Brill's Content, December
12 Steps Back
"I had hoped my article in New York magazine would energize an old debate in alcoholism treatment. Instead, the head of an important rehab center was unfairly fired." By Maia Szalavitz. Originally posted 12/15/2000; Revised: 6/17/2004.
See also: "The
Harm Reduction vs. Abstinence follies of Summer 2000 -
(or, addiction medicine shoots itself in the foot, again.)"
MID-MAY Ninety percent of American alcoholism treatment programs tell patients that they have a chronic disease and that the abstinence-based, 12-step support program Alcoholics Anonymous is their only hope. Most academic researchers, however, disagree. They have long argued that a strategy that offers options, including moderate drinking and a variety of abstinence-based therapies, combats a wider variety of alcohol problems and therefore benefits a larger segment of the population.
This decades-old battle between clinicians and researchers took a critical turn recently when the Smithers Addiction Treatment and Research Center, on Manhattan's Upper West Side, expanded its program to include a self-help group, Moderation Management, or MM, in addition to its support of AA. One of the country's most respected rehabs -- along with the Betty Ford Center, in Rancho Mirage, California, and the Hazelden Foundation, in Center City, Minnesota -- Smithers has treated such celebrities as Darryl Strawberry, Truman Capote, Joan Kennedy, and Dwight Gooden. A former cocaine and heroin user myself, I had chaired a 12-step meeting in Smithers's detoxification program from 1992 to 1998. I knew the innovations at Smithers would make for an explosive story, and an editor at New York agreed. Having been assigned a short article, I secured an interview with Dr. Alex DeLuca, the chief since 1991 of Substance Abuse Services at St. Luke's-Roosevelt Hospital Center, which runs Smithers. I also spoke about the changes at Smithers with several counselors, the previous director, and two patients.
Quitting drinking entirely, though a surefire solution, doesn't take into account alcohol's integral role in our culture and often isn't acceptable to people whose alcohol "problem" may be as simple as being young and irresponsible. Even AA suggests attempting controlled drinking if you question whether you're an alcoholic. Smithers, under DeLuca's direction, had begun to change its program in the early nineties, adding therapies that did not demand complete abstinence. The focus of Smithers's program widened to enable patients to decide for themselves what their goal should be and how best to achieve it. Moderate-drinking treatments, however, are heretical to many AA members who work in the field of alcoholism treatment. They believe that if you can't control drinking on your own, you must quit. And although controlled-drinking therapy is widely available in European and Canadian clinics, few in the United States offer it. Consequently, addiction care in which patients, not physicians, control the course of treatment is unique in American medicine. A 12-step program that relegates control of one's behavior to a "Higher Power" and instructs the patient to "pray" for recovery would be considered alternative medicine, to say the least, in the face of any other disease.
JUNE 7 It seemed that interest in controlled drinking was growing and that my piece for New York could not have been better timed. As I was reporting the story about Smithers -- I had interviewed DeLuca a week or so before -- a segment of the ABC newsmagazine 20/20, hosted by Dr. Nancy Snyderman, explored the subject. The program featured several former heavy drinkers who now drink socially. Illustrating how controversial the issue has become, a guest on the show who worked as an alcoholism counselor predicted that his acknowledgment on the air that he supported controlled-drinking therapy and that he drank socially would cost him his job. Another guest on the show was Dr. Alan Marlatt, a well-respected psychology professor from the University of Washington who studies alcoholism and relapse prevention. Ten years earlier, Marlatt had been one of the authors of a study, "Broadening the Base of Treatment for Alcohol Problems," conducted by the Institute of Medicine, part of the National Academy of Sciences. The study concluded that complete abstinence was too narrow a goal for the treatment of alcohol problems. "Rather than me try to shove abstinence goals into everybody who comes in for help with a drinking problem," Marlatt said on the show, "what can we still do to begin to make progress and get the person on board?" Smithers, then, was doing what the National Academy of Sciences had recommended ten years ago.
