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Annals of Addiction


Twelve-step treatment Programs used to be anonymous. Why is the Hazelden Foundation going public?

THE Great Coffee Debate at the Hazelden Foundation, in Center City, Minnesota, was the type of controversy that is dear to historians–a seemingly trivial event that illuminates larger issues and trends. The debate began in the spring of 1994, when a majority of the counsellors at Hazelden, which is the wealthiest and most influential treatment center for alcoholics and drug addicts in the country, suggested that coffee be banned. Since treatment at Hazelden is based on the twelve-step program of Alcoholics Anonymous, this was a little like trying to be holier than the Pope. Coffee is an integral part of most A.A. meetings, a de-facto sacrament. Members of A.A. have been known to make pilgrimages to Akron, Ohio, to view the coffeepot used by Dr. Bob, the cofounder of the organization. Nevertheless, the counsellors at Hazelden decided that coffee was just another drug. "There was concern that some people could be using caffeine as a stimulant, three-bagging or four-bagging it," Russell Forrest, one of the leaders of the anti-coffee camp, recalls. "What we were really dealing with, I guess, was a question of philosophy."

A ban on caffeinated coffee was implemented, but enforcing the ban was another story. "You had people bringing this stuff in from outside," Forrest recalls, "and there was an underground market, which, of course, you would point out to patients, and you’d say, you know 'Doesn’t this sound like chemical use?' People were opening up packages, and I saw what was in there. It was the strongest brew you could buy. Somebody was getting coffee from South America, and it was sticky and black, and I said, 'What is this? This is not Maxwell House from Bogota.'"

The black market in coffee grew at an alarming speed. Patients were brewing large quantities of coffee in their rooms and flushing the evidence down sinks and toilets. Soon the pipes were stuffed with coffee grounds, and the conflict between a fundamentalist approach to tenets of A.A. and the practical demands of running a treatment center came to a head. As the plumbing at Hazelden became more and more clogged, the maintenance staff rebelled, and the coffee ban was finally and ingloriously rescinded.

HAZELDEN was disrupted for months by the coffee wars, which took place just as the foundation’s president, Jerry Spicer, had begun to encourage use of antidepressant drugs and other therapies that are not traditionally part of the twelve-step process. This was a controversial move, and several staff  members had left in protest. Spicer’s supporters also tended to support coffee.  Phil Kavanaugh, the head counsellor on Shoemaker, one of Hazelden's six primary treatment units, was an outspoken proponent of caffeine. "The problem with the coffee, as I saw it, was that it wasn’t strong enough," he says. "My proposal was that we should put in an espresso bar next to the dining area."'

This was an ideological crisis. The opponents of coffee were registering disapproval of drugs of all kinds, no matter how limited or benign (or therapeutic) their effects might be.  The pro coffee faction was willing to embrace caffeine and antidepressants if they helped an addict get well. This more liberal approach to treatment opened the door to a view of the twelve-step pro gram that could include new drugs which are much more ambitious than anything that has been available before .

The new drugs, which are the consequence of recent research into the neurotransmitters in the brain affect behavior, will act on addiction in much the same way that S.S.R.I.s (selective serotonin re-uptake inhibitors), like Prozac and loft, act on depression. "My belief is that today, in 1998, you should be put in jail if you refuse to prescribe S.S.R.I.s for de pression," says Alan Leshner, the head of the National Institute of Drug Abuse, or NIDA, the federal agency in charge of addiction-research funding. "I also believe that five years from now you should be put in jail if you don’t give crack addicts the medications we're working on now."

The new research is a mixed blessing for Hazelden and other A.A.-based treatment centers. On the one hand, neuroscientists using advanced imaging equipment to observe changes in regions of the brain that are known to govern addiction have provided evidence that addicts do not simply lack will power or character. They have a physical disease, which is what A.A. has claimed all along. On the other hand, the idea that addiction is a disease with the same kinds of physical causes-and cures-as diabetes or clogged arteries challenges the premise of a spiritual cure on which Hazelden has operated for the past fifty years.

