Pubdate: Sun, 10 Feb 2002
Source: New York Times (NY)
Section: Magazine
Copyright: 2002 The New York Times Company
Contact: http://www.nytimes.com/
Details: http://www.mapinc.org/media/298
Author: Peggy Orenstein
Note: Peggy Orenstein is a contributing writer for the magazine and the
author of ''Flux: Women on Sex, Work, Love, Kids and Life in a Half-Changed
World.''
STAYING CLEAN
Patrick T. is prone to citing Oscar Wilde and the physicist Michio Kaku.
He's so well spoken, his manners polished to such a high gloss, that --
aside from the fact that he's been a methamphetamine addict and career
criminal since age 13 whose only formal education is a high-school degree
earned in juvenile detention -- he could blend easily into a gathering of
witty young professionals. Certainly he is equally engaged by his work.
Until recently, Patrick often earned his living robbing drug dealers and
the occasional small business. "There's a lot of thought and energy that
goes into getting loaded and planning a crime," he explains. "It's dramatic
- -- the excitement, the carefree feeling that comes when you succeed. That's
not something that happens in the monotone of everyday life. That's why for
me, feeding my mind and spirit will be as important as anything I do in
terms of abstaining. Because if I get bored. . . . " He lets the threat
hang, unspoken.
Patrick is 30, tall and rangy, with sandy, short-cropped hair and a neatly
trimmed goatee. He and I are in the small library of Center Point, a
substance-abuse treatment facility in San Rafael, Calif., about half an
hour north of San Francisco, where he is enrolled in a six-month
residential program. Patrick is a "retread": this is his second time
through here in a year, initially in exchange for a suspended sentence on
charges of possessing drugs and stolen property. He completed the program
last June and got a job restoring boats in Sausalito, convinced that his
own ship had finally come in. But within five weeks he had moved from
swallowing pain pills for a bad back to downing a couple of beers with his
older brother. Then he started lighting up a few joints. In less than two
months, he headed to San Francisco on a meth binge. He had planned to stay
high until his money ran out, he was arrested for violating probation or he
died. But one night, holed up in a transient hotel with an old crime
partner and a prostitute, Patrick had a revelation. "I was suddenly
disgusted with the whole scene," he recalls. "I had this thought -- or this
thought was given to me -- that I just couldn't do it anymore. I just
couldn't." He called Center Point and said he needed help. Within 24 hours
he was back.
As Patrick talks, members of ''the family,'' as the 40 clients here call
one another, drift in and out, browsing through the self-help books that
line one of the room's walls or -- since the program frowns on privacy --
listening to our conversation. A disheveled heroin addict who has been
through six treatment programs in 11 years comes in to sharpen a pencil.
After he leaves, Patrick says, ''What scares me are people like him, who
are intelligent. That can be one of the biggest obstacles. You substitute
intellectual understanding for actual change.''
I ask Patrick what odds he gives himself this round for staying off drugs.
''Fifty-fifty at best,'' he says, evenly. ''But anyone who'd give their
chances as being any better than that is practicing self-deception.''
[P] atrick is one of thousands of addicts in this country who are doing
exactly what the new conventional wisdom says they should: going through
treatment and probation rather than jail (or in exchange for a lighter
sentence) with the promise of a better outcome. It's the latest salvo in
America's other war -- the one on drugs -- which many would acknowledge
we've been losing for years. Consider: The federal government spends about
two-thirds of its $19.2 billion drug budget on law enforcement and
interdiction. A result has been a skyrocketing prison population -- it has
tripled in the last two decades -- with at least 60 percent of inmates
reporting a history of substance abuse. The cost of warehousing nonviolent
drug offenders is more than twice as great as treating them. Meanwhile, a
study by the RAND corporation's drug-policy center found that for every
dollar spent on treatment, taxpayers save more than seven in other
services, largely through reduced crime and medical fees and increased
productivity. A visit to the emergency room, for instance, costs as much as
a month in rehab, and more than 70,000 heroin addicts are admitted to
E.R.'s annually.
Those facts, along with an enormously successful campaign by the National
Institute on Drug Abuse (NIDA) to portray addiction as a disease rather
than a moral weakness, have already persuaded Californians and Arizonans to
pass voter initiatives requiring nonviolent drug offenders to be offered
treatment with probation in lieu of jail. Similar measures are being
targeted for November ballots in Michigan, Florida and Ohio. By 2003,
systemic changes in the New York courts are expected to divert 10,000
nonviolent drug addicts to rehab annually. And Senators Barbara Boxer and
Orrin G. Hatch, hardly ideological soul mates, have proposed bills to
increase federal funds for treatment, although they differ considerably in
details.
