Thursday, April 5, 2007

Hooked: Five Addicts Challenge Our Misguided Drug Rehab System

By Lonny Shavelson
ISBN 1-56584-684-2

TWO REVIEWS! Craig Whalley and Marty N.

Craig's review:
This book is not easily pigeonholed. It centers on a critique of public policy issues surrounding drug rehabilitation efforts aimed at “street” addicts, who have no resources to apply to private treatment. But the author, Lonny Shavelson, approaches his subject in such an astonishingly fresh, compassionate and insightful manner that he manages to shatter a number of myths about “Recovery” along the way.

Shavelson, a physician and journalist (and neither a “recovery” professional, nor an academic, nor a reformed addict), spent two years following the often-Kafkaesque journeys of five different addicts (Heroin-2, meth-1, crack-1, alcohol-1) as they were dealt with by the network of recovery facilities in San Francisco in the late 1990’s, when that city initiated an “open door” policy promising the availability of treatment for all who sought it. He found that the chaos of the addict’s lives was replicated in the chaos of the rehabilitation system.

In many ways, the author shows, the “System” is designed to weed out those who most need its help. Dual diagnosed? Go to the drug rehab centers and be told treatment is not available to those with severe mental disturbance. Rejected but not despairing, go across town to the mental health center and be told, “sorry, we can’t help you until you stop taking drugs.” Suffer a relapse? Be kicked out of most programs, as though the ability to NOT use drugs is a pre-condition for admittance to a drug rehab program. Homeless? Conclude your rehab by being placed in a cheap hotel room in the same part of town where drugs dominate life.

But there’s another level to this book. Shavelson gives a voice to people rarely heard from: practicing addicts. What we see is, superficially, what we might expect, a group of screwed-up people But he persists for a deeper look and allows their humanity to not just be visible, but to shine through unforgettably. What he reveals are people who are fighting as hard as they can to survive even while they appear, to non-addicts, to be destroying their lives. The addicts are burdened by the results of their “choices,” but they also suffer daily from the other realities that haunt their lives. First and foremost is childhood abuse and neglect. Add some poverty, some emotional distress, and a limited ability to establish healthy relationships, plus lots of unresolved anger and a lack of resources upon which they can draw. The result is chaotic lives. The goal of treatment is, or should be, to bring order, calmness and good mental and physical health in place of this chaos. But more often than not, Shavelson shows, all else is forgotten in the quest for “order.” In fact, the addict himself is often lost, as the “System” demands conformity and rigid adherence to rules and procedures designed to serve the needs of the system itself, rather than the needs of the addict. “Hooked” is, among other things, a classic story of the nature of bureaucracy.

In the end, Shavelson contends, the best hope for these hardcore “street” addicts comes from what seems, at first glance, to be the least likely source: the criminal justice system. Drug courts (a recent innovation), he contends, EXPECT addicts to relapse and are prepared to offer the sort of stern-yet-forgiving guidance that is crucial to long-term success. In fact, the twin poles of “stern-but-forgiving,” and “nurturing and understanding,” he seems to say, are the real sources of treatment success.

One thing missing from “Hooked” (thank God!) is any discussion at all of AA. It’s mentioned in passing, but it’s clear that the author considers it irrelevant to a serious analysis of the issues surrounding addiction.

Most people don't care enough about addicts and alcoholics to pay attention to us, unless we crash a car, break a window, hurt somebody, litter the sidewalk with our bodies, or otherwise make a nuisance of ourselves. Lonny Shavelson is one of the exceptional people who cares, really cares. He spent two years following the lives of heroin addict Mike Pagsolingan, methamphetamine addict Darlene James, crack and alcohol addict Darrell McAuley, alcoholic Glenda Janis, and crack addict Crystal Holmes, as they struggled to survive and to get clean and sober in San Francisco during 1998-2000.

He not only interviewed them and photographed them, he fed them and gave them rides and carried their bundles and their messages and held their babies and searched for them and advocated their cause before counselors and other authorities in San Francisco's addiction treatment and mental health bureaucracies. The result is a book full of heart and wisdom about five remarkable lives, readable as an intensely human story.