JUNE 9 TV Guide reported that former first lady Betty Ford and John Schwarzlose, president of the Betty Ford Center, sent letters to The Walt Disney Company's chairman and CEO, Michael Eisner, and ABC News president David Westin to express their displeasure with the 20/20 program. Ford called the program "unbalanced" and said that alcoholics would die as a result. Snyderman, who had anchored the report, said, "We did a very balanced piece, and I stand by it." A 1996 study sponsored by the National Institute on Alcohol Abuse and Alcoholism supports her decision to discuss both approaches seriously. Surveying more than 4,500 people, the study found that up to 20 years after exhibiting symptoms of alcoholism (technically called alcohol dependence), 27.8 percent of the subjects were still drinking excessively, 22.3 percent were abstinent, and as many as 49.9 percent were drinking moderately. Of the last group, not one person met the diagnostic criteria for alcohol abuse or dependence. Other studies have found that those who make moderation a goal fare no worse than those who choose abstinence. I hoped to make clear in my article that the research strongly supported Smithers's new methods.
JUNE 17 The Seattle Times reported that Audrey Kishline -- the author of Moderate Drinking: The Moderation Management Guide for People Who Want to Reduce Their Drinking, the best-known book on the subject, and the founder of Moderation Management -- had crashed her car in March, killing a man and his 12-year-old daughter. The 43-year-old Kishline's blood alcohol level was three times the legal limit, and she was charged with two counts of vehicular homicide. When news of the accident broke, the National Council on Alcoholism and Drug Dependence jumped on the issue. The de facto voice of Alcoholics Anonymous (which does not make policy pronouncements), NCADD released a statement on June 20 that quoted Kishline's attorney. "Moderation Management is nothing but alcoholics covering up their problem," he said, claiming that this was his client's position. The NCADD release concluded, "This dreadful tragedy might have been avoided if Ms. Kishline had come to this realization earlier."
The press release, however, neglected a crucial fact: Two months before the accident, Kishline had decided that she couldn't safely moderate her own drinking and, following the guidelines written into her program for such circumstances, joined AA. Kishline had announced this in late January on an Internet listserv for members of MM, which The Seattle Times reported in a later story. The president of the NCADD, Stacia Murphy, acknowledges that she knew Kishline had joined Alcoholics Anonymous and that she omitted that detail from her statement. "It wasn't relevant," Murphy says. But of course it was relevant. If people knew that Kishline had at-tended AA after deciding she could not drink moderately, they might think AA, not MM, was the program that failed her. While writing, I called my editor at New York to ask about including Kishline in my piece, but because of the incident's complexity and space considerations, we did not include anything about her accident in the story.
JUNE 29 Kishline pleaded guilty to vehicular homicide, and ABC's World News Tonight asked Dr. Marlatt, the alcoholism expert who had appeared on 20/20, to discuss the efficacy of controlled drinking. Clips from those interviews were used early the next morning on ABC's World News Now and on ABC's Good Morning America. In neither story was Kishline's decision to join Alcoholics Anonymous mentioned -- nor was the fact that Moderation Management recommends AA to members who find that they can't control their drinking. No medical or psychological research was cited in either report. The implication was that moderation does not work and abstinence does.
The editor at New York and I finished the work on my article that evening. I hoped the 800-word piece was balanced and gave enough history that a reader unfamiliar with the debate surrounding alcoholism treatment would find it clear. I quoted Dr. DeLuca, who had said of the changes at Smithers, "It is radical for addiction treatment, but it's really a return to traditional medicine. In medicine, if treatment doesn't work, you change it." I couldn't know then that the media's handling of the Kishline story would affect how my own piece about Smithers would be received, but I signed off, and it went to press.
JULY 3 My article hit the stands in the morning, which I spent at Smithers doing additional research for another story I planned to write about the clinic. My New York article, I had hoped, would highlight the fact that patients at Smithers now had choices and that treatment was finally becoming both more empirically based and user-friendly. I had intended the article to point out that since the 1950s, when Alcoholics Anonymous was adopted wholeheartedly by American hospitals, advances in treatment of alcohol problems had essentially been stalled. In the piece, DeLuca's predecessor at Smithers, Dr. Anne Geller, asked, "Would you want surgery done now the way it was done in the fifties?"
But later that day, when I saw the magazine, the article seemed different to me from the version I had approved with my editor. It was headlined "Drink Your Medicine" and was accompanied by an illustration of a man guzzling booze in bed while a busty, whistling nurse looked the other way. Before I signed off, I had not thought to ask to see the headline or the illustration, both of which I felt were misleading. Stunned, I read and reread the story. One sentence stuck in my head: "But now, in a move tantamount to the Catholic Church's reversing its position on abortion, the legendarily hard-line Smithers...has decided to...abandon the lifetime-abstinence approach." In the draft I had handed in, I had written that Smithers "has abandoned the abstinence-only approach." At some point during the editing process the wording got changed, which might not at first seem that significant -- in fact, even I failed to notice it when I read the piece before publication -- but it misled many readers. Also, the subtle shift between "abstinence-only" and "lifetime-abstinence" made it easy for 12-step advocates to attack Smithers.