As the call to treat drug offenders grows -- an ABC News poll showed that
more than two-thirds of Americans favor treatment over jail for first- and
second-time offenses -- one of the thorniest questions will be how to
define success. Because the truth is, Patrick's estimation of his own
chances is about right. Center Point, which was established in 1971, runs
one of the oldest and largest treatment networks in California and has what
are considered excellent success rates. Still, one-third of its clients
leave without completing the program, even if that means going directly to
jail. Nationally, dropping out of treatment is the rule. Among those who do
finish, few maintain the gold standard of total abstinence for long: a
Congressionally mandated study showed that more than half of cocaine
addicts and nearly two-thirds of those addicted to both heroin and cocaine
were using drugs within a year.
Center Point's adult program house sits at the nexus of the business and
residential districts in downtown San Rafael. Bland, dorm-style bedrooms
line three halls, each room containing two single beds, two dressers, two
night stands, two lamps. Out back, beyond the TV room (which is off-limits
most of the time), there is a concrete slab for smoking breaks. Clients
spend much of their day in a large central room that, depending on the
configuration of chairs and folding tables, serves as dining room, therapy
space or study hall. Its only decor are two small handmade signs: One
reads, ''And the day came when the need to remain closed became more
painful than the risk to open.'' The other, the map of a land called
re-entry, highlights the Ten Concepts -- initiative, effort, completion,
etc. -- that are the backbone of Center Point's program, the precepts upon
which clients are supposed to build their new lives.
The 40 family members file in and sit silently in a circle on
straight-backed chairs. They are mostly white and mostly male, many with
prison tattoos covering their forearms. Most are in their 30's, which is
typical in treatment. They place their hands in their laps, feet on the
floor, and look straight ahead in what is called ''group protocol.'' When
anyone deviates, a brother or sister corrects him. He may not talk back.
When anyone deviates, a brother or sister corrects him. Women and men sit
on opposite sides of the room and may not speak unchaperoned. When anyone
deviates, a brother or sister corrects him.
Strict adherence to what to an outsider can sometimes seem like arbitrary
rules is integral to the therapeutic-community method: a self-help-based
approach to addiction that most of the large drug-treatment franchises
employ. At the heart of the method is the belief that daily interactions
within the family -- a kind of round-the-clock peer pressure -- are the
main agent of change. Drug use is viewed as symptomatic of a ''whole
person'' disorder. If, through resocialization, an individual's attitudes,
values and lifestyle are transformed, the addiction will take care of
itself. Governing everything from how long clients can shower to what they
can drink (no coffee, for example), the rules are supposed to instill
self-control and provide structure for those who may never have had it. The
idea is that if you sweat the small stuff, the big stuff, like not stealing
or not using drugs, will follow.
Instilling a work ethic is also essential to a therapeutic community.
Everyone helps maintain the house, doing laundry, cooking, cleaning. New
clients are assigned a ''big brother'' or ''big sister'' who accompanies
them everywhere, even to the bathroom. As they participate in the family,
write essays exploring such issues as their attraction to drugs, memorize
the Concepts and generally behave themselves, they move up in ''status,''
earning rewards that are both tangible and affirming, like receiving mail.
After three months, clients ease into the real world by finding a full-time
job, some for the first time. After six, they either move to transitional
housing or home, cautioned to attend ''continuing care'' or 12-step
meetings for at least a half-year.
Each day at Center Point is punctuated by group therapy sessions guided by
a counselor, in which a client brings up an issue -- past sexual abuse, a
craving for drugs -- and the rest of the family responds, sometimes
bluntly, with opinions and advice. The feedback is supposed to break
through calcified defenses and challenge ingrained thinking, helping
clients recognize the need for change.
Today is ''grief and loss'' group, and Micky Wickersham, a blond,
ponytailed counselor who is leading the session, asks Sharon A., 32, if she
has anything to share. Sharon is addicted to a volatile combination of meth
and pain pills. She was ordered to treatment by the Child Protection
Program under the threat of losing her 23-month-old daughter. (She also has
an 8-year-old son.)
''I'm drawing a blank,'' Sharon responds, smiling appeasingly.
Wickersham, a 33-year-old recovering alcoholic and meth addict herself,
eyes Sharon, who has been here for several weeks sliding by, evading
attention. Like most clients, Sharon resists kicking up the murk of an
unhappy life. It's time to give her a little push.
''No problem,'' the counselor says, turning to the family for inspiration.
Hands shoot up. One brother tells Sharon that she acts detached from her
own experience, as if it happened to someone else. A sister begs her to
''open up'' for her own sake, then bursts into tears. ''Let us help you,
Sharon,'' she says.
Patrick goes on the attack. ''You want to put things out in a pretty
package so everything will sound good,'' he snaps. ''Forget sounding good.
Sound real.''
Wickersham lets that thought hang for a moment. ''We could unwrap that
pretty package right now,'' she says, sweetly ominous. ''Do you know what
it looks like on the outside?''
Sharon shakes her head almost imperceptibly, looking dazed.
