The .Plan

That new Amy Winehouse song is stupid.

NYT has a great soapbox piece on drug and alcohol addiction treatment programs:

Less than a decade ago, a stint in rehab was assumed to be a body- and soul-wrenching experience. A trip to even an elite facility like the Betty Ford Center in Rancho Mirage, Calif., was sufficiently shaming to keep under wraps — the psychic equivalent of a week in the stocks. Today a sojourn at a boutique establishment like Promises in Malibu, Calif., where until last week Britney Spears was tucked away, is openly discussed and in some quarters glamorized as a hip, if costly, refuge for the gilded set.

That idea is perpetuated — indeed aggressively promoted — by the marketers of a handful of high-end facilities, some of which advertise amenities on their Web sites like private rooms with 600-thread-count bedsheets, high-tech gyms, spa cuisine and ocean views. “There used to be a stigma to coming to a place like this,” said Chris Prentiss, the director of Passages, another exclusive treatment center in Malibu. “Now it’s like wearing a Ralph Lauren shirt.”
–Ruth la Ferla, “… Having a Great Detox”, New York Times, March 29, 2007

The piece emphasizes the “idealization of recovery” in the collective psyche, but I wonder if that’s a totalizing explanation for what’s going on. A much more truthful assessment would be that current trends are being driven by a trivialization of “rehab” through its overuse to reap political gain. Declaring participation in an inpatient program with an eye towards damage control has the unfortunate effect of causing others to turn cynically away from what could potentially be an effective, albeit difficult, intervention.

Here is a catalog of individuals who have loudly announced their intent to enter rehab — defining “rehab” will be an entry for another day — in recent months:

• Gavin Newsom (Feb 2007)
  
• Isaiah Washington (Jan 2007)
  
• Tara Conner (Dec 2006)
  
• Ted Haggard (Nov 2006)
  
• Bob Ney (Oct 2006)
  
• Mel Gibson (Jul 2006)

More thorough reporters would dig beyond the transparent doublespeak of the initial press release and write stories on longer term outcomes, but unfortunately they are ensnared in this conspiracy as well. When it comes to all things psychological, the nature of the doublespeak (“I take full responsibility for my disordered conduct / I am an alcoholic and am powerless in the face of my genetic disease”, “I am going into therapy to show you that I am taking responsibility for saying bad things about gay people / by going into therapy I am entitled to place the blame of my moral defects on factors external to my soul”) is such that the initial decision is the only one that matters. We are willing to dock moral points if Mel Gibson does not enter therapy, but we are unwilling to dock moral points if he fails therapy. That we would hold a person morally responsible for some choices but not for others — how did this strange set of circumstances come about?

As an aside: in case formulation conference last week, there was a lively discussion of a man who had totally exploited his aged mother out of house and savings and was now (after having run out of money and cocaine) in the ED claiming suicidal intent and demanding to be hospitalized at Hotel Harborview. At one point during the discussion, my attending said, flatly, “He has a moral defect.” After months and months of listening to mental health professionals prattle on about childhood circumstances, genetic susceptibilities, and multiaxial diagnosis, it was a breath of fresh air.