The botched sentence provoked a widespread misconception that Smithers had rejected abstinence entirely. New York had posted my article on the Web three days earlier, on Friday, June 30. The story was picked up by the New York Post, where it was featured on the morning of July 3 with a headline even more lurid than my original article's: "Booze goes on menu at famed celeb rehab clinic." Because the Post's piece was written over the July Fourth weekend, one of the two reporters told me, she couldn't reach any academic researchers. Instead, the reporters interviewed several AA members -- one of whom said, "I've tried moderation, and I ended up back in rehab" -- and a former NCADD president who called MM "a deadly piece of advice." No one from Smithers was quoted about the changes in the clinic, although the reporter said she had tried to contact officials there. The Post was the first, but certainly not the last, newspaper to report that Smithers had supplanted Alcoholics Anonymous with Moderation Management. Given the media attention and controversy about Audrey Kishline, the New York piece was vulnerable to misinterpretation. The dramatic headline, titillating illustration, and table-of-contents rubric -- "Giving up on abstinence" -- only made matters worse. Asked about this later, New York magazine senior editor Jessica Lustig says she wouldn't change a thing about the magazine's handling of the story: "We thought the headline and illustration were perfectly suited to the story. They were really carefully chosen. Any story can get distorted in the tabloids, and we have no way of controlling that." Lustig refused to comment further.
Almost immediately, abstinence-only advocates mobilized. Still upset by the 20/20 program, newly energized by the Kishline tragedy, and enraged by the notion that Smithers had abandoned abstinence, they flooded the center with e-mail messages and telephone calls to denounce Moderation Management as a sham. From this point on, the press conflated the two stories, implying that Smithers embraces a pro-drinking program started and now renounced by a drunken killer.
The press office at St. Luke's-Roosevelt, which oversees Smithers, refused to comment while it assessed the situation. DeLuca and other employees say they were not allowed to talk to the press. No one could correct the false impression, given by my piece and others, that abstinence was no longer practiced at Smithers -- and no one was able to tout the government grants that Smithers had received to study alternatives to strict abstinence. The reporting that followed became preposterously distorted -- to the point that a correspondent for The Times of London suggested that rising vodka sales in New York City were due to Smithers's new policy and the HBO program Sex and the City. According to the writer, Smithers had "discreetly loosened its rules to allow patients the odd slurp of what they fancied."
JULY 9 The news that Smithers had embraced a new philosophy gave a fresh line of attack to Adele Smithers-Fornaci, the founder's widow. The center was founded in 1971 with a $10 million gift by R. Brinkley Smithers. He died in 1994, and his widow has had a contentious relationship with St. Luke's-Roosevelt ever since. Just weeks after her husband's death and months before a benefit she had hoped would raise money for a redesign of the center, the hospital insulted her by announcing the sale of the mansion in which Smithers was housed. She hasn't been associated formally with the center for more than five years, and she is also in protracted litigation with the hospital over alleged mismanagement of the endowment. Smithers-Fornaci purchased full-page advertisements in the Sunday New York Times and New York Post calling Moderation Management "an abomination." The advertisements said that Smithers has "not learned [its] ABCs: A=Alcoholism is a disease, B=Booze has no place in its treatment, C=Controlled drinking does not work."
JULY 10 A St. Luke's-Roosevelt statement said that Smithers "has a long and proud tradition of treating alcoholism by advocating total abstinence. While we recognize there may be other legitimate alternatives in the treatment of this difficult disease, no change in our own program policy was ever approved. Since Dr. Alex DeLuca does not support the program philosophy, we have accepted his resignation as Director of Smithers." DeLuca claims that he never offered to resign and that he was told by his superiors that he had to do so or he would be fired. "They didn't even give me a chance to do damage control," DeLuca says. "We could have turned this into a real opportunity to promote what we were doing. If it wasn't so sad, it would be funny. I met with my supervisors every week for two years. To say that they didn't know what I was doing is absurd."