''You like to present yourself as a middle-class white woman with a little
drug and alcohol problem who some stuff happened to and now you're here to
get your life back.''
''No,'' Sharon says softly. ''I don't mean to.''
''Do you know what's inside that box?''
Sharon shakes her head again.
''Because I'm going to tell you,'' Wickersham continues. ''You are a
homeless dope fiend with no education who chose drugs over your kids.''
Wickersham goes on to say Sharon could become the woman she pretends to be
by dedicating herself to the program. She could take advantage of Center
Point's G.E.D. tutoring and vocational training. She could learn a new
values system. She could get her children back. ''Do you want this
program?'' Wickersham asks.
''Yes,'' Sharon says.
''Let me hear you say it.''
''I want this program.''
''Again.''
''I want this program.''
''Choose four men and four women,'' Wickersham says. ''Look into their eyes
and say, 'I need your help because I want this program.' ''
Sharon steps across the circle to a brother who is addicted to crack and
meth. ''I need your help because I want this program,'' she says softly.
''Sharon, I need your help because I want this program,'' he replies.
She moves on to three more men, then to the women, who cry and hug her.
Finally Sharon stands before Wickersham, unexpectedly grabs the counselor
by both hands and yanks her to her feet. ''I need your help because I want
this program,'' she says, a tear rolling down her cheek.
It's a poignant, triumphant moment. Sharon has admitted her problem. She
has allied herself with the group. She has bonded with her counselor. And
she has been offered hope that, with diligence, she can turn her life
around. On other visits, I would watch a prison-hardened man weep like a
little boy over the death of his father. I'd witness a woman mourn over
neglecting her children. I'd listen to a brother grieve years of
molestation by a coach. The family would confront or cajole, console or
criticize. As moving as it all was, I wondered: can such catharsis, or even
a series of them, keep an addict clean?
''Of course it can't,'' says Sushma D. Taylor, a clinical psychologist and
Center Point's C.E.O. ''But they're related. Our clients are seeking
emotional sanctuary, especially the many who have suffered abuse. The only
way you can grieve the things that have been done to you is to cry in a
place where you know the tears are going to get mopped up and somebody is
going to put you back together and say we love you, where no matter how
ugly the past is, it can be viewed within the context of being a
therapeutic issue.'' Realistically, the groups can't resolve past traumas
in six months, Taylor says. They are just a step toward self-awareness,
toward learning healthier ways of coping with pain.
Later, when Sharon is cleaning the bathrooms, I ask her how the attention
felt. ''I wanted to hide in a corner while it was happening,'' she says.
''But afterward I felt exhilarated. It really did feel like something had
lifted off of me.'' She sighs. ''I still fear I won't be able to open up,
though. They say doing jail time is easier than treatment, and I think
that's true. This is not easy.''
In July, when California enacted Proposition 36, which diverts drug
offenders to a variety of treatment programs (depending on availability),
Mike T. was just the sort of addict whom the public had in mind. He is
affable, nonviolent and employable, and he has never been in treatment.
Mike pleaded guilty to possession and has one other charge pending -- he
tried to draw on a forged check at a bank, a crime largely influenced by
his drug use.
Mike is a natural athlete, a former ski instructor, but two years of daily
methamphetamine use has ravaged his body and destroyed his stamina. While
other members of the family play basketball in a nearby park, he takes a
break on the sidelines. It's a rare time outdoors, an hour away from the
relentlessness of 40 personalities rubbing up against one another in the
cramped public rooms of the house.
Mike is dressed for the game in sweat pants with an American-flag motif.
Other days, he sports an Old Glory T-shirt or tie. The patriotism is a
legacy of his father, a retired Air Force colonel who considers addiction
''a weakness.'' Mike's not sure what he thinks. As a teenager he watched
his mother drinking herself to death. He used to water down her wine, but,
he says, ''she always caught me, and it just made things worse.''
Mike's own drug use started, as did nearly everyone's in the family, in
junior high. He was a pothead, a party boy who added cocaine to his
repertory in high school. In his 20's, he switched to methamphetamine (also
called crystal meth, ice or crank), a cheaper, longer-lasting and easily
made form of speed that has swept the West and Midwest and is quickly
moving across the country; it's the dominant drug at Center Point. Meth can
be snorted, shot or smoked. At first, Mike says, the draw was the extra
staying power during sex. Eventually, though, he was doing several
''blasts'' a day. A college dropout, he supported himself when he could by
trimming trees or working construction. When he was on a run, he'd rely on
unemployment, petty dealing, cashing bad checks and mooching off friends.
By the time he was arrested in August for a small-time sale (a charge that
was later knocked down to possession), his family had cut him off
financially. He lost his apartment, hocked all his belongings and was
living in his truck.
