methadone to Prozac. Want to quit crack but not marijuana? We have techniques. Prayer? Not necessary.
"No matter how you put it, it's pretty damn radical," says John Bellamy Taylor, director of evaluation services for Smithers. "It is radical for addiction treatment, but it's really a return to traditional medicine," argues Dr. Alex DeLuca, chief of addiction medicine for St. Luke's-Roosevelt Hospital, which runs Smithers. "In medicine, if treatment doesn't work, you change it. I humbly submit that this is the way alcoholics should be treated."
Why has Smithers broken ranks? Pressure from managed care, for one -- which has resulted in the closure of half of U.S. rehabs over the past fifteen years and is forcing the survivors to prove that what they do actually works. Comparative research hasn't been kind to them, either. "We do find that people who go to twelve-step meetings do better," says DeLuca. "But it doesn't work for some, and I'm not going to tell them, 'Come back after you have suffered some more and are ready to do it our way.' I can't operate that way as a physician." DeLuca's predecessor, Dr. Anne Geller, puts it more bluntly: "Would you want surgery done now the way it was in the fifties?"
The change has been so dramatic at the new Smithers that it's as if the inmates have taken over the asylum. AA and abstinence are recommended, not required. Counselors cajole rather than confront. The kinder, gentler Smithers aims to improve relationships, productivity, and health even if lifetime abstinence cannot be achieved.
None of this makes sense to traditionalists. Anything but total abstinence is viewed by them as a slippery slope, "enabling" continued denial and compulsive use. Asked to comment on the new Smithers, Christine Anderson, a spokesperson for Hazelden, expresses shock. Radical? "Boy, I'd say so," she says. Despite the research, Hazelden "will stay with our current model. We are sticking strictly with the AA concept." The Betty Ford Center did not return calls.
Kenneth Lewis, a Smithers counselor for eighteen months, admits he found the change difficult. "It conflicted with my training," he says. (Many counselors recovered through AA themselves.) "But it gave me a chance to rethink what I believed. I found that my belief system was faulty."
"The Minnesota Model's traditional assumptions are under enormous challenge," says William White, author of Slaying the Dragon: The History of Addiction Treatment and Recovery in America. "People are moving away from 'This is our program' to offering a menu, real options." As for Smithers's patients, most seem to prefer those choices to old-style coercion. "Some people melt," says DeLuca. "They're so relieved that it's not the nightmare they thought it would be."