These portraits -- all too familiar in many ways to anyone who has experienced addiction from the inside -- must deeply touch even the non-addicted with the pain, the obstacles, the gallows humor, and the extraordinary determination and survival skills of its subjects' lives. By profession an emergency room physician, Shavelson also has credentials as a journalist, author, and photographer, and he writes concisely and vividly, with an eye for the graphic detail and the telling anecdote.

Mike shooting up with one hand while driving his pickup truck on the freeway, Darlene withdrawing into a tarpaper cave dubbed the Opera Boxes under the freeway after Public Works bulldozed her homeless encampment, Darrell losing his beloved dog while double-parked outside a bar to get a drink, Glenda cheerleading her program's basketball team, Crystal trying to scam the Drug Court judge -- these and many other scenes and stories make for a rich tapestry that kept me turning the pages.

Shavelson succeeds as a biographer in showing his people as three-dimensional, contradictory, believable, alive, intelligent, and worthy of your interest and compassion; and you may find yourself, as I did, crying over Glenda, and anxious to learn Mike's court sentence, and proud of Darrell, and laughing and cheering with Crystal, and wanting to rage and storm at the mistreatment of Darlene.

If there were nothing more to Shavelson's book than these deeply felt, vivid and memorable five characters -- faces we can see on the City streets every day -- the book would be well worth buying, reading, and sharing with friends. It is so rare that anyone takes addicts, especially hard cases, seriously enough to get close and pay attention and write well.

But Shavelson's book is not merely a biographical study; it is also, as its subtitle indicates, a brief for reform of the substance abuse treatment system. Each of Shavelson's people has a series of encounters with one or another island in the archipelago of San Francisco's more than 130 drug treatment programs, and the author sticks with them before, during and after, tape recorder and camera in hand.

A highlight of the book is the story of Mike's journey through Walden House, perhaps the premier rehab program in the city. Walden House is a Therapeutic Community inspired by Synanon and based on the premise that all the addict's old habits, behaviors and thoughtways must be torn down and rebuilt along clean, structured, disciplined lines. A tight schedule of groups, meetings and chores with few if any free moments, a thick book of written and unwritten rules, a system of public penance for any neglect of duty or infraction, and unquestioned obedience to staff members make up the recipe for creating an overpowering community aiming to reform and rebuild the individual addict from the ground up.

Walden seems to work for Mike; he works hard, stays clean and seems to be developing into a model participant who is assigned to mentor newcomers. But on his last day he drops a note that says "I love you" in the laundry basket of a female member, in flagrant violation of Walden rules, and he is called into a House Meeting. There he sits alone in the center of the room on an old hardwood chair, facing a godlike staff member in a padded armchair, and surrounded by the assembly of residents. The staffer barks a command, the residents snap to attention and chorus "Thank you." Then comes an ordeal of confrontation, accusations and vilification hurled at the violator, renewed with each response, until he breaks down in shame and humiliation.

In this case, Mike is allowed to remain a Walden member, but he does not last long. Soon he is shooting heroin again, and when he is found out, he is kicked out of the program, banished from its services, and ostracized: no member may speak with him or even acknowledge him on the street. The author asks: what kind of medical treatment stops and kicks the patient out on the street just when he most needs it?

Darlene's odyssey through treatment begins in a Central Intake Unit where counselors are supposed to find treatment slots for them within 48 hours. But Darlene is not only homeless, she hears voices, and nobody has been able to find out whether her auditory hallucinations came before her drug addiction or are one of its symptoms. She not only needs drug treatment, she needs mental health treatment. Most of the drug treatment programs don't want her because of her voices, and the mental health system doesn't want her because of her drugs.

Despite author Shavelson's energetic and informed intervention on Darlene's behalf, she gets ping-ponged from one closed door to the other, and Public Works repeatedly rips up her ingenious and cozy self-made refuges until she ends up sleeping in doorways. Shavelson's last-ditch effort to find her someone who will help her takes them to the Haight-Ashbury Free Clinic, where her case touches off a war within the staff over the proper role of treatment. Darlene in the eyes of the treatment system is Trouble; yet, as Shavelson points out, Darlene is also very typical. If the system can't help Darlene, it isn't doing its job. If the system can only help the easy cases, what good is it?