Mike says he feels ''blessed'' by the opportunity he has been given, both
because he has avoided prison, the threat of which terrifies him, and
because it has helped him kick meth. ''Meth did nothing but destroy me
physically, mentally, emotionally, the whole nine yards,'' he says.
Even so, Mike won't rule out going back on the drug once he's off probation
(''Aug. 31, 2004,'' he repeats like a mantra). ''I know myself well enough
to know I may use,'' he says. ''I don't know for sure. I like the lifestyle
I'm living now. I look forward to getting something better than what I have
in life. But who's to say what will happen?''
To be a drug addict is to engage in a perpetual internal dialogue about
whether you truly have a problem, whether you really belong in treatment.
While acknowledging his meth addiction, for instance, Mike doesn't see why
he should stop his daily marijuana use -- even though smoking pot after
treatment triples the chances of a return to harder drugs. ''So every day I
ask myself: am I wasting a seat here? Is there somebody that needs to be
here to save their life, who is sick and tired of what they're doing and
wants to get help? Because part of me says: I'm 34 years old and I'm
healthy and if my choice is to smoke my pot and use drugs, then that's what
I'm going to do.''
Mike often suggests that he'll leave Center Point, that he'll head up to
Tahoe and get a job on the ski slopes. Of course, the more likely result of
walking away is jail. ''I know,'' he says, his eyes skimming the action on
the basketball court. ''In my heart I know I have to stay. If I walked out
of here now I'd go right back to where I was. I'd end up living in the back
of my truck.'' He turns toward me, leaning forward intently. ''But I still
think about how to get high every day. And that's the part of my addiction
that eats me alive.''
A few days later, Mike stops me in the hallway, asking me to define
addiction. Maybe, he says, his father is right and it's simply a failure of
will. ''I didn't smoke pot until I was 12,'' he reasons. ''I had a choice
then. And I still have a choice every day. So what does 'addiction' mean?''
He has every reason to be confused. Is addiction a spiritual disease? A
physiological illness? A character flaw? A sin? Genetics, in part, explain
why, when two people who are equally curious first try a mood-altering
drug, one walks away with a shrug and the other finds salvation. But
environment plays a role as well: economic disadvantage and family
dysfunction can drive the need to self-medicate (according to NIDA, an arm
of the National Institutes of Health, there are actually 72 separate risk
factors for drug abuse). Hanging around druggie friends has an impact, too,
as does boredom.
Drug use, of course, is not the same as addiction. The former is clearly a
choice. But over the last decade, scientists have begun to see the latter
as something else: a chronic, relapsing brain disease. At some point (when,
precisely, is unclear) the neurochemistry and receptor sites of a user's
brain change radically, causing drug-seeking to become as biologically
driven as hunger, sex or breathing. Long after the addict quits, some of
those brain changes remain, creating a vulnerability to relapse. The
implications for the criminal-justice system are profound, reinforcing the
need for treatment: it would be ineffective, not to mention inhumane,
simply to punish someone for an illness without helping to heal him.
Some researchers, however, call the brain-disease model little more than a
gimmick, one that undercuts the role of choice and personal accountability.
''I'm not disputing the fact that certain areas of the brain light up when
an addict thinks about or uses cocaine,'' says Sally Satel, staff
psychiatrist at the Oasis Drug Treatment Clinic in Washington and a fellow
at the American Enterprise Institute. ''But it conveys the message that
addiction is as biological a condition as Multiple Sclerosis. True brain
diseases have no volitional component.''
Casting addiction as a brain disease rather than a behavioral disorder,
Satel says, gives addicts an easy excuse for relapse. It also suggests that
the remedy is primarily pharmacological, which has not, so far, proved
true. ''The search for a magic-bullet cocaine vaccine has been under way
for 10 years, and I'm skeptical anything will come of it,'' she says. ''The
only way to get better is to harness free will. Ask any addict; they'll
tell you.''
Alan I. Leshner, under whose leadership NIDA aggressively promoted the
brain-disease concept, agrees that addicts should not be let off the hook.
''The danger in calling addiction a brain disease is people think that
makes you a hapless victim,'' he says. ''But it doesn't. For one thing,
since it begins with a voluntary behavior, you do, in effect, give it to
yourself.''
Nor does biology trump responsibility. ''Just like any other disease, you
have to participate in your own treatment and recovery,'' he says. Still,
he doesn't like the moral tenor of Satel's argument. ''What about people
with high cholesterol who keep eating French fries? Do we say a disease is
not biological because it's influenced by behavior? No one starts out
hoping to become an addict; they just like drugs. No one starts out hoping
for a heart attack; they just like fried chicken. How much energy and anger
do we want to waste on the fact that people gave it to themselves? It can
be a brain disease and you can have given it to yourself and you personally
have to do something about treating it.''
