In July, Reveal, the broadcast channel of the Center for Investigative Reporting, released its eight-part series American Rehab, which centered on an investigation into the drug treatment program Cenikor and the group’s emphasis on “work therapy.” Examining how Cenikor was able to transform “tens of thousands of people into an unpaid, shadow workforce,” Reveal traced Cenikor’s development, struggles, and ultimate success as it placed “patients” into difficult, and often dangerous, jobs across Texas and Louisiana, keeping the money these workers earned and providing little else in terms of actual therapy or rehabilitation. Led by reporters Shoshana Walter, Laura Starecheski and Ike Sriskandarajah, the series is based off Walter’s previous reporting on the issue, which was a finalist for a Pulitzer Prize in 2018 for national reporting.
American Rehab’s early episodes deal extensively with the history of a group that directly influenced the formation of Cenikor: Synanon. In doing so, the reporters reached out to several members of the Alcohol and Drugs History Society for advice and assistance on the history of addiction treatment. We’re really useful people to ask: roundtable participant Nancy Campbell’s book, co-authored with JP Olsen and Luke Walden, The Narcotic Farm: The Rise and Fall of America’s First Prison for Drug Addicts outlined the history of the Lexington Narcotics Farm, where “work therapy” got its start, and panelist Claire Clark’s book The Recovery Revolution: The Battle Over Addiction Treatment in the United States deals extensively with the long and complicated history of how “therapeutic communities” like Synanon influenced addiction treatment and rehabilitation. These books, as well as Campbell, Olsen, and Walden’s series, “Lessons from the Narcotic Farm” from 2012 (click the links to see parts 1, 2, 3, 4, 5, 6, 7, 8) and contributing editor Jordan Mylet’s initial reaction to the series here, provide further details for those interested in how American drug treatment came to the disturbing point Reveal reveals.
In response, now that the entire series is available, we decided to post a roundtable of reactions to the podcast. Participants include Nancy Campbell, professor and department head of Science & Technology Studies at Rensselaer Polytechnic Institute; Erin Hatton, associate professor of sociology at the University at Buffalo and the author of Coerced: Work Under Threat of Punishment; Claire Clark, associate professor of behavioral science at the University of Kentucky; Jordan Mylet, doctoral candidate in history at the University of California, San Diego; and me, Emily Dufton, managing editor of Points and author of a forthcoming book about the history of medication-assisted treatment in the US. Our responses focus on the long history of work therapy in addiction treatment, the concept of coerced labor, the promotional model at the heart of many treatment programs, further reflections on Synanon, and assessments of the series’s conclusion.
We welcome your thoughts on American Rehab and thank the reporters for bringing ADHS historians into the conversation. We hope you’ll enjoy our thoughts on American Rehab, and that you’ll listen to this important and informative podcast.
Soon after our book, The Narcotic Farm: The Rise and Fall of America’s First Prison for Drug Addicts (Abrams, 2008), came out, JP Olsen, Luke Walden, and I were ushered onto a landing above a factory floor where uniformed federal prisoners hunched over cable assembly benches that stretched as far as the eye could see. Inmates at FMC Lexington assemble specialty cables for the Department of Defense. As put by UNICOR, the 86-year-old Federal Prison Industries program, the FMC Lexington UNICOR facility houses an electronic cable factory, and, since 1994, the UNICOR Customer Service Center staffed by inmate tele-service agents from the facility that once housed the nation’s effort to find a cure for addiction and treat 1,500 “postaddicts” at a time, along with over 300 in the nearby “satellite camp” for women. When we were there, in 2012, closely spaced bunk beds occupied every nook and cranny of the women’s facility, which once housed the infamous inmate-run Matrix House.
UNICOR’s publication Factories with Fences characterizes Federal Prison Industries, which commenced when the first narcotic farm opened, as a “national asset.” During World War II and the Korean War, most FPI output—parachutes, cargo nets, bomb casings, and wooden pallets—went towards the war effort. Now organized into “business groups,” UNICOR has this to say about the cable assembly that takes place at FMC Lexington:
“The Electronics Business Group (EBG) is relied upon by the nation’s military to provide cost-effective, precision manufacturing. Product lines include custom and standard cable assemblies and wire harnesses to meet the most demanding specifications. EBG specializes in producing top quality electronics items where reliability is essential and the manufacturing process is not easily automated. Its in-house braiding technology engages multiple, high strand conductors with numerous twist configurations and shields of various construction. EBG is skilled at working with a wide range of conductor alloys, gauges, insulation and jacket components.”