The elimination of entire fields of therapeutic practice by cheap and powerful psychoactive drugs is a familiar story. Outside of a few high-income neighborhoods in New York City, for example, it is hard to remember that Freudian analysis was once standard medical practice rather than a culturally specific activity for people with a hundred dollars to spend for an hour on an analyst's couch. Those who champion the new drugs for addiction see a similar future for A.A.based therapies. Why bother with Hazelden, which charges around fifteen thousand dollars a month, when pills can produce immediate and measurable results at a fraction of the cost? "Look, if swinging a dead cat over your head helps, then I'm for it," Alan Leshner says. "But if someone says never, ever use medication I can’t understand that at all."

THE Hazelden Foundation sits on the shores of a small lake, surrounded by four hundred and eighty-eight acres of nature trails and tall pines. It looks like a well-run monastery or a small but fashionable resort. It was established in 1949 as a retreat for alcoholic priests. The original white shingled farmhouse has been replaced by tan brick buildings, and the Hereford cattle that used to graze on part of the land are gone, but the addicts at Hazelden today, many of whom are wealthy and some of whom are famous, live much as patients did fifty years ago, recovering from what they are told is not only a disease of the body but also a profound disturbance of the soul.

There are six treatment units at Hazelden, four for men and two for women, each named for a Hazelden founder or for one of the founders of Alcoholics Anonymous. When patients arrive for their twenty-eight-day stay, they are admitted to Ignatia, the detoxification unit. (Sister Ignatia was a Roman Catholic nun who helped Dr. Bob dry out alcoholics.) At Hazelden, unlike the more literalminded A.A. treatment centers, including the Betty Ford Clinic, many of the new patients are placed on Librium, or, at any rate, they have been since Jerry Spicer liberalized Hazelden's drug policy.

Hazelden is legally, if not philosophically, independent of A.A., and treatment there has long incorporated behavioral psychology and other less than spiritual methods. But, because A.A. does not run treatment centers; of its own, Hazelden is the closest thing to the institutional voice of the A.A.-based treatment community. It is a nonprofit foundation, run by an independent board of directors, and has a twenty-five-million-dollar endowment that is funded by corporate donors like ITT CBS and Goldman Sachs.  The publishing arm of the foundation brings in twenty million dollars a year by distributing manuals and workbooks to treatment centers across the country. It also publishes Melody Beattie's bestselling "Co-Dependent No More." The foundation has forty thousand alumni, who make donations, buy T-shirts, and attend retreats and reunions on the Center City campus.

WILLIAM COPE MOYERS is typical of recent Hazelden alumni. He was the troubled son of privileged parents, he overcame an addiction to crack cocaine, and he stayed in Minnesota, becoming a pillar of the A.A. community. Moyers went to Hazelden for the first time when he was twenty-nine years old. He is now thirty-seven, and he works as Hazelden’s director of public policy.  He appears to be a younger, faster-talking version of his famous father, Bill Moyers. As he speaks, it is as if the down-home cadences familiar from hundreds of hours of public-television viewing were being played back with one finger pressed impatiently on the fastforward button.

A former reporter for Newsday and CNN, Moyers has been in treatment for addiction to crack three times since 1989–twice at Hazelden and the last time at the Ridgeview clinic, outside Atlanta, in 1994. "1 had been sober for three years and two months," he recalls, in a nasal prep-school drawl. "I was working at CNN. I named my second son after Tom Johnson, the president of CNN, because Tom had been really good to my family. And I stopped taking care of myself in recovery. And one day I decided, in the summer of '94, that I was never going to repeat the insanity of the past, because who would want to, but I might just try it my way. And I'll never, ever forget holding the crack cocaine in hand and thinking, This is going to last me a week. It lasted me four hours."

Several days later, he was removed in an inner-city crack house by the anta police and taken to Ridgeview. family was very angry," he recalls.  “My wife was very angry: 'How could you do this? Doesn’t your family mean more?'  And those are the questions that millions of people ask. And I couldn’t explain it, except that I had stopped doing what I needed to recover."

As he reaches the summation of what describes, in the A.A. language of the moment, as "my personal journey," Moyer spreads his arms wide. "There are two things more powerful than me," he says, thick blond eyebrows rising high on his forehead and wiggling just a little to underline the point. "One is my disease.  And the other one is God. God, disease, William Cope Moyers."