A year into his research, Shavelson encounters Glenda, a Lakota woman of 37 who looks 70 and has been getting drunk since she was a teenager on the reservation. There is a Death Prevention Team in the City, a six-member crew of probably the most dedicated and pragmatic city employees in the urban jungle; they make the rounds of the alleys and empty lots at night, trying to save lives. Glenda tops their list of homeless persons most likely to die.

Unlike Darlene, Darrell and Mike, who desperately wanted treatment, Glenda only wants to drink; she wants nothing to do with rehab programs of any kind. One afternoon, stretching the rules considerably, the Death Prevention team lures Glenda into a taxicab and basically kidnaps her into treatment: first the emergency room, then detox, then to Friendship House, a Native American drug rehab. Against her drunken will. But after two sober weeks at Friendship House, Glenda begins to heal. Her numerous scars have begun to close, her eyes are clear, her voice is calm and soft.

Surrounded by affection, by culturally familiar foods and symbols, and showered with positive reinforcement, Glenda begins working through her load of pain and discovering the beauties of life as a sober woman. After three months, she is beginning to look like a transformed person. Her graduation ceremony is a moving ritual of rediscovery and renewal.

The next day the program throws her back into the same infested hell where she came from. The program has a 90-day funding limit and there is no appropriate clean and sober housing available for her. Within weeks she relapses; months later, she dies. What point is treatment, even excellent treatment, if it stops just when it starts working, and if there is no aftercare, no coordination with housing and other social services?

Crystal, a small time crack dealer and user, also enters treatment involuntarily. Busted for possession, she finds herself in San Francisco's Drug Court, which refers her first to outpatient treatment. Street-smart and a con-artist, she goes along for the ride but soon relapses and lands back in court. After two more relapses in two other programs, Crystal begins to realize that she has a more serious problem than she thought, and asks for, and gets, full-time inpatient treatment, and eventually becomes a proud and successful Drug Court graduate.

She is one of the lucky ones. Most of the other addicts have nobody who follows their cases through thick and thin, who can refer them to the appropriate program, find them social services, mental health services, housing, medical care, education, whatever may be available and whatever would help her stay straight. She has all of that and more, in the person of a Drug Court judge. Part actor, social worker, teacher, doctor, psychiatrist and priest, with the threat of state prison as a backup, the Drug Court judges emerge as the real therapeutic heroes of Shavelson's book. It is an irony, not lost on Shavelson, that the clinical ideal of continuous case management, matching, referral, coordination of services, and follow-up, toward which the civil treatment system theoretically strives, is a living reality only in this narrow sliver of the criminal justice system, the Drug Courts.

Shavelson argues that his five individuals are broadly representative, and that their experience with the treatment system in San Francisco is typical of or better than the national picture. Of course, Shavelson only saw and his people only experienced a relative handful among the scores of programs in this one city. Still, Shavelson brings a formidable array of statistics and authorities to the case. The nation today has fewer addicts, but they are worse off. A high proportion, perhaps a majority, have dual diagnoses: trauma, psychosis, bipolar disorder, and other psychiatric disorders. A tiny proportion of substance abuse programs and an even smaller number of mental health programs are qualified and willing to treat such addicts.

Getting bounced from one system to the other without help from either one, as was Darlene, is the rule rather than the exception, according to knowledgeable professionals whom Shavelson quotes.

Cutting addicts off from peer group contact and from services just when they need them most, after a relapse, is the iron rule at Walden House and, in one form or another, at many other treatment centers.

Connecting the addict with other social services, even just following up the addict after treatment to see what happens, is exceptional. Only a highly visible program such as Walden House maintains some kind of follow-up statistics, and they are not encouraging. True, of those who spend two years in the program, 75 per cent achieve stable recovery; but 90 per cent drop out before graduation. The less prominent programs, typically, have no evidence-based idea what happens to their clients/patients after they leave and no supportable claim whether what happens within their walls "works" or not.

