My dad’s company had season tickets to the White Sox. On muggy Midwest summer days we’d go as a family—always sitting in the same seats, 25 rows above first base.
I told this to a counselor I’ll call Bill, when he asked me to remember a childhood memory. It was part of the confrontational circle, a form of group therapy with a self-explanatory name. A half-dozen other clinicians looked on as Bill laid into me. “I bet you don’t go to those games with your family anymore, do you?” Bill asked in a way that felt more like telling. I shook my head no.
It was the summer of 2012, and the beginning of my third round of treatment for an opioid addiction I’d been trying to kick since I was 17. Now, I was 22 and out of excuses for where all my money went. I’d confessed to my mom that the pills I’d been using had escalated to heroin. At the behest of a counselor, I checked in to a residential program, the kind of rehab you probably recognize from television, the kind reserved for serious cases.
This confrontational circle felt more like gaslighting than therapy. Bill’s voice filled with anger when he called me selfish, a liar, a junkie: all the words I called myself. I tried to tell the therapists that my whole body hurt and that I didn’t think my addiction was a “spiritual malady,” like they’d suggested. Bill kept at me. He poked fun at my withdrawal symptoms. He insisted I was arrogant and intellectualizing; I needed to feel the gravity of my situation. Toward the end of the session, I looked up at the other therapists. Their eyes were aimed at the floor.
My stint in rehab occurred at one of the oldest and most reputable treatment institutions in America. Yet the various components of the program were designed to embarrass me—a brutal technique that has little scientific evidence to suggest that it works. In the Handbook of Alcoholism Treatment Approaches, William Miller, a clinical psychologist, ranks the confrontational approach I endured as 45th out of 48 treatments in terms of effectiveness. Hallucinating on psychedelics ranks 32nd. Educational lectures, which we did for an hour or two each day, rank last.
In the US, the treatment community mythologizes “addicts” and “alcoholics”—terms that I’ve stopped using—as developmentally arrested juveniles, and most programs are based on these assumptions. We’re thought of as whiny ingrates who stop maturing the day we start using. Ever since my demeaning stint in rehab, I’ve been trying to reckon with the sorry state of addiction treatment in the United States. That’s what led me to become a journalist who covers drugs and addiction: I wanted to understand why some mental health disorders are treated with medication and effective therapy, while addiction remains stuck in the murky world of folk wisdom. I wanted to understand why so many of my friends were dying.
Little did I know, as I embarked on my search to untangle the field’s failures, that a group of researchers were attempting to reinvent rehab, using technology I’d never heard of. ‘mHeath,’ short for mobile health, is a new kind of treatment delivered by smart phone, not dissimilar from the deluge of programs you’ll find in the app store. But unlike mobile meditation apps or therapy-by-skype, these treatment apps are designed by clinical researchers and offer programs to curb addiction that are based on scientific evidence.
I wanted to understand why so many of my friends were dying.
Most importantly, these apps buck one of the oldest stereotypes of treatment—that unmooring a person from their life is the only way to curb addiction. Granted, apps alone aren’t a panacea that alone can reform the rehab industry. But by building flexible programs that fit the nuances of their clients’ lives, this mini-movement of doctors, researchers, and developers is attempting to give addiction treatment a modern makeover—a welcome smoke signal in the midst of a massive crisis.
For the most part, addiction treatment has skirted evidence-based medicine, flourishing outside the mainstream. Since the gospel of Alcoholics Anonymous spread in the early 1940s, the abstinence-based group has held an outsized influence on rehab. AA teaches that addiction is created by the loathsome qualities of one’s character. People who are fearful, selfish, and willful turn to alcohol (and drugs); rid them of their deplorable personality and their dependence will follow. The result is what we have today, a mostly unregulated for-profit industry that continues to preach abstinence and character building as the answer to addiction.
That’s especially true when it comes to opioid addiction. A 2015 study found that patients who received only counseling were twice as likely to die from a fatal overdose than their counterparts who received medications for opioid use, like buprenorphine and methadone. But fewer than half of the 12,000 licensed addiction treatment facilities in the US offer medication for treating opioid addiction. The reason for this goes back to the folk wisdom of mainstream substance abuse treatment: To treat addiction, one’s body must be chemical free. At the facility I went to in Minnesota, for example, even the coffee was only half-caffeinated.
