Addiction has been a part of the human condition since time immemorial. Ever since the earliest farmers noticed that fermentation in fruit provided unexpectedly pleasant results, the joy of imbibing in alcoholic beverages has always been tempered with the consequences of overdoing it. Various forms of treatment have been tried over the years, some more successful than others.
The history of rehab facilities is a story of how human beings have attempted to understand the tough parts of our nature, and in doing so, how they have shed more light on the human condition.
The Roots of Rehabilitation
Indigenous Americans were familiar with alcohol, of course, but only for ceremonial purposes; the idea of drinking recreationally – and drinking with abandon – was an introduction made by European colonists. Native tribes had no structures in place to control drinking, or its effects, and colonists happily traded distilled spirits and wine to the natives for land and other vital resources.
This was around the year 1750, and it marked the first form of organized rehabilitation in America.
Eventually, senior tribesmen came to understand the nature of the alcoholism that was plaguing their people – primarily because, as leaders, they were heavily subjected to colonists plying them with alcohol to make them more susceptible to offering concessions. To stem the problem, tribal leaders would encourage younger members of the tribe who had become addicted to alcohol to use their ancestral heritage and beliefs to guide them back to sobriety. In these “sobriety circles” (so named because the shape of the circle was believed to ward off the spirits of evil), elders used the idea of something larger than the self as a way to provide some focus on how to overcome the temptation to drink – remarkably similar to how modern Alcoholics Anonymous and other 12-Step groups espouse the concept of a “higher power” from which addicts can draw the strength it requires to abstain. Alcoholics Anonymous even incorporated the idea of a “sobriety circle” into its Circle and Triangle logo.
Traditionally, addiction was considered to be a moral failing and a question of choice on the part of the drinker, and treatment was in line with that school of thought and included:
- Sentencing to a mental asylum
- Religious-based interventions involving prayer
Benjamin Rush, however, believed that alcoholism was an issue of the drinker losing control over himself, and identified that it was the properties of alcohol – and not the choice and morality of the alcoholic – that were the roots of the problem. His seminal work on the topic, An Inquiry into the Effects of Ardent Spirits Upon the Human Body and Mind (1785), was the first notable challenge to the widely accepted belief that alcohol itself posed no risk to people (and that the only people who would get drunk were of dubious moral character). Rush advanced the concept of alcoholism as a medical condition – a chronic disease – and further advocated that successful treatment of alcoholism would require drinkers to be weaned off their substances of consumption, as opposed to methods that we now would understand to be harmful.
Rush’s contributions to psychiatry are so renowned, his face is on the logo of the American Psychiatric Association.
Benjamin Rush’s Inquiry was the catalyst for two significant shifts in the scope of the American perception towards drinking: the burgeoning temperance movement latched on to Rush’s calls for government limitations on drinking, and the creation of “sober houses,” specialized hospitals for the exclusive purpose of treating alcoholics, an idea put forward by Rush himself. He posited that alcoholics could be sequestered in these sober houses until they could safely reenter society.
With concern over the effects of alcohol gaining steam, various organizations were formed to either champion the virtues of abstinence, or offer support and assistance to people who had fallen foul of alcohol’s addictive effects. Small community groups had been in operation since 1840, but the opening of the New York State Inebriate Asylum showed how seriously the problem of alcoholism and addiction was being taken. Founded in 1864, it was the first single-purpose hospital in the United States specifically designed and built for the treatment of alcoholism as a mental condition. Three years later, the Martha Washington Home in Chicago became the first dedicated rehabilitation center for alcoholic women in America.
The Keeley Cure
While these institutes were obviously a seismic step forward in the understanding of alcoholism as a medical issue, ideas of actual rehabilitation still had a long way to go. Coinciding with the formation of temperance organizations and societies, the mission of treating and curing addiction became something of a cause célèbre in the mid-19th century. It drew all manner of well-meaning and well-educated people who all had different – and somewhat unorthodox – ideas for treating alcoholism.
One such example is that of Dr. Leslie Keeley, an Irish-born surgeon who, in 1879, promised he could cure alcoholism and other addictions with a secret, specific formula. All he would publicly say about the formula was that it had to be injected four times a day, and that it contained gold.
Dr. Keeley’s approach has gone the way of blood-letting and lobotomies, but one of his ideas – a 31-day stay in a treatment center that offered healthy food, exercise, and fresh air – would prove very influential in fashioning the approaches of modern-day rehabilitation facilities: providing a secure, comfortable, and healthy place for recovering addicts to learn how to live without their chemical crutches.
The Keeley Institutes, as they were so called, became so popular that from 1879 to 1965, there were more than 200 facilities across the United States and Europe.
The work done by Benjamin Rush and Leslie Keeley, as well as hundreds of other physicians and scientists in America, reflected the growing discontent with the presence and influence of alcohol in society. The temperance movement saw its biggest victory in 1920 with the passing of the 18th Amendment to the U.S. Constitution, which made the production, sale, and public consumption of alcohol illegal. Ostensibly to “reduce crime and corruption, solve social problems […] and improve health and hygiene in America,” Prohibition proved instead to be a colossal failure.