Nor, despite all the millions of public funds that are disbursed to the more than 40 entities that run more than 135 drug rehab programs in San Francisco, is there any oversight, accountability, or coordination. In an afterword, Shavelson writes that his experience in writing the book hammered certain conclusions into his consciousness. They are:

Relapse: When an addict in rehab gets worse and heads back to drugs, the programs must increase treatment, not withdraw it.
Detox: Each and every rehab program must be required to have a formal, structured association with a drug detox center where it can send relapsed clients.
Humiliation: Abuses and humiliation in the name of therapy must cease. Cities must establish an ombudsman to monitor the rehab programs, and addicts must be allowed to access the ombudsman without repercussions.
Psychological counseling: All rehab counselors must be trained to recognize and treat the multitude of addicts who also have psychological disorders, and refer them to appropriately intensive additional care when needed.
Case management: Cities must establish a comprehensive case management system to guide addicts through the maze of programs and services. The case managers should not work for any particular rehab program, but rather represent and advocate for the addicts in the overall system.
Oversight: Government agencies that provide funds to the programs must assure that addicts are receiving comprehensive and effective treatment.
Funding priorities: Federal funds and efforts must be shifted from drug interdiction abroad to drug rehab at home.
Summing up, Shavelson asks himself, "Does drug rehab work for those who are most disastrously addicted?" and answers:

I still don't know. In the two years of this investigation I rarely saw rehab done well enough to learn if it might work. What we today call drug rehab does not provide consistent and coherent help to the majority of addicts who come seeking it. It may well be that the nature of the beast of addiction makes effective treatment of addicts a pie-in-the-sky dream, even with the best that rehab could offer. Or it may be that the frustratingly unimpressive treatment results we see today with those most intensely addicted are merely what happens in a rehab system that is as ill as the addicts themselves.

Rehab can work, he stoutly believes, based on the glimpses of good treatment he saw here and there, but not in the way that it is put together today.

This is a book that ought to stir the public and lead to a thoroughgoing reform of the treatment industry, much as Charles Dickens' novels led to reform of poorhouses and boarding schools, as Upton Sinclair's The Jungle led to the cleanup of the meat packing industry, or Jessica Mitford's expose helped reform the funeral business. Shavelson's documentation is thorough and well-informed; his human characters are compassionately drawn and real; and his agenda is on the table.

His book corroborates the principal findings of the Hester-Miller Handbook of Alcoholism Treatment Approaches, reviewed here earlier, but much more vividly, with more passion, and as a gripping, colorful human story.

Like any sincere and well-intentioned reform effort, Shavelson's proposals will draw fierce opposition from entrenched interests in the treatment industry, who thrive in the present climate of non-oversight and non-accountability, as well as from political conservatives, who see all treatment, even when enforced by Drug Court judges, as so much "coddling the addict."

The ideas that addicts should have access to an ombudsman, and that case managers should advocate for the addict rather than for the institutions, although commonplace in other medical contexts, are still considered almost seditious in the addiction setting, where blame for the failures of deplorably bad treatment is routinely thrown on (and accepted by) the addicts themselves. But when an author makes the case as vividly and persuasively as does Shavelson, perhaps the public will listen and a reform of the treatment industry will finally commence.

I want to add as a postscript some of my favorite little snippets from the book.

As a LifeRing speaker and activist who frequently advocates in a treatment setting, I am keenly interested in how the professional practitioner approaches the addict. Does the practitioner define the addict as "one hundred per cent zero" when it comes to the power to recover, so that only an external force can bring change, or does the practitioner look for the inner struggle, the internal voices of desire for recovery, the native resilience and survival instinct, and build on that?

I was tickled to read the dialogue between Darlene and Dr. Pablo Stewart, the resident psychiatrist at the Haight Ashbury Free Clinic, one of the several clinical Good Persons in this book.

Darlene, in her first interview, is telling Dr. Stewart that if an addict doesn't want to get off drugs, "you can just talk at them until your eyes turn blue, and they'll just tell you to fuck off."