God and his disease have found a very effective PR. guy in William Cope Moyers. "Addiction is the last great disease that still mystifies people, to which there's still a stigma attached, and which is not being addressed as a public-health issue," Moyers says. His mission is to change that, and this month Hazelden is launching a campaign that is modelled on the successful campaigns of advocates of treatment for breast cancer and AIDS. The cornerstone of their efforts is a congressional bill sponsored Minnesota legislators, Democratic senator Paul Wellstone and Republican Representative Jim Ramstad, which would force health-care insurers to fund addiction treatment on a par with other major illnesses. The bill would direct hundreds of millions of insurance dollars a year into the month-long inpatient programs on which Hazelden has built its reputation. In the nineteen-seventies and the early eighties, when addiction became a big business, insurance companies paid for such treatment, but with the rise of managed-care systems in the late eighties, the money dried up.

The Wellstone-Ramstad bill, which, if passed, would assure Hazelden’s prosperity for years to come, will be the focus of attention at a congressional hearing on addiction on March 24th, at which Jim Ramstad, Paul Wellstone, and William Cope Moyers will testify. Five days later, PBS will air the first installment of a five-part series on addiction and recovery hosted by Bill Moyers. Judith Moyers, the wife of Bill Moyers and the mother of William Cope Moyers, is the co-executive producer of the series. She is also an active member of HazeldeiA board of directors. The sponsors of the Wellstone-Ramstad bill hope to begin further hearings in Congress immediately after the Moyers series ends, on March 31st, with an episode on "The Politics of Addiction." "Am I naive about the benefits of raising the debate about parity at the same time as the series is going to air?" William Cope Mor ers says. "No. Is this some kind of grassyknoll conspiracy~ No. There's no way we could ever pull that off "

Paul Wellstone has been working with the Hazelden lobbyists. "Frankly, William and the others are very smart," he says. They make sure that representatives from other treatment centers are involved in meetings, and that the campaign doesn’t look like a Hazelden publicity grab. The point is to turn the more than 1.1 million recovering people in America into a powerful grass-roots lobby for twelve-step addiction treatment. Thanks to A.A., alcoholics and addicts are already the best-organized sufferers of any major disease. But the Twelve Traditions of A.A. appear to prohibit the kind of affecting personal stories that have become a staple of daytime talk shows and congressional hearings alike. Tradition Ten, for example, states, "Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never to be drawn into public controversy." Tradition Eleven instructs A.A. members to "always maintain personal anonymity at the level of press, radio and films." Hazelden is not the same thing as A.A., of course. I think there has been too literal an interpretation of anonymity," Jerry Spicer says.

Opponents of the Wellstone-Ramstad bill will point to the shoddy practices and poor results that contributed to the closing of approximately half the treatment centers in America over the past ten years. Even for successful treatment centers, like Hazelden, the rate of patients who complete their stay and remain free of addictive behavior for at least a year is not particularly good. But such objections annoy William Cope Moyers. "Why is it that policyrnakers question the success rate of addiction treatment when they don't make the same demands on the recovery rates for other major illnesses?" he asks.  "The reason that sentiment exists is that policymakers and the public don't see recovering people."

HAZELDEN has traditionally been very protective of its patients. The anonymity of Alcoholics Anonymous informs the relationship between the institution and the addicts who go there.  Until recently, there was no director of public policy. The public was not part of the equation, and certainly the press was not. At Hazelden, an addict retreated into a self-contained world. The buildings at Hazelden that replaced the original farmhouse, which is referred to as "the old lodge," are linked by long, sloping passageways that branch off without warning into cinder-blocked dead ends or open suddenly onto views of ice fishermen's huts on South Center Lake. Hazelden legend holds that the labyrinthine tunnels are a deliberate part of the therapeutic process, a reminder to addicts that they must ask for help if they want to get well. The most obvious signs of Hazelden's spiritual mission are square cardboard placards in the halls that say "Quiet Please: Fifth Step in Progress." The Fifth Step is as essential a part of the treatment process here as a radiology lab is to the operation of a modern hospital. The Fifth Step directs alcoholics to admit "to God, to ourselves, and to another human being the exact nature of our wrongs."