All about technology, about the products of a form of labor that “is not easily automated,”—and not about incarcerated laborers nominally paid for work. There is ample evidence of hypocrisy in the United States’ continuing exploitation of racialized prison labor at home, where more than one million prisoners participate at any given time, and its promotion of fair labor standards to competitors abroad. Perhaps this will be Reveal’s next frontier. Continuities between these decades-long institutionalized prison labor practices, and those documented on American Rehab are apparent.
Belief in the power of work to rehabilitate the nation’s junkies and force drug users into the mold of productive citizens led to the nation’s first and only “narcotic farms” in Lexington, Kentucky (1935), and Fort Worth, Texas (1937). Work therapy was integral to “the cure” at the farms. All “patient-inmates” residing in these institutions had jobs in the sprawling prison-hospital and grounds. At Lexington, inmates produced massive amounts of food—and they were decidedly not vegan. Close to 95 percent of “pork products” consumed at the institution were produced there. Surviving photos show inmates gathered in the “beef class” in front of butchered animals to learn the trade. Former inmates recounted getting up before dawn to milk cows, and are shown literally making hay, picking kale, and baking in massive kettles.
The Needle Trades Industry was one of the first of four prison industries initially pursued at Narco—an irony not likely lost on former drug users who sewed and pressed prison uniforms and tailored “going-home suits” in vast rooms full of donated Singer Sewing Machines.
The number of “industries” expanded over the years. Vocational therapy at the Lexington Narcotic Farm offered options ranging from auto mechanics to barbering to blueprint-making to cobbling to factory work to woodcraft to photography, printing and dark-room work. Patient-inmates kept the institution running by participating in agriculture, food service, laundry, maintenance, and custodial work. Formal apprenticeships were offered for X-ray technology, dental hygiene, and sign painting—as the archives attest, staff worked to secure jobs for graduates. Narco was a model city for retraining the previously unemployable. Workers were paid nominally, spending their wages at the commissary where they could purchase candy, cigarettes, and toiletries, including shampoo made within the institution. But they were paid.
But in the mid-1960s, change was in the air. “Residents” were no longer permitted to work for wages. As the prison industries and farm phased out, the long-time dependency on patient-inmate labor became apparent as hundreds of jobs in food services, sanitation, and laundry went vacant.
In 1966, Congress passed the Narcotic Addict Rehabilitation Act (NARA), a wholesale rethinking of drug treatment. Sentences, previously based on the mandatory minimums of the 1950s, were shortened to six months. Institutional routines altered. No longer did everyone have a “job” with time off for group and individual therapy, recreational activities such as basket-weaving, oil painting, or bowling, or the entertaining “extravaganzas” for which Lexington was famed. Overnight, incarcerated addicts became NARA “clients.” They were returned to their hometowns for treatment and rehabilitation after Lexington staff assessed their suitability for treatment. If there was no treatment provider back where they came from, the National Institutes of Mental Health (NIMH) would contract with the Salvation Army, therapeutic communities (TCs) such as Daytop Village or Phoenix House, or faith-based organizations to provide it. What was the nature of drug treatment when provided by these organizations?
Overnight expertise flourished as agencies got into the game of addiction treatment and aftercare. Treatment approaches at Narco once seeded Synanon. Now these new “providers” imitated Synanon. While some individuals were genuinely interested in the goal of rehabilitation, many more sought profit and proffered the cheapest treatment alternative available—abstinence-based programs reliant on the barely paid labor of ex-addicts and para-professionals. Therapeutic Communities or TCs avoided expensive medical staff and veered away from pharmacologically-based approaches emerging in the mid-1960s. NARA shifted the centralized, “big tent” federal drug treatment system to a decentralized, community-based drug treatment infrastructure. NARA prepared the ground for what we have today—state rather than federal oversight, mixed public and private treatment providers, and insurance reimbursement for those lucky enough to have health insurance or to live in a Medicaid expansion state.
Thanks to NARA, TCs like Synanon and Daytop became state-of-the-art in the 1970s; hundreds of programs copied TC techniques and literally elbowed their way into the game.
