[Hpn] The nightmare of recovery

chance martin streetsheet@sf-homeless-coalition.org
Fri, 08 Jun 2001 14:15:02 -0700


http://www.salon.com:80/books/feature/2001/06/07/therapy/index.html

The nightmare of recovery

A powerful new book on the drug war's trenches argues that treatment is the
answer -- but our current system dooms more addicts than it helps.

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By Laura Miller

June 7, 2001 | Those who believe, as most sensible people do, that the
current war on drugs is a boondoggle and a disaster also usually say that we
ought to be spending our dollars on treatment, not law enforcement, if we
want to diminish the trade in illegal drugs. As long as rampant demand -- in
the form of a buzz-hungry populace with fistfuls of ready cash -- waits
inside our borders, enterprising individuals and organizations in other
countries will find a way to supply it, no matter how many helicopters we
send to Colombia or smugglers' boats we seize off the coast of Florida.
Menacing teenagers will shoot each other on street corners and grizzled
bikers will cook up methamphetamine in backwoods sheds provided there are
enough people, in the end, willing to pay enough money for those little
packets of white powder. (Or at least as long as selling that white powder
remains against the law, but let's stay in the realm of political
possibility.) 

But if "treatment" has become a buzzword for citizens tired of seeing
billions of their tax dollars wasted on hunting down South American drug
lords and warehousing nonviolent offenders in prisons, Lonny Shavelson, a
physician and journalist, argues that it's often not a whole lot more than
that. In his new book, "Hooked," which follows five addicts through the
torturous process of getting help for their substance abuse problems in San
Francisco in the late 1990s, he makes a powerful case that America's drug
treatment program is hopelessly flawed. Despite "a burgeoning movement in
states across our nation to shuffle drug offenders from prison to
treatment," he writes, "before we shift hundreds of thousands of addicts
into rehab, we must first treat the treatment system."

As these five stories unfold -- at times "unravel" seems the better word for
what happens -- the truth behind Shavelson's prosaic play on words becomes
agonizingly clear. Lives are ruined and lost, hearts shattered, precious
second and third chances squandered, trusts betrayed, hopes stubbed out.
And, in a few rare cases, people do manage to miraculously pull themselves
out of the pit. Shavelson wants to see those exceptions become the rule, and
in figuring out how we can make that happen, he overturns a few of our most
cherished notions about addiction and recovery.

The five people he writes about in "Hooked" are part of the kernel of
hardcore substance abusers whose lives, according to Shavelson, constitute
the front line of the drug war: "the most resistant, demanding, often
unlikable, and arguably the least deserving of treatment service ...
precisely the type of difficult junkie that rehab programs must succeed with
if they are to make a dent in the crime, violence, and craziness that
comprise the drug problem." Although the number of illegal-drug users in the
U.S. declined from 1979 to 1998, the number of drug-related hospital visits
and deaths went up, and most people picked up by the police for criminal
offenses test positive for drugs. The Justice Department says drug users
account for "an extraordinary proportion of crime."

Shavelson documents their blasted lives: Darrell is a lonely, homeless
alcoholic and crackhead who has flunked out of several rehab programs,
attended thousands of Alcoholics Anonymous meetings and been hospitalized
for countless injuries, including falling out a window, while wasted. Mike
is a skilled plumber whose unendurable memories of being molested as a child
send him back to heroin again and again despite his heartbreakingly fervent
desire to redeem himself in the eyes of his kids and girlfriend. (In the
book's opening pages, Mike is described as shooting up while driving a truck
down California's Highway 101 -- steering with his knees -- getting in a
wreck and then, once ascertaining that he's uninjured, continuing to shoot
up in a ditch beside his totaled pickup.) Glenda is a tiny, sweet-natured
Native American who has been drunk and homeless since age 16 and looks 60
instead of 37, her actual age. Crystal is a cocky crackhead who boasts of
her fearsome street reputation until she trusts Shavelson enough to confess
that she was a streetwalker and a "victim." Most daunting of all is Darlene,
whose auditory hallucinations ("noises," she calls them) could be caused by
psychosis, or by the speed she injects as often as twice a day, or by the
brutal conditions of her life in various homeless encampments, each
makeshift shelter eventually bulldozed by the authorities without warning.