The architects of Prohibition failed to consider just how much ordinary Americans loved their alcohol. Citizens resorted to brewing their own alcohol, using cheap grains and their bathtubs to distill dangerously impure liquor, which was responsible for hundreds of deaths and thousands of cases of blindness and paralysis. Organized crime syndicates enticed – and enforced – the continued production and sale of alcohol in underground bars known as speakeasies. Sometimes this was done with impunity, as the booming black market for alcohol meant that police officers, judges, and lawmakers could be bought off. It’s no coincidence Prohibition was in effect for the entire decade known as the “Roaring Twenties.”
Thirteen years after Prohibition was ratified, the 21st Amendment to the Constitution decriminalized the production and sale of alcohol in the public sphere, upon which the federal government imposed regulations to wrest control away from organized crime mobs and open up a lucrative stream of revenue in the process.
Bill W. and AA
AA has spawned similar support groups for a number of other addictions, such as Narcotics Anonymous, Gamblers Anonymous, and Overeaters Anonymous, to just name a few.
For addicts who are uncomfortable with the idea of investing their recovery in the “higher power” of the original AA vision, there are secular and agnostic groups that will provide patients with a more relatable rehabilitative experience.
Marty Mann and the National Committee for Education on Alcoholism
An early member of Alcoholics Anonymous was a woman named Marty Mann. Her experiences with achieving sobriety due to AA (she was one of the first women to complete the 12-Step program) inspired her to combat the still-existing stigma that alcoholism was a moral failing and not a medical condition.
To that effect, she helped launch the National Committee for Education on Alcoholism, which advocated what were, at the time, radical notions about alcoholism and alcoholics:
- Alcoholism was a disease.
- Alcoholics were, therefore, sick people.
- Alcoholics could be cured.
- Alcoholics deserved to be cured.
- Alcoholism was (at the time) the fourth most widespread health problem in America, and deserved public action.
The committee further called for hospitals to admit alcoholics, and for the establishment of alcoholism centers and “rest centers,” for long-term care. Today, the committee exists as the National Council on Alcoholism and Drug Dependence, which continues the work of “fighting the stigma of alcoholism and other drug addictions.” They have since found that alcoholism cannot be cured but can be effectively managed.
Progress and the Price It Paid
Mann’s efforts to have alcoholism recognized as a medical problem gained traction. In 1951, the U.S. Food and Drug Administration approved prescription of the Disulfiram for the treatment of alcohol dependence, but as an example of the still-experimental nature of treating alcoholism as a health concern, Disulfiram dosages were often dangerously high, occasionally causing fatal reactions. In 1956, the American Medical Association declared alcoholism to be an illness, and called on hospitals to admit alcoholic patients with the same priority and care as patients with other conditions. And it was not until the 1960s that the National Institute of Mental Health established the National Center for Prevention and Control of Alcoholism.
Unfortunately, not all advances were so beneficial. The United States Narcotics Farm in Lexington, Kentucky was founded to treat incarcerated drug addicts who “voluntarily” offered themselves for treatment, using experimental methods to treat addictions and rehabilitate patients. While some aspects of treatment were legitimately conducted in the interests of the patients (such as using methadone to treat heroin addicts, which continues to be a primary option for such cases), the Central Intelligence Agency used the opportunity to carry out experiments of their own. Patients were given LSD in an attempt to see if the substance would act as a mind control agent or a truth serum.
In 1975, the facility was converted into the Federal Medical Center, as the government decentralized substance abuse rehabilitation and turned the work over to individual states.
Drug rehabilitation has come a long way, and there are still calls for it to progress beyond the treatment models that are commonly employed today. Progress in psychology has shed light on human patterns of thought and behavior, and the resultant psychotherapy has become an integral element of any substance abuse treatment program. Further research in pharmacology has opened new options for treating withdrawal symptoms and gradually weaning addicts off their cravings, preparing them for the mental and societal rehabilitation offered by therapy and aftercare programs, like Alcoholics Anonymous and respective 12-Step groups.
The idea of using pharmacology and psychotherapy as part of the same treatment spectrum has its roots in what is known as the Minnesota model of treatment. Developed in the 1950s, the Minnesota model combines the best practices surrounding the various aspects of rehabilitation (mental, emotional, and social), in order to provide as holistic and all-encompassing a treatment paradigm as possible. By the 1980s, it was the “linchpin” of almost every program that sought to treat alcoholics and drug-addicted patients.
However, as influential as the Minnesota model is, it has come under its own criticism for being developed without scientific basis, suggesting that as progressive and comprehensive as the currently accepted standards of substance abuse rehabilitation are, the future of drug and alcoholism treatment is still being written.
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David W. Newton is a board certified pharmacist and also has been a board member for boards of examiners for the National Association of Boards of Pharmacy since 1983. His areas of expertise are primarily pharmaceuticals as well as cannabinoids. You can read an article about his expertise in CBD on the National Library of Medicine.
Reviewed by: Kim Chin and Marian Newton