We wrote several Points posts on Matrix House, one of the most notorious “houses” to grow up within the institution at Lexington. Just as some of Shoshana Walter’s interviewees claimed that Cenikor saved their lives, some Matrix House survivors did, too. But at Matrix House, stairs were scrubbed with toothbrushes, residents did menial labor to the point of physical and mental exhaustion, sexualized torture was rumored, people were forced to wear dunce caps or shaven heads, and there was even a mock crucifixion. Was this simply the aberrant result of charismatic leadership in a cult-like ethos? Was it due to lack of federal or state regulation or oversight? Was it an anomaly?
No. What happened at Matrix House and Synanon are the predictable, systematic results of embedding the techniques of coercive persuasion and humiliation within drug treatment settings. What happened at Cenikor is the predictable outcome of profit-driven corporations willing to disregard basic human rights. Petrochemical companies paid Cenikor directly—workers, often referred to as “Cenikors,” were paid in cigarettes. In other words, they were not paid for back-breaking, spirit-crushing work.
“Work shall make you free” invokes historical traumas ranging from chattel slavery to Auschwitz. The darker and more coercive self-organized TCs were social hierarchies—newcomers started at the bottom and worked their way up the ladder of chores and degradations to graduate to greater responsibilities—which often involved coercing people lower on the ladder to do things they didn’t want to do. Living spaces were kept physically and symbolically “clean.” Peer evaluations were constantly conducted and the level of scrutiny intensified over time. Former addicts cooked and cleaned and maintained what was basically a dystopian community rooted in the techniques of coercive persuasion. It is no coincidence that many “cenikors” quoted on American Rehab called the “treatment” to which they were subjected “brainwashing.”
No system based on shame, humiliation, and coercion can possibly be therapeutic. Doing that to “troubled teens” or people at high risk for relapse is so repellant that it should be criminal. Instead, we have allowed individuals and organizations to capitalize upon it. Work is not treatment. American Rehab has powerfully put before us the scale to which the rehabilitative enterprise has failed hundreds of thousands of people. Such practices should be criminal.
What are we waiting for?
American Rehab is indeed a “knockout,” as The New Yorker recently described it. In this podcast, and the related series of articles from Reveal, Shoshana Walter and colleagues provide a well-researched and riveting account of the underside of addiction treatment in America today.
As a sociologist of work and labor who has spent the last several years studying unpaid (or underpaid), unrecognized, and exploited labor, I particularly appreciate the podcast’s focus on the role that such labor has played—and continues to play—in these treatment programs.
Program officials’ ability to call this labor “work therapy” relies on America’s longstanding embrace of work as both punishment and cure for individuals’ perceived moral failings, particularly those who are marginalized by race and class. My research has focused on manifestations of this contradictory cultural embrace in two American institutions: prisons and social welfare.
Most readers will be aware that prisoners can be compelled to work in the U.S. Indeed, they are the sole exception to the Constitution’s prohibition of slavery. The era of mass incarceration can thus also be seen as a new heyday of unfree labor. Less known is that the criminal justice system’s reliance on compulsory labor extends far beyond prison walls. As Noah Zatz and colleagues have shown, parolees, probationers, and debtors are often compelled to perform unpaid labor in the name of “community service,” or are required to maintain a job—any job, no matter how precarious, undesirable, or dangerous—to avoid being sent to prison. For all such carceral workers, I have argued, compulsory labor is construed as both punishment for and antidote to their criminality.
Meanwhile, American poverty governance has long deployed labor as both penalty and remedy for poverty. This can be seen in 19th century poorhouses (and Britain’s workhouses before them), in which arduous labor was often the linchpin of a broad-based strategy to make being poor—and, even more, receiving alms—as miserable as possible. More recently in 1996, President Bill Clinton restructured the U.S. welfare system to make work its centerpiece, while (incorrectly) proclaiming that unpaid labor (“workfare”) and other work-centric programs would instill “the basic values of work, responsibility and family” that public assistance recipients supposedly lacked.
In both cases, the belief that compulsory labor is an appropriate punishment for people’s (real or perceived) wrongdoings as well as a way to reorient their moral compass has both justified and allowed these problematic labor regimes to flourish. Through my interviews with more than 100 such workers, I came to understand how they view their labor and the coercion that undergirds it: how, for example, any form of noncompliance can land incarcerated workers in solitary confinement (more than 15 days of which, the U.N. has declared, is “torture”) or push workfare workers and their families off welfare and into the streets.