As it stands, standard rehab boasts only moderate success. On average, about 40 to 60 percent of people who receive treatment will slide back into addiction, according to the National Institute on Drug Abuse. That’s just the rate for patients who’ve been through quality programs, staffed by professionals with advanced clinical degrees. The relapse rate for fly-by-night or more old school operations is likely much higher. (They didn’t participate in the drug abuse institute’s study.) Still, as the overdose crisis takes more and more lives, politicians like Chris Christie and Bernie Sanders have made anodyne calls for more rehab “beds,” to serve the roughly 20 million people who meet criteria for a substance use disorder.
Here’s where apps come in. They are made by clinical researchers, who, with the help of developers and designers, deliver a program to your smartphone. But unlike most in-patient facilities, these app-administered treatments are beginning to operate with oversight. In September 2017, Pear Therapeutics’s app called reSET became the first of its kind to be approved by the Food and Drug Administration, a process that ensures that the treatment has been through rigorous testing and proven effective. The conditions are so dire, and the demand is so great, that the FDA recently expedited the approval process for Pear’s new app for opioids, called reSET-O.
Of course, some cases require more support than others. By the time I was 17, my life was a series of six-hour cycles: Get high, be sick, repeat. At a time when I was supposed to be seeking out new experiences, my world was confined to my opium bunker of an apartment. I had few friends and lots of dealers, many of whom barely spoke English: Our common language was the metric system. Back then, had apps been around, I probably wasn’t the ideal candidate.
But as several national surveys suggest, severe cases like mine are the exception, a stereotype reinforced by the harrowing tales of addiction memoirs. In real life, addiction is as varied as the people who experience it, and the majority of people recover from their addiction without formal treatment. Surveys show that many drug users manage to maintain a semblance of normalcy: They go to school, hold down jobs, and stay in reasonably healthy relationships. Yet in the one-size-fits-all world of rehab, people who display any sign of problematic using are convinced to fly to expensive centers in Southern California or Florida to get the wakeup call they need.
The premise of mobile treatment apps is that there’s nothing magical about treating addiction. There’s no moment when the clouds part and a spiritual awakening takes hold. Curbing addiction is much like stopping a bad habit or shifting any deeply ingrained behavior; like smoking or nail-biting, it takes time, support, and constant effort to change. You’re on your phone all day, the apps suggest, why not curb a harmful behavior, without missing work for three months? They allow for time and room for the messy process of addiction to slowly untangle: You don’t need to wait until the problem gets worse, they suggest, you can get help now.
Search addiction treatment in Apple’s app store and you’ll get some 10,000 results. Right now, only a few apps offer evidenced-based treatment, but that number is about to balloon. President Trump’s Opioid Commission emphasized the need to use telemedicine and technology—like mobile health apps—to reach rural communities affected by overdoses. For less severe cases of addiction, like people who are still able to hold down a job, apps like Annum and Ria Health involve zero in-person interaction and are designed to help reduce heavy drinking patterns. Other apps fit into the space after rehab: Outfits like WeConnect and Sober Grid operate like social networks for people to stay connected post-treatment, while Triggr Health uses machine learning to predict when a patient is headed for a relapse.
Even though many of these programs are digitizing common rehab practices, they present their methods with a modern spin. For instance, rather than using loaded phrases, like “clean,” to describe abstaining from drugs, Triggr Health uses a more medically accurate (and less morally loaded) word: “remission.” Rather than proselytizing abstinence as the only route to recovery, many of these apps use phrases like “wellness” and “quality of life” to describe the users’ ultimate goal.
And, unlike the majority of residential centers, including the one I went to, none of these apps shies away from medication. In fact, for some apps like Annum and BioCorRx (which launched a beta version in September 2017), medication is central to their treatment approach. On top of a digital regimen, an app like Annum connects the user with a psychiatrist board certified in addictions who can remotely prescribe craving-reducing drugs that will be delivered by mail.
In places like Florida and California, the residential treatment industry has been dubbed the Wild West of health care. This lack of regulation has traditionally been a boon for hucksters looking to convert their beachside homes into “treatment centers.” But these lax standards have also left an opening. “We looked at the entirety of the landscape and saw a lack of clinical evidence across the board,” says Corey McCann, CEO of Pear Therapeutics. “That’s a gross failing of the field; patients deserve better.”
Because apps are pre-programmed, they provide some protection against rogue counselors, like Bill, who might offer a vastly different experience than has been written into a treatment plan. And within these programs, the apps are designed to leave room for users to set their own goals—vastly different from my tour in rehab, where I was punished for not adopting the pre-packaged abstinence-or-nothing approach.