However desperate their situations, these five people entered treatment at
an opportune moment. In 1996, the new U.S. drug czar, Gen. Barry McCaffrey,
shifted a bit of the nation's drug policy focus from law enforcement to
rehab, declaring that "effective treatment can end addiction" and that drug
policy goals "can only be accomplished with a significant expansion of
capacity to treat the nation's drug users." (Most of the money, however,
still goes to enforcement.) And San Francisco had launched a much-ballyhooed
"treatment on demand" policy that promised to get all addicts seeking help
into a treatment program within 48 hours. You'd think that seeking rehab
just at the time when officials had recognized the importance of treatment
would give these addicts a boost -- but you'd be wrong.

According to Shavelson, the main factor causing people to abandon their
search for rehab is basic bureaucratic disorganization on the part of
treatment providers. That's not the kind of ideological beef that makes for
chest-thumping Op-Ed columns, but it's the kind of problem that causes vast
sums of money to be sucked up into a system that offers scarce positive
results. Addicts have to make their way through a chaotic patchwork of
services and programs, each covering a small, specific need and each looking
for a reason to refer difficult clients elsewhere. Negotiating this thicket
of paperwork and conflicting agendas makes dealing with the average HMO seem
like a snap and -- guess what? -- organization and persistence are not
common traits in drug addicts.

For example, the question of whether Darlene's aggressive, incoherent
behavior results from mental illness or substance abuse (speed can induce
psychotic symptoms) -- a question that, as Shavelson points out, isn't
particularly relevant to helping her -- stymies her progress through the
system. He describes her experience as "a cyclonic quest for rehab: referred
to and then immediately kicked out of three drug treatment programs ...
referred by the city's mental health counselors to the substance abuse
counselors; referred back to mental health again in circles that have spun
me dizzy just watching."

For another example, Glenda, joyfully sober for the first time in decades
after three months in a terrific Native American-run inpatient program,
steps out of it and into a treatment vacuum. The room found for her is in a
"clean and sober" Salvation Army housing facility, but it's three blocks
from the place where she used to hang out all day drinking with her street
pals, and no one supervises her recovery beyond the Salvation Army's weekly
drug tests. Two days later, she's drunk again and kicked out of her room and
onto the street. A year and a half after that, she's dead.

Shavelson convincingly argues that all the money spent on treatment programs
will go to waste unless each addict is assigned a case manager, someone who
can guide him or her through detox (which "provides medical social services
during those days it takes to get sober and withdraw"), then rehab (a
program that seeks to resocialize the addict in a clean and sober
environment) and finally getting the housing and employment he or she needs
to become a functional member of society. Instead, he observes irately, "the
seeming lack of any management that could impose order on the myriad
substance abuse programs and services that have proliferated since the
mantra of rehab took hold across the country" means that people get briefly
cleaned up and then dumped back into the nightmare from whence they came,
without anyone accounting for their need, as Mike puts it, "to learn how to
live all over. Like from the beginning."

Mike, though, ran up against more than just bureaucratic hassles and
inadequacies. After weeks of waiting to get in (during which time he almost
died of an overdose), he became a model member of the famous San Francisco
"therapeutic community" Walden House, but then relapsed shortly after moving
on to transitional housing. Afraid of going back to Walden to plead for
readmittance, he went on a heroin binge, then tried, without much success,
to stay clean on his own. Shavelson sees this, too, as an avoidable
calamity. Walden adheres to a common rehab philosophy that Shavelson calls
"abstentionist." It imposes a long list of regulations on house residents,
and punishes even the slightest infraction with long periods of "reflection"
time on a bench in the communal hallway. A major violation like Mike's
relapse means automatic ejection from the program -- unless the prodigal
submits to a grueling group meeting in which he must sit in a chair in the
middle of the room while the entire community pelts him with accusations and
abuse. 