American Rehab shines a light on another major site of coercive labor in America: drug rehab programs. Companies such as Cenikor extol the value of “hard work” as a therapeutic treatment for substance abuse. Yet even if hard work were therapeutic (and there is no evidence that it is), why would it be therapeutic to not be paid? That is, why would it be therapeutic to be deprived of the rights and benefits that we, as a culture, have attached to work? Aren’t those the very elements that bring “dignity” to work? Without such rights, benefits, and dignity, “work therapy”—much like incarcerated labor and workfare—is productive labor that does not earn the rewards of productive citizenship. In short, it is a site of “predatory inclusion.”
American Rehab is thus right on target in critiquing this labor as unremunerated. But there is another profoundly problematic aspect as well: coercion. The people who find themselves in programs such as Cenikor are not usually there by choice and they cannot freely leave. Often, as Reveal’s reporting has made clear, they are sent to such programs by the criminal justice system: judges who “spare” them from prison by sentencing them to these addiction treatment “work therapy” programs (in some cases, even when they do not have substance abuse issues). For such workers, failure to complete the program for any reason—including workplace injury—will result in their incarceration. Even if there is no direct threat of prison, those suffering from the mistreatment, marginalization, and criminalization that often accompany substance use in America (particularly those already marginalized by race or class) often cannot afford decent care and therefore face a Hobson’s choice: no treatment at all or an exploitative program built on coercive unpaid labor. In either case, treatment programs like Cenikor wield immense power over their clients: the power to put them behind bars or push them to the streets. So, like incarcerated and workfare workers, rehab workers labor in order to comply—and simply survive—within this unjust and exploitative system.
In college I watched a documentary called Titicut Follies, a gut-wrenching exposé of the conditions at the State Hospital for the Insane in Bridgewater, Massachusetts in the mid-1960s. Director and producer Frederick Wiseman used an observational approach that film critics later classified as direct cinema. There was no voice-over narration or narrative arc; Wiseman recorded and juxtaposed scenes that self-evidently damned both the psychiatric profession and the criminal justice system. Inmates are stripped naked and taunted. A doctor ashes his cigarette into the liquid being tube-fed to a patient. A foreign-accented psychiatrist grills an inmate convicted of child abuse about his sexual history in an intake interview. The confrontational exchange is so graphic that the Massachusetts Superior Court moved to ban the film and restricted its viewing to educational use until 1991.
I thought about Titicut Follies while listening to American Rehab, Reveal’s serialized podcast tracing exploitative addiction rehabilitation programs backwards from Cenikor to Synanon. (Disclosure: I’ve researched and written about both programs and communicated with two Reveal reporters in the course of their research.) Although I’d anchored the history in my dissertation-turned-book to the origins of a notorious cult, I’ve never been a fan of the true-crime genre and was struck to find a few familiar sources repackaged in serialized podcast form. As a graduate student I had immersed myself in Synanon’s prolific cultural production and delighted when I discovered the movie David, directed by direct-cinema pioneer D.A. Pennebaker. Today, the documentary’s vintage jazz soundtrack and black-and-white film seem quaint– “60’s cool,” as Reveal describes them— even to the people who remember them. The podcast production team easily spots the beginnings of Synanon’s eventual downfall in the documentary’s depiction of a confrontational “Game” session and in a former member’s present-day enthusiasm for the session’s “brainwashing.” But the podcast episode about Synanon elides one important historical argument: brainwashing and abusive forms of talk therapy weren’t Synanon’s inventions. Synanon was just the place where people struggling with addiction bought into them.
Those therapies were ineffective but, American Rehab seems to argue, therapy was never really the point: Synanon’s supposedly novel form of addiction treatment was essentially a front, a method for coercing unpaid labor to fuel its other industries. Listeners may assume that Synanon’s savvy promotional campaigns were simply a means to this end. But in Synanon, especially in the early years, the production of these campaigns– the newspaper and magazine stories, documentaries, tours for researchers and elected officials– may have been the most significant form of labor.
That labor generated national attention but it also recalled an older tradition. Walker Winslow, a prominent journalist and the biographer of psychiatrists Karl and Will Menninger, made a historical analogy that Synanon residents and graduates often repeated: Synanon founder Charles Dederich was Dorthea Dix (scroll down to this final essay). Dix was a nurse and asylum reformer who had championed a “moral model” of psychiatric treatment as a corrective to the inhumane treatment of people with mental disorders by almshouses, prisons, and asylums in the nineteenth century. In this utopian vision of the nineteenth century asylum, grand buildings became centers of cultural activity. Theatrical programs, literary journals, and handicrafts were both forms of treatment and public evidence that residents were capable of supposedly upright behavior and higher thought. Politicians toured asylums; tourists picnicked on their verdant grounds. The end result, writes literary scholar Benjamin Reiss, was that asylums “became at once laboratories for purifying the national culture and theaters where this process could be observed.”