Bill Wilson, who co-founded Alcoholics Anonymous with Bob Smith (Dr. Bob), was a member of the Oxford Group, a religious movement that attained its greatest influence in the nineteen-twenties and thirties. Wilson also drew on an eclectic variety of other sources, including, most significantly, William James's "Varieties of Religious Experience." His intention in founding A.A., he wrote to Carl Jung, was to make the conversion experiences that James described "available on an almost wholesale basis." Supporters of drug therapy in the A.A. community note that Wilson, in his later years, also experimented with LSD; his eventual fixation on vitamin B3 as a cure for alcoholism led to a rebuke from A.A.'s governing organization, the General Service Board.

Shoemaker, the unit at Hazelden on which I spent a week recently, looks like a ski chalet, with an open common area where there are couches and chairs and a color TV, and a split-level kitchen with a coffee machine and a large framed poster displaying the twelve steps. The unit is named for the Reverend Samuel Shoemaker, a leading Oxford Group publicist and the pastor of New York’s Calvary Episcopal Church, where Bill Wilson attended missionary meetings before founding A.A.

The patients, or "peers," as they are called, begin their day at seven-thirty in the morning with a period of meditation. They then go to a lecture down the hall, and return to the unit for a group discussion, or "Process," before disappearing for individual counseling or relaxation sessions. At times, the scene suggests freshman week in a college dorm. At other times, the unit resembles a house full of people who have been stripped of their skin. The threat of failure weighs heavily on the residents of Hazelden.  For their First Step, they must surrender themselves to a higher power. "I just don't know how I feel about the higher power," Josh, an aeronautical engineer, said to me one afternoon in the Shoemaker lounge.  If Josh failed to believe in a higher power, his counselor had told him, he would use drugs again and probably die. "A friend of mine was here with. me, and he was having the same problem," he said. "And the day after he left he started to use."

The models for the arduous transformation of self that Hazelden demands are the counselors, most of whom are recovering addicts themselves, and former Hazelden patients who return to Center City in the evenings to talk to the current residents. There is a sameness to the stories that the former patients tell–of lost jobs, broken homes, an inability to stop using drugs or drinking, difficulties in treatment, the moment of connection with the higher power, and the lifelong importance of attending A.A. meetings at least once a week. Not all the stories end well. One evening, a ponytailed biker named Jim related his difficulties finding work, confessed his desire to drink, and finally broke down in tears.  Sitting on the long couches in the Shoemaker living room after Jim's talk, many of the peers seemed put off.  "It's depressing," said Damien, a lanky young crack addict from Michigan. "If my dad knew that my treatment was going to consist of a bunch of crackheads and addicts like myself, he never would have spent fifteen thousand dollars to send me here."

It is hard to find a single person at Hazelden who doesn't appear to want sincerely to get sober, or who doesn’t profess a strong belief in the tenets of A.A. Yet nearly all the patients also admit to terrible cravings that go on for hours and threaten to obliterate any hope they have of staying sober once they leave. The intensity of these cravings is similar to those noted by Thomas De Quincey in 1822, in "Confessions of an English Opium Eater": "Think of me as one, even when four months had passed, still agitated, writhing, throbbing, palpitating, shattered; and much, perhaps, in the situation of him who has been wracked.... My dreams are not yet perfectly calm: the dread swell and agitation of the storm have not wholly subsided."

ONE reason that Hazelden may find it difficult to accommodate the new drugs that people like Alan Leshner claim will revolutionize the treatment of addiction is that the A.A. philosophy fervently rejects the idea of a "cure." Addicts are always "recovering," or "in recovery," regardless of how many years of sobriety they have attained. They are forever members of the A.A. community. This is literally true in the warm cocoon of Minneapolis-St. Paul, an hour's drive from Hazelden, where A.A. members in need can find a meeting dedicated to almost any addiction at almost any time of the day or night.  Recovering addicts with money settle down in spacious turn-of-the-century houses off Grand Street in St. Paul or near one of the lakes. They get married, raise children, and lead comfortable lives shadowed by the fear that old demons will be stirred up.