[I] n art therapy the clients are drawing one of the five elements in
pastels, after which they will explain their choice to the group. Patrick
is halfheartedly crayoning the ocean while describing the sculptures he
used to make in jail from bits of leftover soap. ''My proudest achievement
was a giant Oakland Raiders emblem,'' he says, holding his hands about a
foot apart, ''with big letters that said 'Commitment to Excellence.' ''
Patrick refers to himself as ''institutionalized'': he has spent so much
time in prison that the prospect is no longer a deterrent. ''I'm
comfortable there,'' he explains. Patrick is pretty comfortable at Center
Point too, perhaps too much so. He volunteers to speak in every group
(though maybe because of that, he is rarely called on). He follows the
rules meticulously and reprimands anyone he finds slacking. A few brothers
call him ''Center Pat'' behind his back, saying he has just perfected
rehab: once he leaves he'll surely relapse.
Patrick is determined not to let that happen. ''Last time I didn't extend
myself,'' he explains. ''I participated just enough to not be confronted by
a counselor. And behind the scenes I ran my own deal. I got someone to
sneak coffee into the house for me every day. I didn't respect 'quiet
time.' And those little things got bigger and bigger.
''Honestly, a lot of the rules are petty, and I'd still just as soon not
follow them,'' he continues. ''But we agree to do that when we come here.
Learning to keep that agreement, learning not to do what it is we feel like
doing, those are important things. I don't want to be quiet. I don't want
to not drink coffee. I don't want to do many of the things asked of us
here.'' He shrugs. ''But then, what I want to do has often times proven not
to work.''
Responsibility. Self-worth. Community. Those are the things Patrick hopes
to cultivate this round. That last piece is critical to any addict's
treatment. Familiar cues -- smells, places, people -- can have a Pavlovian
effect: a heroin addict who has been clean five years in prison may vomit
on the ride home as the bus passes old haunts, instinctively anticipating a
fix. An addict's best bet is to change environments entirely, but for
Patrick, as for anyone, ditching old pals is painful, even frightening. ''I
have a history and fun memories of using with my friends,'' Patrick says.
''I don't have a good sense of who I am outside drugs. I don't have much
experience with real life.''
Later, during an evening therapy group, a middle-aged meth addict who is
about to complete the program and move to transitional housing discusses
the daily obstacle course of temptation he navigates on his way to work at
a nearby supermarket. ''I see the dope fiends, and I can smell it on
them,'' he says. ''It reminds me of old times, of making dope, using dope.
I have heavy triggers. Any kind of chemical smell. At work I'm fortunate; I
don't have any of those smells. But I've seen dope on the sidewalk and
didn't mess with it. Or people leave their keys in their vehicles. One guy
had one of those restored cars from the 50's with fins -- he left the keys
in and the motor running while he ran into the market. I'm a dope fiend. I
have sleazy thoughts. But I don't act on them. I carry the Ten Concepts in
my pocket, and I read them in the street. That's how I work my way through
it.''
Dennis Labogin, the program manager who is leading the group, smiles.
''Eleven years later I can still spot the perfect robbery,'' he says.
''That's who we are. No matter where we are these thoughts will drag us
down. And the only people who will understand is us.''
Not all people with a drug or alcohol problem will self-destruct the way
Patrick and Mike and Sharon did. In fact many, like President George W.
Bush, will quit spontaneously before their lives unravel. Others do well
(at less taxpayer expense than treatment) on probation with contingencies:
rewards for abstinence and sanctions for testing positive for drugs. Those
tend to be lighter-weight users with more to lose. Have they not yet
contracted the brain disease? Or has it not progressed as far? Or, as Satel
might say, have they merely harnessed their free will?
Both sides of the brain-disease debate agree on one thing: a significant
subset of addicts do need help, which jail alone can't provide. ''I'd be
happy with incarceration if it were effective,'' says A. Thomas McLellan,
director of the Treatment Research Institute and professor of psychiatry at
the University of Pennsylvania. ''Here's what happens now. They go to jail.
Why? They've broken the law, and we're going to teach them a lesson.
They'll realize it's bad, and they'll stop. Then they leave jail and go
into the parole system. The parole officer has a caseload of up to 1,000
people. The individual is not monitored or only monitored briefly. And,
anyway, he was supposed to have learned his lesson. What happens is
relapse.'' McLellan and James W. Cornish undertook a study comparing
punishment in conjunction with treatment to stricter punish without
treatment, to see which was more effective in reducing crime. They found
that opiate addicts who were forced to increase the number of times they
met with their probation officers were twice as likely to be rearrested or
reincarcerated within a year as those who received only standard probation
but with therapy and naltrexone, a drug that blocks their high.
The question remains, however: Just how effective is rehab? The treatment
system, which evolved as a piecemeal, grass roots movement, has been
subject more to faith than to scrutiny. In many states, like California,
the rehab industry remains largely unregulated, with lax licensure and few
standards for quality or effectiveness. Since conventional wisdom blames
the addict for his relapse, if the courts are involved only the addict is
sanctioned: judges rarely ask whether programs delivered the services promised.