When I first interviewed DeLuca for New York in May, he had been happy to discuss his accomplishments at Smithers. He worked with colleagues on three different million-dollar federal grants to study newer options for substance-abuse treatment, and he'd published results in the Journal of Substance Abuse Treatment. In addition, DeLuca had painstakingly taught the counselors at Smithers that what they'd learned in their own abstinence-based recovery might not always hold true for their clients. "The changes I made were structural and in the hearts and minds of the counselors. It took me ten years," he says. "The center doesn't have a treatment philosophy other than what I've written, and I have never rejected abstinence. I still think it's the safest way for people to recover, but I'm not going to turn them away if they are not yet ready. I can't work that way." Carol Bohdan, a spokesperson at St. Luke's-Roosevelt, refused to comment for this piece.
On the evening of July 10, CNN's Larry King Live devoted an hour to what had by then been transformed into the Kishline-Smithers story. The show began with emotional testimony from family members of those killed in the Kishline crash. Margaret Penny Sowards, the prosecutor in the case, was interviewed next. She said that she wished she could recommend a stiffer sentence than the four and a half years that legal guidelines allow. King asked, "You'd like to -- you could ask for more, couldn't you?" Sowards said, "I'm constrained by the law in terms of what we would get. We have to have aggravating circumstances to justify it, [and] there just aren't any of those present in this case unfortunately."
Then King moderated a roundtable that included an AA member, actress Mariette Hartley (best known as Dr. Claire Morton from Peyton Place); the president of the Betty Ford Center, John Schwarzlose; former senator Bob Packwood, who recovered from an alcohol problem without AA but supports the organization; and, to balance the discussion, a Moderation Management board member. The conversation focused on personal stories. No attempt to discuss scientific data was made; no alcoholism researchers were booked. "The goal of that show was to put together a panel with a variety of personal experiences and viewpoints to discuss the issue of alcoholism," a spokeswoman for CNN said. DeLuca says, "Anecdotes are sexier than science. It's fine to have people share their experience, but medicine is not anecdote -- or shouldn't be."
As the show aired, reporters were calling me to track DeLuca down. While on the phone, I tried to explain the distortions that had evolved from my story. I then left a message for DeLuca suggesting that he return the calls if he wanted to. I spoke to Jennifer Steinhauer of The New York Times, who was covering DeLuca's firing, and told her that Smithers had not cut abstinence from its program. Although an article by Sam Howe Verhovek in the previous day's Times had correctly stated that Smithers had "decided to adopt Ms. Kishline's [moderation] program as one approach," and DeLuca agreed to call Steinhauer to clarify what he had done with the program, Steinhauer's story, which appeared the next day, implied that controlled drinking was far more important than it was. "Dr. Alex DeLuca," she wrote, "recently decided to steer the clinic...toward an approach that advocates controlled drinking." Steinhauer's piece missed the distinction between advocating Moderation Management and offering it as a treatment option; she refused to comment further for this article.
The next day, a group run by a former publications editor for the NCADD, which had organized the initial anti-DeLuca onslaught, released a statement titled "Victory for Abstinence-Based Treatment." "Thanks to an incredible outpouring of concern, support and action," it read, "the director at the Smithers treatment program quit and the hospital has agreed to abandon the moderation-management model."
EPILOGUE On August 11, Audrey Kishline was sentenced to four and a half years in prison. "It's hard for me to say this," Kishline's sister, a recovering alcoholic, told The Seattle Times, "but I don't think [Kishline's sentence is] stiff enough." The Seattle Post-Intelligencer indicated a week later that the family of the father and daughter killed in the crash would sue Kishline in civil court. Two sources close to Kishline say she had never renounced Moderation Management and that she still believes it can help some people -- a fact that had been lost weeks before. Dr. Alex DeLuca is considering suing St. Luke's-Roosevelt for defamation and wrongful dismissal. Adele Smithers-Fornaci has added to her ongoing litigation against St. Luke's-Roosevelt: She wants $60 million and her late husband's name removed from that of the treatment center. And the final irony: In an attempt to persuade those who might now consider controlled drinking a viable therapy for alcohol problems, the Smithers Foundation has announced plans to reprint a pamphlet, "Experimentation: The Fallacy of Controlled Drinking Where Alcoholism Exists." It was published in 1963.