Cassandra McIntosh, a psychologist specializing in counseling, believes that this all-or-nothing abstinence methodology leads to worse outcomes. Unlearning compulsive, near-automatic behaviors, will inevitably involve numerous attempts, but if you drink or use in a rehab, even a single time, you’re liable to get kicked out. “When you send heroin addicts to rehab, they’re at risk of overdosing,” she says. The reason: After weeks of abstinence, our tolerance to opioids diminishes, creating an astronomically high risk of overdosing in cases of relapse.
Medications like buprenorphine and methadone cut that risk by half or more. McIntosh helped design an online platform for WorkIt, one of the first companies to provide Web and app-based treatments. From the company’s home base in Ann Arbor, Michigan, WorkIt offers remote access to apps, including online text and video chats with coaches and counselors for $75 a week. WorkIt also has a brick-and-mortar clinic for medication consults and recovery support group meetings. (A more minimal program, priced at $25 a week, involves access to an online addiction program and a weekly check-in with a coach.)
WorkIts’ offerings feel a little like a class: You write in a “craving log,” and do exercises under categories like “Body” and “Mind.” One WorkIt user, Lindsey, who struggled with opioids, tells me she found the prompts easy to follow; they were often as simple as: Did you give yourself 15 minutes today to walk and clear your head? But the exercises are based on Cognitive Behavioral Therapy and Motivational Interviewing, two techniques that research suggests work better than the 12-step approach I was taught. (WorkIt’s treatment for alcohol did have an abstinence-based bent to it, one user tells me.)
Not everyone is gung-ho on treatment apps. Therapists and psychiatrists fear that insurance companies will find the low cost of apps enticing, leaving patients who require other kinds of treatment without appropriate options. (A low-end stint in rehab can run $14,000 a month; compare that to $300 for a monthly app subscription.) Some, like my own therapist, argue that the intimate client-therapist relationship can’t be replicated on a screen. And in-person treatment leaves less room for evasion. You’re forced to show up as you are, in whatever state of mind. (This may be true, though a 2014 meta-analysis found that “internet-delivered cognitive behavior therapy” was as efficacious as face-to-face therapy sessions.) Though most apps take steps to keep data secure, many still fear putting their intimate medical information online.
Yet the most powerful effect of a more informal approach to rehab might be de-stigmatizing addiction treatment. Brandon Bergman, associate director of Harvard Medical School’s Recovery Research Institute, told me that clinically vetted apps might appeal to users who are already comfortable using technology. According to Bergman’s research, 11 percent of the 22.4 million US adults who have resolved their substance use problem used “recovery-related online technology,” like Facebook groups, subreddits, or a phone app that wakes you up with a motivational slogan. Treatment that resembles these more informal options provides a gateway to other kinds of assistance.
“As long as treatment is seen as this big ordeal, you’ll have a swath of people who don’t want any help,” Bergman says. But if it’s on your smartphone? “You’ll have way more people engaging with recovery processes,” he says. Aside from being rigorously tested by some of the field’s leading psychiatrists, treatment apps may ultimately make it easier for people to get over that first hurdle: finding help.
Ultimately, my recovery happened in spite of my residential stint. With my parents’ financial support, I found a therapist and a psychiatrist who could help me manage my depression and guide me to a fulfilling career. I made friends who convinced me I wasn’t damaged goods and who taught me what self-compassion looks like. Many of these friends are people I found online—I’m delighted to be part of a tight-knit addiction bubble on Twitter. Of course, online forums are not treatment, but being online and connecting with readers gives me the kind of solidarity and community that I thought only AA meetings could provide.
And, on paper at least, I sound like a success story. After rehab, I finished college and then a master’s in journalism. Now I write (precariously) for a living. But if we’re going by the molecules in my bloodstream—THC and ethyl glucuronide, probably from an edible or a gin and tonic trying to finish this story—then I’ve failed the abstinence that defines traditional recovery.
On paper at least, I sound like a success story
I went to rehab when I was 22. Now I’m 28, and I look back on my treatment experience with bewilderment. I’ve known more than a dozen people—friends from high school and treatment, some sources—who’ve died from drug overdoses. They were all “treated,” went abstinent, and eventually died from an overdose. Conventional thinking would conclude that they failed their treatment. But I don’t see it that way. They didn’t fail treatment, it failed them. When I sat through that confrontational circle five years ago, I experienced a field clinging to tradition. But this new generation of providers gives me hope that people struggling with addiction can receive care that recognizes their dignity.