As public interest in treatment grows, though, researchers have been
taking a closer look at traditional methods to tease out the strengths and
limits. ''For many counselors the litmus test of good treatment is whether
you can get the patient to cry,'' says Richard Rawson, associate director
of the Integrated Substance Abuse Programs at U.C.L.A. ''If you look at the
data, there's not a lot to support a causal relationship between talking
about feelings and not using drugs and alcohol. I'm not suggesting it
should be ignored. Having a safe place to process that material is an
important element. It's the other half of the equation: 'O.K., so we've
done therapy. What do I do next?' ''
One answer, Rawson says, is to incorporate techniques that have been proved
in clinical trials. Medications like naltrexone, along with with
counseling, work well with heroin addicts. Meth and cocaine addicts,
particularly males, respond to cognitive behavior therapy. Used primarily
in outpatient programs, cognitive therapy does not focus much on the
psychological causes of addiction. Instead, therapists act more like
coaches, teaching addicts why they develop cravings and working on coping
skills, like planning in microscopic detail how to get from today until
Wednesday without using. For less severe addicts motivational enhancement
therapy peels away resistance to change through positive reinforcement
rather than confronting an addict with his denial.
Those methods are slow to gain ground in a field wary of outside
intervention. Counselors -- whose only qualification is often that they,
too, are in recovery -- resist replacing entrenched, it-worked-for-me
ideology. Consider the maxim that an addict has to be ''ready'' for
treatment, that he has to ''hit bottom.'' That idea gives providers a free
pass when rehab fails. It's also a myth: addicts forced into treatment by
the courts do surprisingly well. Apparently if you lead a horse to rehab he
may indeed quit drinking.
Beyond that, the newer remedies require extensive training. Though a
counselor like Micky seems especially dedicated (and Center Point does
integrate some science-based methods into its programs), nationally, the
turnover rate among counselors is an estimated 50 percent. And with
starting salaries around $18,000, the applicant pool is limited. ''In many
places you can work at McDonald's one day and be a drug counselor the
next,'' Rawson says. ''People you do train tend to go on to something else
as soon as they get some skills. It's hard to develop a cadre of skilled
people in those conditions.''
Another factor in successful rehab is matching a given addict to the
program and services that will make him stick. Each approach will work for
some, but none for all: the therapeutic community that clicks with a
homeless crack addict who suffers from post-traumatic stress may not be
appropriate for a medical resident who can't stop dipping into the
morphine. With long waiting lists for treatment slots and pressure on
programs, which are paid per client, to take whoever walks in the door,
that has not been an easy task.
While improving all these aspects of treatment may well lead to better
outcomes, according to a study of more than 10,000 addicts in 96 programs,
the single most important factor (assuming a program is well run) is the
length of time an addict stays in it. And 90 days -- not the
managed-care-driven 28 or the brief 3-to-5-day detox that is the most
common ''treatment'' in many cities -- was the minimum for enduring
benefits to manifest.
Little of this was taken into account by California's Proposition 36. The
state's 58 counties are applying the law in virtually 58 different ways.
Since each county can decide how to allocate its funds among direct
services, administrative costs and probation departments, some are still
emphasizing punishment over treatment. Either way, while the $660 million
over five and a half years is the state's biggest infusion of cash into
treatment, it isn't enough to cover the cost of long-term care for all who
will need it, whether for day or residential programs.
Although it's too early to predict how the experiment will play out, even
the staunchest supporters of treatment are skeptical, particularly as other
states prepare to follow California's lead. ''There is promise here,'' says
M. Douglas Anglin, co-director of the U.C.L.A. Drug Abuse Research Center,
a node of the National Drug Abuse Clinical Trials Network. ''But there are
also fears about a possible quagmire. The voters rammed Prop 36 down the
throat of all the agencies involved. And at the end of it all, we may find
no reduction in drug use or crime, and that treatment was received by fewer
than intended and for a shorter period than intended. It will look like
treatment doesn't work.''
At lunch, most of the men reflexively hunch over their plates, left arm
slung around the top, shoveling in their food as if they're in prison.
Mike, who works in the kitchen, stands at the front of the room wearing a
paper hat on which he has written ''Sinbad'' in Magic Marker. I sit at a
women's table with Sharon. It is ''dress for success'' day, so she's
wearing a long flowered skirt, green sweater and elegant black heels, all
salvaged from a local donations bin. Despite years of drug abuse and
personal neglect, Sharon is a beauty with an easy smile. She's a caretaker
too -- always concerned about whether I've had enough to eat or how far I
have to drive after a long day of reporting -- but the brothers and sisters
are right: she has the disconnected quality of someone who is treading
water against a rising tide of panic. She speaks quickly, her words
slurring together, and tends to finish her statements by asking, ''Does
that make any sense?''