Transcendentalists in Dix’s circle inspired Dederich: Synanon, part lab and part theater, spun off studies about addiction treatment and produced a wealth of cultural material. In reviving the moral model of treatment, Dederich also reproduced its failures: the asylum movement’s attempt at uplift was ultimately unsuccessful, leaving “a legacy of stigmatization on the insane and deepening fissures in the national fabric,” Reiss concludes.
Titicut Follies begins with a cheerful musical number, “Strike Up the Band,” performed by inmates holding pom-poms and singing with blank faces through clenched teeth. The dissonance between the theatrical content and the performers’ apparent emotional state is initially disturbing. The larger context is even worse: after the film reveals the hospital’s sordid conditions, we learn that the coerced performance occurs immediately after an inmate’s funeral.
“The show must go on,” sing the Follies’ inmates at the end of the movie, and so Reveal does, exposing the continued fallout of a flawed original ideal. American Rehab’s image of Synanon’s beginning is accurate: the jazz is Sixties-cool and the Game is stomach-churning. But the full story would include why the residents were playing to begin with.
Wally Mawson wanted to stay in Synanon House. A thirty-five-year-old heroin addict on probation for theft, Mawson felt that the place was “his only chance to stay away from dope and eventually getting busted, violated, or death.” But the California Department of Corrections (CDC) didn’t agree.
In October 1959, Mawson’s probation officer ordered him out of Synanon on the grounds that it was “off limits.” If he continued to reside there, Mawson would be formally violating the condition of his parole that forbade him from associating with other addicts. Still, Mawson refused to leave. In court, the judge ruled in favor of the CDC, and Mawson was sent to San Quentin State Prison to serve the remainder of his original sentence—three and a half years.
While waiting to be transferred to San Quentin, Mawson wrote to his former Synanon housemates: “It seems much is attempted, very little accomplished in the solution to delinquency as well as the social problem. Being a bureaucracy, of course, I realize the many barriers and uncompromising situations that must arise… The benefit of the doubt must lay with the human. Instead, it seems reversed and the state becomes the oppressor.”
Over the next few years, Synanon residents’ struggles with California officials continued. The CDC ordered dozens more parolees and probationers out of Synanon. Individual judges sometimes sided with Synanon members after they appealed to remain in residence, but CDC policy stayed the same. Meanwhile, Santa Monica city officials worked to evict Synanon from its beachfront home by suing the organization for operating a hospital in a residential zone; in 1961, Charles Dederich, Synanon’s founder, spent a month in jail for the same charge. As the Santa Monica lawsuit worked its way through federal court, Synanon members wrote letters to President Kennedy asking him to step in, somehow, to protect their home.
If your only source of information about Synanon was Reveal’s American Rehab podcast series, the fact that its residents clashed so quickly and frequently with state officials might come as a surprise. Despite its title, American Rehab tells the story of Synanon as if it existed on its own little island—at first alight with all-night jazz jam sessions, later dark and dangerous, but always untethered to the larger society, especially state power. The absence of a discussion of the state in this history is odd, particularly given that the 1950s and 1960s marked the dawn of a decades-long national obsession with illicit drugs and addiction—much of which focused on what local, state, and federal governments should do to stop the spread.
When it came to Synanon and other grassroots recovery groups like it, the battle was over who would have ultimate authority over treating addiction. Should Synanon be subject to state regulations and medical licensing requirements? How should grassroots recovery groups be incorporated into the existing penal and welfare systems—if at all? And then perhaps the biggest question of all: should treatment be a mandatory or voluntary process?
One of the ways that postwar lawmakers thought they could eradicate the traffic in illicit drugs was to rehabilitate—or “cure,” as they would say—existing addicts. In the 1950s, most politicians, as well as federal narcotics agents and public health officials, spoke about drug addiction as a deadly contagious disease that demanded institutional confinement and professional medical attention to contain. The same state and federal officials who supported harsh sentences for drug dealers also pushed for “compulsory hospitalization” for addicted offenders. By the early 1960s, as the community mental health movement captured the imaginations of officials in the National Institute of Mental Health and the Kennedy administration, the tide turned in favor of a decentralized system based on local treatment centers.