New arrivals from Hazelden ease into the recovery community at Fellowship Club, a turreted Victorian mansion that used to belong to a local brewery. A Hazelden-run halfway house, Fellowship Club costs close to three thousand dollars a month for a four-month stay.  Fellowship Club residents attend individual and group counseling sessions much like those on the treatment units at Hazelden, and are expected to find full-time work within their first two weeks of arrival. The jobs they find, at the Y.M.C.A. or Sam Goody, or at the Camp Snoopy amusement park in the Mall of America, often bear little relation to the jobs they held before.

Hazelden has opened halfway houses like Fellowship Club in Chicago, New York, and West Palm Beach. These new facilities are intended to act as incubators for the recovery culture, re-creating the close-knit atmosphere of MinneapolisSt. Paul in other cities. Not all patients can afford to stay in facilities like Fellowship Club, however. The day after Josh left Hazelden, we met at a halfway house called Crossroads, a converted motel by the side of a highway in Minneapolis. His room, which cost sixteen dollars a day, looked out on a parking lot. His roommate, who was lounging in a sleeping bag, chain-smoking cigarettes and stubbing the butts out on the floor, was barely nineteen.

Josh was alternately hopeful and subdued, talking about his love of mathematics at one moment and then quoting from the Big Book, the collection of inspirational essays and stories about travelling salesmen getting drunk on hooch that is the A.A. bible. When he left Hazelden, he said, he cried because he was afraid. At home, he had dinner with his mother. "It was difficult to see her," he recalled. "She was checking me out, looking at my face, trying to see some change that had happened to me while I was at Hazelden. She wanted to hear that everything is fine, that I've done good, and now we're ready to go and start up our life again. And that isn’t how I feel.  And the more I told her, I could look at her face and see her getting sad and disappointed. But I told her that I had to tell the truth. I'm not better. I'm sitting on the fence. And a little breeze could come along and push me over to the other side."

THERE are few reliable statistics about how effective programs like Hazelden actually are, and the statistics that do exist are not particularly encouraging. In one recently completed, unpublished study, Pat Owen, Hazelden's director of research, was able to reach seventy-one per cent of a representative sample of recent patients, a number just above the acceptable minimum-participant rate. Of that sample, more than half said that they had successfully stayed sober for a year. However, if one estimates that the vast majority of the remaining twenty-nine per cent did not stay sober, the success rate falls to approximately thirty-five per cent. If one then assumes, according to standard protocols, that perhaps one-quarter of the respondents did not tell Hazelden the truth, the success rate declines below one-third.

Nor do A.A. methods work particularly well outside the white, middle-class communities that Hazelden has traditionally served. "I'm not really for something that's going to tell me I'm powerless," says Peter Hayden, the director of Turning Point, a rehabilitation center that serves the African-American community in Minneapolis-St. Paul. "Maybe if you're Ted Turner, then you need to hear that you're powerless. When you've got a history of step and fetch it, then it becomes pretty tough to stay in a program where all you hear is how powerless you are and how you need to submit."

Dumping hundreds of millions of insurance dollars into A.A.-based treatment centers, many of which are far less capable than Hazelden, seems unlikely to put much of a dent in what remains a terrifying and costly disease. Nevertheless, nearly everyone involved in the treatment of drug addiction supports the Wellstone-Ramstad bill. "The greatest cost offset for treatment is crime," says Dr. David Lewis, of the Center for Alcohol and Addiction Studies, at Brown University. The people who could afford the insurance that the bill would provide don’t commit that many violent crimes, and the bill is unlikely to save taxpayers much money. But for Dr. Lewis and others like him the Hazelden campaign is "a chance to move the discussion away from prisons and stereotypes, and to focus on the fact that addiction can be treated just as effectively as heart disease or diabetes." Is that a political strategy? "I call it educational, but it's politics, sure.