Sharon doesn't remember most of her past, but what she does recall is a
shattering pastiche of rape, abuse and violence. Like Mike, she was
homeless when she arrived at Center Point; since dropping out of school in
eighth grade the closest she has come to having a legitimate job was when
she provided in-home service for her elderly mother, a position she was
relieved of when it was discovered she was filching pain pills. She is
currently studying the Ten Concepts. It's no surprise that she's stuck on
Trusting and Support. ''They make no sense to me at all,'' she says.
About half as many women as men enter treatment, but the ones who do are
more than twice as likely to have additional mental disorders like anxiety,
depression or post-traumatic-stress disorder. Though estimates vary,
perhaps as many as two-thirds, like Sharon, were raped or molested before
substance abuse. At least half have been victims of domestic violence.
Because victims of such traumas are more likely to become addicts, and
because, according to the National Center on Addiction and Substance Abuse,
addicts are more likely to abuse and neglect their children, breaking the
cycle among that population takes on particular urgency. Yet women, perhaps
in response to the aggressive, male-dominated nature of many programs, drop
out of treatment at far higher rates than men. Most of the women at Center
Point are in a separate, single-sex program with their small children. The
seven in this house are either childless or have grown children, or their
kids live with relatives. For that latter group, regaining custody is a
preoccupation. One of Sharon's table mates shows me three marbles she
carries with her: a clear blue one to represent her son, a green one
representing her daughter and a clear marble for the mother she would like
to become.
Sharon's children are currently with their fathers. Her daughter's dad is
also an addict, in a day program in another town. Her son's father is
clean. As much as she wants to set a better example for her kids, Sharon
would never have quit using drugs on her own: she likes, and needs, to be
loaded too much. Even so, she's indignant over her predicament. She talks
about leaving treatment to be with her daughter. But to be with her
daughter, she needs to stay in treatment.
Micky Wickersham, Sharon's counselor and a mother herself, had told me that
the hardest thing for a female addict is to admit she has been a bad
mother. Sharon is no exception, arguing with herself over what constitutes
child abuse. ''I love my children,'' she insists. ''I've never done any of
the stuff my mom did to us. I would never even conceive of doing that to a
child. I wouldn't beat them. So in my eyes, I don't feel like I was a bad
mother.'' She pauses a moment, considering. ''But granted, there was drugs.
I understand that. There was the drugs. But. . . . '' She breaks off again,
looking at me helplessly. ''Does that make any sense?''
Sometimes Patrick's dreams seem locked in the amber of adolescence. He
imagines being an actor someday or maybe a drummer. Other times, his goals
are more practical. He'd like to be a good father to his 10-month-old
daughter, a good partner to his girlfriend (who has been clean for more
than three years). He'd like to go to college. He also fears that he is
programmed for failure. ''You know, everyone falls,'' he told me. ''And
some people don't get back up. It scares me to think that I wouldn't be
able to stand up again. It wasn't easy for me to come back here. If I had
to make that choice again, it would be harder still. I feel awfully
concerned about that.''
On this night, however, Patrick is optimistic. He's about to move up in the
family hierarchy, gaining freedom and privileges. Labogin is supposed to
quiz him on one of the Ten Concepts, but instead Patrick opts to recite
them all. He closes his eyes and begins. ''Empathy,'' he says. ''The
ability to imagine how others feel.''
I glance around the room. Some of the brothers and sisters are leaning
forward, eyes shut in concentration, whispering the words along with
Patrick. Others, like Mike, stare straight ahead in silence. I wonder
whether Mike will experience the epiphany in treatment that will allow him
to make more permanent change. Or whether probation and the threat of
random urine tests will, in fact, keep him clean until 2004. Maybe the day
he's a free man he'll celebrate by lighting up a fatty. Then a week, a
month, a year later, break out the crank. Or maybe, just maybe, he'll
discover he likes looking at life without the scrim of a ganja buzz. Maybe
Sharon will get clean for her kids -- or for herself -- and stay sober, at
least for a while. Maybe Patrick will last four months this time or a year
or 10 years. Or maybe staying clean in treatment is, for the moment, all he
can manage. And though on the surface this may look discouraging, the
opposite is true. Failure, even serial failure, can actually be a form of
success.
Though among heavy users, some will go through treatment once and remain
clean indefinitely, most will cycle through repeatedly, just as some
smokers need multiple tries to kick cigarettes or dieters try over and over
to slim down. ''Treatment catches up with you,'' says U.C.L.A.'s Douglas
Anglin. ''For heroin users with a five-year history of addiction, it may
take 10 or 15 years to help them come out of it, but if you start when
they're 25, by the time they're 40 they're pretty much rehabbed. If you
don't, most of them burn out by 40, but they don't get clear until 55 or 60.''