In 1966, Congress passed the Narcotic Addict Rehabilitation Act (NARA), which kept elements of both strategies. The law gave federal judges the option of committing certain drug offenders to the federal narcotics farms in Lexington, Kentucky, and Ft. Worth, Texas, in lieu of prison time, while also facilitating the development of community treatment centers for patients upon their release from the hospital. The latter part of the bill would be feasible, lawmakers thought, because of the rise of grassroots recovery groups like Synanon—whose growing popularity stemmed from their tireless self-promotion work, as Claire Clark noted in her piece. NARA made drug rehabilitation a part of the Johnson administration’s community-oriented War on Poverty. In 1967, Synanon even applied for funding from the Office of Economic Opportunity, the agency responsible for managing Johnson’s poverty programs.
The key issue that bedeviled Johnson officials during the War on Poverty—how much autonomy to grant neighborhood activists—is the same one that frustrated California officials when it came to Synanon. In fact, NARA was actually modeled in large part on California’s civil commitment program, which officially began in 1961 but had been in the works since the mid-1950s. When Synanon burst onto the SoCal scene in the late 1950s, the California Department of Corrections saw it first and foremost as an obstacle to their state program of institutional confinement and strict probation based on the cutting-edge Nalline drug test, which claimed to detect the level of a person’s opiate addiction by measuring pupil size. (Nalline, or N-allylnormorphine, is used today to reverse opioid overdoses under the brand-name Naloxone.)
Richard A. McGee, the CDC head, justified its removal orders to probationers at Synanon by touting his department’s “ambitious new program for control and treatment of the addict.” Surely, McGee argued, “no one expects a state department to turn its thousands of parolees over to an uncontrolled, unresearched private agency.” And while many of Synanon’s neighbors supported the program by donating food and services, others were immediately apprehensive—especially in the Santa Monica city council and police department. The police chief stationed officers to watch Synanon House at all times, on the grounds that it “attract[ed] felons and narcos” to the neighborhood. Moreover, the city’s eviction suit nearly shut Synanon down multiple times in the early 1960s. In the end, Synanon had to agree to register its residents with the CDC and call the police if any probationer split from the program.
Long before Cenikor and the Prison to Rehab pipeline existed, then, law enforcement officials exerted pressure on community rehabs to assimilate into the criminal justice system. While Reveal does a stellar job of exposing the exploitation that undergirds many modern-day drug rehabs, it doesn’t tell the full story of how this system came into being at all. Once the podcast reaches the Reagan-era War on Drugs in its fifth episode, it broadens its lens to link Reagan’s support for private rehabs like Cenikor to his penchant for slashing social services and facilitating mass incarceration. But when it comes to decades before, American Rehab leaves unexamined the critical role played by government officials in shaping America’s patchwork system of addiction treatment.
There is no doubt that Cenikor wouldn’t exist today without Synanon, a point that Reveal demonstrates clearly. Yet it also seems to try to turn a linear genealogical narrative—Synanon begetting Cenikor—into an historical explanation for why America’s troubled rehab industry looks the way it does today. To understand the full history of today’s system, however, we must examine the postwar struggle for control over addicts and their treatment that shaped the course of Cenikor and Synanon alike.
I’ll start by saying that I enjoyed American Rehab. Reveal is an excellent and entertaining program, and the reporters did an admirable job bringing the story of Cenikor’s birth and ongoing, if troublesome, success alive. Their archival research was particularly well done. The audio clips of Synanon founder Charles Dederich and member Kandy Latson were some of my favorite moments of the episodes.
My problem, though, was that American Rehab was almost too entertaining, and the reporters’ understanding of the larger complications that haunt American drug policy, some of which my fellow roundtable participants elucidate above, was a little too pat. Listeners should absolutely be angry at how Cenikor’s “patients” are treated. But they should be even angrier at the system that allows places like Cenikor to exist and thrive. This is a system that has been built and refined over decades, and a closer examination of it shows, as my fellow panelists discuss above, that Cenikor is not unique in its exploitation of human labor in the guise of treatment, nor are government officials at the state and federal levels unique in supporting this specific kind of program as a means to promote the “treatment” and “rehabilitation” of addicts.
This is not to say that focusing on Cenikor was in any way a bad idea. Given the severity of its abuses, as well as the organization’s reach and power, Cenikor is an important group for Reveal to spotlight. The hundreds of people Cenikor sends to work in dangerous conditions every day, and the innumerable thousands of dollars they earn from this labor, is insane.