The best that can be said for A.A.based treatment methods is that they work for some people some of the time. Yet treating addiction with drugs alone may not be as simple as some neuroscientists believe. The poor, uneducated addicts who cost society the most are also the least likely to take their medication: compliance rates for naltrexone, the anti-addiction drug that is most commonly prescribed today, are as low as fourteen per cent.  Nor are there any guarantees that neuroscience will actually be able to deliver a pill that works.  Dopamine, which was identified as the so-called master molecule of addiction by Dr. Nora Volkow and her colleagues at the Brookhaven National Laboratory last year, is also the master molecule of pleasure. Without it, life would appear in even shades of gray. A drug that blocked dopamine surges, regardless of their cause, would block the naturally occurring highs of sex, or French cooking, or a summer afternoon in the park. What the new research on dopamine indicates, then, is that there will be no single cure for addiction. Unlike Zoloft and Prozac, which work on depression regardless of its cause, a drug that blocks cravings for crack, say, will. not block cravings for other drugs, like alcohol or speed.

What the twelve-step treatment program may finally have in common with the new drugs being developed by N1DA is that neither will be able to deliver a cure. Addiction is a symptom, more urgent and dramatic, perhaps, of the constraints inherent in the human condition. The source of these constraints–our souls, ourselves, the chemistry in our brains–is hard to put a finger on.

THE laboratory run by Dr. Marilyn Carroll at the University of Minnesota is only a few minutes by car from Fellowship Club. Dr. Carroll runs one of the preeminent addiction-behavior research programs in the country. "I personally don’t think the medications are going to work on their own," she says. "The brain has ways of being unbelievably plastic, of getting around whatever roadblocks you try to put up."

The white-walled rooms of Dr. Carroll's basement lab are home, at the moment, to forty-eight rats and thirty-four monkeys, all of whom are addicted to alcohol, heroin, or crack cocaine. The animals are subjects in a variety of tests, some of which involve the promising D-1 antagonist SCH23390, which NIDA hopes will eliminate cravings for crack. Some of the monkeys watch television, to see if the competing stimulus will lower their desire for the drug. "Their favorite is 'The Sound of Music,'" Carroll says, “and they like watching 'Oprah,' too. What they don’t like, for some reason, are the nature shows."

Ten rhesus monkeys, or Macaca mulatta, live in one of the rooms.  They poke their fingers out from between the wire-mesh cage fronts, make faces, and scream. Sticking out of the walls inside their cages are two stubby steel nozzles. The first is for water. The second is connected to a thin wire coil, like the inside of a cigarette lighter. Inside the coil is a rock of crack. In order to smoke the crack, the monkeys must push a lever an ever-increasing number of times, until a green light goes on above the pipe.

A room full of crack-smoking monkeys is very different from a treatment unit at Hazelden. None of the monkeys tell personal stories. None take the Fifth Step, or surrender to the will of a higher power. At a low dose of SCH23390, a rhesus monkey named Lars will press the lever ten out of every ten times the drug is offered. At higher doses, however, his desire for crack radically diminishes: he will press the lever fewer than three times for every ten trials. Lucifer, another monkey, is doing even better: at high doses, his desire for crack declines to zero.

When we come to an eighteen-year-old monkey named Opus, however, Dr. Carroll. rolls her eyes. "Out of twenty monkeys, you might have one or two that are exceptional, that are crazy about drugs," she explains. "We don't really know why." As she speaks, Opus pokes a finger through the wire at her, scratches at the number tattooed on his chest, and picks at the hair between his toes in a way that an addict of any species might find familiar. According to his chart, Opus will press the lever a thousand and twenty-four times for a hit of crack in ten out of every ten trials. Low doses of SCH23390 have no effect on his desire for crack: he still. presses the lever in ten out of every ten trials. On the highest possible dose, the number declines only slightly, to nine times out of ten that the drug is offered.

"He was our first monkey," Dr. Carroll says, looking at Opus and shaking her head like a disappointed but understanding parent. "We didn't know he'd be this way." The monkey looks back at Dr. Carroll, waggles his finger, and utters a guttural noise, whether in protest or to signal some more urgent desire it is impossible to say.  Maybe he is appealing to his higher power. Or perhaps his brain is wired in some unpredictable way. While we are standing there watching him, the monkey's eyes fade and go blank. Then he twists his head around, and his face lights up again as he gazes at the crack pipe inside his cage. *

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