Perhaps the epiphany Patrick experienced during his last binge in San
Francisco, the one that may have saved his life, was a direct result of his
last round of treatment. He thinks so. ''I couldn't even enjoy being high
with a pocketful of money,'' he recalls. ''I hope I never forget how
demoralized I felt.''
Or, as another brother who has been through treatment three times and is
addicted to meth, crack and alcohol puts it, ''All that recovery
information ruins your high totally and completely. It's a conflict of
interests to have that understanding and use.''
If treatment is conceived of as an ongoing process rather than as a cure, a
different, more optimistic notion of success emerges. Although addicts may
relapse, a year after treatment their drug use decreases by 50 percent,
according to the National Treatment Improvement Evaluation Study, and their
illegal activity drops as much as 80 percent. They are also less likely
than before to engage in high-risk sexual behavior or to require emergency
room care. Other studies have shown that they are less likely to be on
welfare, and that their mental health improves.
For chronic addicts like many of those at Center Point, it may be that
treatment should never entirely end; it should just be tapered down. ''You
don't let a schizophrenic out of case management,'' argues the University
of Pennsylvania's Thomas McLellan. ''Your expectation is that there will be
a relapse if they leave. Good practice would be to continue to monitor and
support that person to see early signs of intensification. At that point
you intensify treatment not to 'cure' but allow them to remain in a state
that maintains them and doesn't have an impact on society.''
Perhaps, then, Patrick clean, even for just the six months he's in a
program, and Mike clean for three years, and Sharon clean for as long as
the Child Protection Program breathes down her neck -- or even Patrick,
Mike and Sharon returning to treatment two, three, five times -- while not
optimal, may, for now, be good enough. If, that is, during that time they
cost the taxpayers less, they work and pay taxes themselves and they do
less harm to society, themselves and their children than they otherwise
would have. Even as researchers push for reform in the system, that
perspective may be the most pragmatic. ''We expect too much from
treatment,'' McLellan says. ''The relapse rates are about the same as for
hypertension, diabetes, asthma or any other chronic illness. At the same
time, we're not asking the right questions. Treatment providers and
researchers have been focused on whether someone uses drugs or alcohol
after treatment. I don't care if you drink. I don't care if you use drugs.
I do care if you're honest and not stealing from your employer or driving
drunk or stealing from cash machines.''
On a late January evening, I visit Patrick, but not at Center Point. He
left the treatment center on Thanksgiving Day, less than two months into
his program. After accusing a young counselor (who eventually left) of
abusing power, Patrick became the focus of rumors and suspicion himself.
Nor was he entirely innocent: he had manipulated the counselor into
sneaking him out of the house -- a major taboo. As punishment, Patrick was
assigned a series of essays on topics like criminal thinking; for two
weeks, he also had to rise at 6:30 and clean the house. In the end, though,
it was a petty argument that undid him: he threatened to pound another
client, then stormed out of treatment. By the time he cooled down, it was
too late to return; invoking violence is an unpardonable offense.
At that moment, I would have put Patrick's odds of staying clean at around
zero, but he surprised me. He went home to his girlfriend's, and he didn't
use. When he was tempted by the wine at her family's holiday dinner, he
left and went to an Alcoholics Anonymous meeting. Some friends from his
first round at Center Point were there and helped him through; they still
visit him regularly.
Since the suspension of Patrick's jail sentence was contingent on his
remaining in treatment (followed by six months of modified house arrest),
after Thanksgiving he turned himself in. He is now serving three months at
the county jail, where he requested placement in an in-house therapeutic
community. ''A better man would've stayed at Center Point,'' he says,
looking stockier in his prison blues, the muscles of his face strung tight.
''I didn't. I made a bad choice in leaving. But I realized that this time,
I didn't have to keep on making bad choices.''
Patrick may have jumped, but through a combination of his own motivation
and a multilayered local treatment network, he fell right into a safety
net. Jailhouse therapeutic communities have a lousy track record -- their
recidivism rates are similar to incarceration alone. Unless, that is, they
have a continuing care program. Patrick's does. After his release, he
expects to enroll in it, to attend daily A.A. meetings, to find a pro bono
therapist and embed himself in a clean and sober community. He already has
a job lined up with a tree-trimming service and plans to look into grants
for college. Those are exactly the steps experts would recommend for him.
Still, he's uneasy. As a result of his free weekend, he and his girlfriend
are expecting a second child. He worries that the pressures of fatherhood
will overwhelm him. ''I'm desperately scared about that,'' he admits.
All along the Plexiglas between us, people have carved their names,
striking a blow against anonymity, announcing that they were here and are
now . . . where? I study Patrick through the scratched pane and ask him one
more time: How does he rate his chances of staying clean? ''The same as
they were when we first met,'' he replies. ''About even.'' Then he smiles
slightly and corrects himself. ''Well, maybe now they're better than even.''
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MAP posted-by: Beth