The problem is that American Rehab didn’t go far enough. It analyzed Cenikor, but then it stopped. Cenikor is a juicy story worthy of a podcast, but the entire story of drug treatment and rehabilitation in America, Cenikor is not. Instead, Cenikor is just one part of the enormous and troubling history of how America has long struggled to figure out what we’re supposed to do with drug addiction. If Reveal had dug deeper into the system that allows Cenikor to exist, as well as the problems surrounding the solutions that American Rehab references in its final episode, we could have seen that Cenikor–and other programs like it–are products of a larger system that allows these exploitative and profitable systems of American drug treatment to thrive.
And why are these programs allowed to exist? For two reasons: one, because they are extremely lucrative for those running these businesses, which allows foundations like Cenikor to make sizable lobbying contributions to sympathetic politicians who oversee their programs. And two, because our country has yet to settle on a consensus regarding the definition of what “addiction” is, how it is treated, or how a person achieves “recovery.” Since we can’t decide on what to do about addiction, as one clinician in St. Louis told me last year, “anything goes.”
American Rehab’s fifth episode, “Reagan with the Snap,” is one of the shortest episodes of the series. It discusses Ronald Reagan’s support for Cenikor in the 1980s, pulling the program out of destitution and giving it renewed life and financial support. Reagan liked Cenikor for the same reasons his wife, Nancy Reagan, liked the anti-marijuana grassroots parent movement (something I discuss in my book): these were private programs that took on the issue of drug use and addiction, and did so (supposedly) without federal funds or involvement. Letting private groups handle the expensive process of rehabilitation allowed the Reagan administration to overturn a decade of increased federal funding for treatment and move that money back to where Reagan thought it belonged: in law enforcement and interdiction. When Cenikor patients began selling football equipment to other private groups, increasing its ability to self-fund its operations, this appealed directly to Reagan, whose administration was famous for its desire to make the federal government so small you could “drown it in a bathtub.”
But the idea that drug rehabilitation centers exist outside of federal support is a con as great as Cenikor’s appeal to potential clients: basic research shows that Cenikor has consistently–and recently–lobbied for support on both a state and federal basis. Cenikor continues to thrive because, given America’s ongoing struggles with drug misuse and overdose deaths, the federal government needs to support drug rehabilitation centers ($1.8 billion was allocated for the opioid crisis in 2019), and Cenikor prides itself on being “successful.” But “success” is often more a matter of successful lobbying and self-promotion, as Claire Clark outlines above, than successful rehabilitation. People I’ve spoken to while researching my new book on the history of medication-assisted treatment have compared the influx of federal funds to the Wild West, where funds are up for grabs, people are trying to get them, and anything and everything can be considered “drug treatment”–work therapy like at Cenikor included.
This leads to an important question, perhaps the most important one when studying addiction and treatment in America. If, as my fellow panelists have shown, coerced labor is not effective treatment, then what is? I recently spoke to William L. White, author of the canonical book Slaying the Dragon: The History of Addiction Treatment and Recovery in America, and he said that, while on the surface defining concepts like “addiction” and “recovery” seems simple, these questions touch upon some of the most controversial issues in the field. The very concept of “addiction” has shifted radically over the years, from the language surrounding the problem (“inebriety” to “dependence” to “addiction” to “substance misuse disorder”) to the understanding of the issue (from a moral failing, to a chronic disease, to a brain and learning disorder). For White, “recovery” is the more important aspect of the matter, and he defines it in three general ways. For recovery to truly occur, a patient must be in remission, showing abstinence or deceleration to subclinical drug use; they must experience an enhancement in overall health and functioning; and they must repair the personal and community relationships that were weakened because of drug use.
To achieve these ends, according to White, there is no single solution. As he explained to Points in 2014, “I avoid recommending any treatment program that claims to have THE solution to addiction. That type of institutional and clinical arrogance is more associated with fraudulent exploitation and harm in the name of help than stable long-term recovery. Also not recommended are programs that continue to use confrontation and humiliation as therapeutic devices, in spite of decades of research on their ineffectiveness and potential harm. The programs with the best long-term recovery rates offer a wide menu of ‘active ingredients’ that can be combined, sequenced, and supplemented to address the needs of individually and culturally diverse patterns of alcohol and other drug problems. And they provide clinicians with track records of achieving such nuanced treatment.”
In other words, for White, treatment must be aligned with the needs of the person being treated. There is no single, catch-all solution. Other treatment clinic operators I’ve spoken to in St. Louis and Washington, DC, agree. For truly successful rehabilitation, when a patient walks in the door, everything must be on the table, so that patients can work with their doctors to find what helps.