This militaristic, "tough love" approach has disreputable roots in the scary
Synanon movement that started in the late '50s and flourished in the '70s.
Synanon, which practiced a form of "attack therapy" called "The Game,"
eventually was discredited when its cultlike antics expanded to include
stockpiling weapons and placing a live rattlesnake in the mailbox of a
lawyer who'd sued the group. Nevertheless, with some significant toning down
of its more extreme aspects, the Marines-like, zero-tolerance model persists
in therapeutic communities like Walden, which claim that the addict is like
an irresponsible child whose personality must be broken down and rebuilt
from the ground up in a highly structured, rigorously sober environment.

While it no doubt works for some people, Walden's strategy spectacularly
failed Mike. Shavelson considers it abusive and self-defeating and points
out that Mike's underlying psychological problems (particularly intrusive,
recurring memories of being raped as a child) never got treated at Walden.
The constant demands of the community's daily routine kept Mike distracted
from his demons much as heroin once did, and the harsh, humilation-based
methods used to reinforce the house's regimented lifestyle discouraged him
from opening up about a past he remembered with tremendous shame. Worst of
all, when he relapsed -- which most recovering addicts do -- the emotional
ordeal that is the price of returning to Walden was more than he could face.

Not surprisingly, a new treatment philosophy has emerged in recent years,
called "harm reduction." One advocate tells Shavelson that harm reduction
defines what it wants from addicts as "any positive change." Its first
commandment is "Meet the clients where they're at." Instead of jettisoning
addicts from the program if they don't stay clean, harm reduction offers
them different kinds of services, congratulates them for using fewer drugs
and does whatever it can to help them "have less violent lives, steal from
fewer people, become somewhat less crazy, and even, possibly, a bit
happier." The zero-tolerance side considers harm reduction to be an
unconscionable betrayal of the addict, who is engaged in a life-or-death
struggle in which halfway measures don't work. (One of the drug users
Shavelson interviewed, Darrell, agrees.) McCaffrey condemned harm reduction
as a plot devised by drug legalization advocates.

Whichever approach works best, the existence of these competing approaches
has resulted in a "drug treatment world ... divided into two armed, deeply
entrenched encampments that to this day continue to fire bullets of contempt
at each other's rehab philosophies." Shavelson clearly favors harm
reduction, particularly in the case of someone like Darlene. Remarkably
eloquent despite the utter confusion of her life, at one point she drags
Shavelson into a store and shows him the cover of a comic book:

It's a busy, medieval scene. Dark, ominous castles are surrounded by wooden
carts filled with dozens of blood-soaked, nearly naked women's bodies. Men
in armor, holding swords, gawk at their exposed, bloodied flesh. I look at
Darlene, puzzled. "Shrinks always want to know about the noises in my head,"
she says ... "That's a picture of my noises. It's the place I don't want to
go no more."
 
She later explains that she's afraid to stop shooting speed because the
"noises" might not go away and she'd be proven to be crazy. Darlene may
indeed need structure in her life, but first she needs intensive
professional psychotherapy.

Yet Darlene does, eventually, make it to Walden (albeit in a special program
-- one that wisely combines full psychiatric care with drug rehab). So does
Crystal, a rehab candidate who, while free of psychosis, is almost as
unpromising as Darlene because she enters the system without the slightest
desire to get off drugs. Shavelson, ever the pragmatist, doesn't think much
of the bullying ways of attack therapy, which addicts voluntarily endure.
But he finds himself, to his astonishment, endorsing a practice that
superficially seems even more disrespectful: coerced treatment. The reason
is simple: He has seen it work. Glenda, the most "pitiful, disheveled,
near-death, long-term street alcoholic" he had ever known, was kidnapped and
forced into rehab by concerned homeless service workers and came out "three
months later -- cleaned up, sober, and healthy."