This is hardly news to Dr. Stewart, and he has an answer. Holding up his thumb and forefinger pinched together, he says, "Just possibly, that person who you're speaking about may have the teeniest of desires" to deal with her drug problem.

Darlene joins in the game, holding up her fingers and pinching them together harder. "Well, what if that person only has the teeniest, teeeniest, tiniest wanting to be off drugs?"

"Then," says Dr. Stewart, standing up and offering her his hand, "I would think that such a person would do very well in this clinic."

Here the doctor knows that telling Darlene she is powerless over drugs or that she has an incurable progressive fatal disease is a sure way to drive her out of the clinic. What keeps her coming back is his solemn acknowledgement that something within her, something of her own, no matter how concealed and tiny, is right and good; and he bonds with that quality in her, no matter how fragile, and builds the therapeutic relationship on it. That seems to me an example of the LifeRing way: finding, acknowledging, reinforcing and ultimately empowering the sober place within the addicted person, rather than shaming and humiliating the person for displaying the symptoms of their affliction, as so frequently happens.

Another example of what I think of as the LifeRing approach shines through Glenda's remark about her counselor in Friendship House: "Evelyn tells me, 'Glenda, you're a strong, wise lady.' She says all kinds of things about me that make me feel really good." The counselor Evelyn is a strong, wise lady herself, and she knows that focusing on Glenda's many deficiencies and shortcomings would be a pointless and abusive therapeutic exercise. Glenda has been beaten up enough. Healing cannot come by reopening the wounds that her addiction has inflicted on her; it must begin with recognizing and reinforcing her positive, sober side.

Another gem, in my view, is Shavelson's conversation with Drug Court counselor Marillac after observing her run a meeting. He thought Marillac would be tougher with the Drug Court patients, because they were mandated to be there.

Marillac shakes her head. 'It's just the opposite.' She smiles. 'I have to be more relaxed with them here. The fact that they're mandated to be in rehab doesn't make their treatment easier, it makes it harder. They have to show up, but then I have to win them over to wanting to change their lives. If I act tough, all I get is an addict who's pissed at another authority figure. So I've got to grab at what good they have inside of them, and they have to see me grabbing it, bringing it out - accepting them.'

It's ironic, Shavelson observes, that rehab in the coerced setting of Drug Court turns out to be more compassionate than rehab in many voluntary programs. Not only compassionate, but more pragmatic and more likely to be effective. "Grabbing the good" that is inside the addict, bringing it out, accepting them because of it -- these methods awaken and mobilize the inner motivation to get clean and sober, without which no treatment approach has the slightest chance of success. That, too, is to my mind a "LifeRing" type of approach.

Also very true and significant in my eyes is Shavelson's observation, made after watching Mike stay clean and sober on his own for weeks while waiting to get into treatment, that "the fierce power of an addict's obsession with drugs is matched, when the timing is right, by an equally vigorous drive to be free of them." Linking up with and mutually reinforcing that vigorous inner drive to be free is, basically, what our LifeRing self-help groups are all about. That vigorous drive for freedom, if given peer support, can do more than match the obsession for drugs, it can overpower it, break it, and pen it up harmlessly for life. Shavelson's observation ought to be made into a poster and hung in every treatment room, where it might do far more to promote recovery than the disabling platitudes typically found there.

There's much more to like in this gem of a book, which ought to win its author big awards. If it has one flaw, it's that it ignores the big elephant in the center of the room. By far the greater part of the rehab industry that Shavelson finds misguided and inadequate is of course erected on the 12-Step model. Shavelson, however, maintains a diplomatic silence about this whole topic. However, the fact that he quotes all of his subjects by their full real names and publishes their photos, with their express consent, speaks volumes. This book is a powerful manifesto calling for more effective alternatives, by someone who passionately cares about people.


Photos: Mike Pagsolingan in Walden House, Mike in relapse; Darlene James with her shopping cart, Darlene in treatment with Dr. Stewart; Glenda Janis on the street, Glenda with counselor Evelyn at Friendship House. By Lonny Shavelson, from the book.

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