So what does American Rehab offer as a solution? Toward the end of the last episode, “Shadow Workforce,” Shoshana Walter and host Al Letson suggest that “we know the medications that work,” but don’t go into any further details. Because they’re discussing opioid use specifically, they’re most likely referring to the three FDA-approved medications that make up medication-assisted treatment (MAT) for opioid use disorder: methadone, buprenorphine, and naltrexone.
It’s true that, if methadone and buprenorphine are used to treat opioid use disorder after a nonfatal overdose, they can cut the rate of opioid mortality by over 50%. These drugs are important components of many individuals’ recovery from addiction, and their utility cannot be overstated.
But suggesting that the medications are the totality of the solution–that these drugs are the only things that really “work”–is problematic. As a “bio-psycho-social disease,” White explains, the use of methadone and buprenorphine alone to treat opioid addiction may be sufficient for some patients, particularly those who have a high level of “recovery capital” (which White defines as the internal and external resources needed to sustain long term recovery from addiction) and who need little else in terms of counseling and other therapeutic or vocational programs.
But for most patients, whose issues often include more than just opioid use, the sole use of a MAT drug is an insufficient form of treatment. Even Vincent Dole, who pioneered methadone maintenance treatment in the 1960s, argued in 1989 that, “I urged that physicians should see that the problem was one of rehabilitating people with a very complicated mixture of social problems on top of a specific medical problem… The strength of the early [methadone maintenance treatment] programs as designed by [Dole’s partner] Marie Nyswander was in their sensitivity to human problems. The stupidity of thinking that just giving methadone will solve a complicated social problem seems to me beyond comprehension.”
To suggest that MAT is a simple solution for opioid addiction also ignores the fact that the field itself is rife with exploitation. Buprenorphine, first synthesized in 1966 but not made available for addiction treatment until 2003, was once viewed as the “holy grail”: an opioid-based addiction treatment drug that, when mixed with the antagonist naloxone, prevented heightened levels of diversion and misuse.
But Indivior, the company that produces the expensive brand-name version of buprenorphine/naloxone called Suboxone (which, given Indivior’s history of “product hopping” to protect its patent, is one of the only forms of buprenorphine available), has recently pled guilty to a federal felony related to making false statements about its medication. According to Reuters, Indivior “engaged in an illegal scheme to boost prescriptions of the film version of its opioid addiction treatment Suboxone.” The group “made billions of dollars by deceiving doctors and healthcare benefit programs into believing the film version of Suboxone was safer and less susceptible to abuse than similar drugs.”
An extensive, and fraudulent, marketing campaign–similar to that of OxyContin, which launched the most recent opioid epidemic in the 1990s–brought Suboxone, which can be prescribed in a private clinic, to the American public. But its relative inaccessibility and high cost has made Suboxone unavailable to all but the most affluent patients (or to those who get it through diversion or via Medicaid, where Suboxone is one of the program’s 50 most expensive drugs). This has created what Drs. Helena Hansen and Samuel Roberts call “the two tiers of biomedicalization”: methadone–available at stigmatized and highly regulated urban clinics–is available for low-income, often Black and Brown Americans, while buprenorphine is available from private physicians for those who can afford the prescription fees and high cost of the drug, who are usually White. All of this makes clear that MAT is not the total solution to the opioid crisis that American Rehab suggests it is. The racism, fraud and drive for profit at the heart of MAT’s availability means that, while hardly as punitive and predatory as the forced labor of Cenikor, these medications aren’t the sole form of treatment that works, nor is the system simple and unproblematic.
There is a distinct and important power in the story American Rehab tells. For decades, human beings have been abused by a system that harms them in the name of “healing.” And this abuse has been allowed to continue unchecked for so long because people suffering from substance use disorders are some of the most vulnerable, disposable, and profitable people in this country. Selling fake treatments to suffering Americans is as old as heroin itself, which was first marketed in 1898 as a treatment for morphine addiction.
Still, I hope that, by making people aware of the insufferable abuses abundant within Cenikor’s treatment program, American Rehab helps to change the landscape of addiction treatment in America. But I also hope that it pushes listeners to learn even more about the larger system of exploitation, abuses and predatory practices that have long defined the history of addiction treatment in America. In no other medical field has this much harm been involved in the “healing” of a medical problem, and listeners should be wary of any program that calls itself, and only itself, the “solution.”