The system ultimately failed Glenda, but it succeeded with Crystal, who was
charged with selling crack and sent to San Francisco's drug court instead of
criminal court. Drug courts, originally established in Florida while Janet
Reno was the state's prosecuting attorney, supervise an addict's recovery in
much the same way that Shavelson envisions case managers doing it, from
detox to rehab and on through getting a GED, getting out of debt and finding
employment. The addict is required to take regular drug tests and report to
the court every two weeks. If the addict doesn't comply, he or she is sent
back to criminal court to face jail time. There's ample evidence that drug
courts have the highest success rate -- that is, the lowest dropout rate and
recidivism -- of any method of dealing with addicts, therapeutic or
criminal. And this despite the fact that they fly in the face of one of the
recovery movement's core truisms: that a substance abuser has to be truly
ready and willing to quit in order to get sober.

Boasting from the start that "I can fake my way through any program. I'll
take 'em for what they got," Crystal graduates two years later a changed
woman. Shavelson attributes this success to the fact that despite her
relapses and occasional truancies, the drug court judge and rehab team
"simply [stuck] to her like glue." More an exquisite piece of theater than
it is anything else, a drug court walks its charges through a predictable
series of rebellions and transgressions, intensifying treatment when they
start using again instead of kicking them out, manipulating them into the
kind of program they need. The threat of being sent back to criminal court
is the drug court's stick, and lavish praise for those who clean up their
acts is its carrot. Crystal's stint in Walden is predictably "stormy" and
she shrewdly observes that "when things get deeper at Walden than 'Don't do
dope,' they don't know how to deal with it. But I talked to the judge and my
Drug Court case manager and they're insisting I have a therapist at Walden
'cause I need some real help with this depression or I'll be back on the
crack pipe." 

The great irony of drug courts, though, is that you have to be a criminal to
end up in them. Darlene, who supported herself with petty thefts but never
got caught, managed to get the care she needed only because Shavelson went
to bat for her, getting her a meeting with a gifted psychiatrist and
pleading her case when his clinic tried to have her kicked out for
threatening a worker. Mike does eventually wind up in jail for burglarizing
his sister-in-law's house for drug money, but stands little chance of
getting into drug court because the break-in was residential, not
commercial, and prosecutors don't want to seem to be coddling offenders who
have been "terrorizing the community." Not only that, but because he has
been convicted of a couple of other minor, nonviolent felonies in the past,
he faces a three-strikes penalty of 25 years to life -- a grotesque travesty
of justice, given how badly he wants to be a responsible husband and father
and how well he might do with the right kind of help.

"Hooked," with its tales of lives horribly mangled by everything from
childhood abuse to mental illness to bad luck and, of course, addiction,
gives the lie to the boot camp mentality that prevails in our public
conversation about drug abuse. You need only look at the "before" and then
the radiant "after" photos of Darlene and Crystal (beaming as she graduates
from drug court) to see the kind of results that playing drill sergeant will
never get us. Drug courts -- derided by some as "hug courts" -- don't coddle
addicts, but they don't abuse or abandon them either. Shavelson has good
things to say about a recent judicial mandate in New York that would send
nearly all nonviolent drug-addicted offenders into rehab, but cautions that
California's recently passed Proposition 36 doesn't insist on the kind of
coordinated monitoring needed to make its similar directive pay off.

If you believe, as I do, that the war on drugs is really just a job creation
program for people who'd otherwise be out of work now that the Cold War is
over (the spooks and soldiers go to Colombia and the weapons-plant workers
go to the prison-industrial complex), then, alas, it's hard to see the kind
of revelations found in "Hooked" having much effect on public policy.
Despite McCaffrey's own endorsement of the drug court model, you just have
to do the math to see that things haven't changed that much. As McCaffrey
left the Office of National Drug Control Policy at the end of 2000, the 2001
budget allocated $50 million to drug courts, $420 million to new prisons and
$1.3 billion to fight the drug war in Colombia.

- - - - - - - - - - - -
About the writer
Laura Miller is Salon's New York editorial director.

Copyright 2001 Salon.com

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