In Working Through Rehab, my non-fiction about kids and drug treatment, I feature a chapter entitled “Play Gone Wrong”, which draws attention to the corrupted pleasure-seeking that leads thousands, even millions of people into drug rehab programs each year. Life is full of games, games in which the rules break down and become bad games, play gone wrong. The phrase makes a cameo in The Situation, as the proposed and later rejected title of a book Bryan “Weed” Tecco has once written on the subject of role-playing video games: his area of expertise. Another cameo is that of an eight year boy, an abandoned child drifting in a hallway of an Oakland apartment building, playing old-fashioned games of cops and robbers, good guys and bad. In both The Situation and its predecessor, Crystal From The Hills, this child makes an appearance, calls for troubled adults to drop adult pretense and play his primitive games, on his terms and by his rules. But those games don’t last long. This kid is likely a future gamer; a drug user, or dealer, perhaps. Alone yet adult-seeking, he’s an attachment disorder in progress, a beta element in a bigger, darker game.
Halfway through The Situation, Weed takes a minute to describe his book, which he imagines—God bless him—that some will be moved to read. His literary polemic is a twenty-something’s take on a tired social commentary: that youth are becoming consumed by newfangled electronica, or worse, that a core of youth is desensitized by repeated exposure to violent themes in games like Grand Theft Auto, Call Of Duty, the Battlefield series, and so on. These games are becoming more popular than film or music, the previous major exponents of desensitization, the media reports. Violence continues to sell, but now it’s more interactive. The fourth wall is penetrated; the audience, once passive and merely ticket-purchasing, is seated at the console, in charge like it’s never been or felt before. Bryan Tecco is as skilled as anyone in this medium, and as such, has earned the right to say a few things, to disapprove from within the ranks. Well, within a speech aimed at Jill Evans, more or less the novel’s embodiment of feminine disapproval, he outlines the way things ought to be in the world of play: there ought to be more room for creativity, interaction…building things, performance. Killing is not where it’s at, where he’s at, he declares to her mild and pleasant surprise.
It’s a curious outcry from Weed, arriving as it does just before a watershed passage in which he pulls a firearm on one of his followers, and ultimately pistol whips him. Moments after, he’s performing donuts in a stolen vehicle, reveling in the kind of reckless driving that would belong in something like Grand Theft Auto. It’s the kind of hypocrisy that prevails when action films conclude with a hero’s plea for peace. For the record, I’d not grudge astute readers calling me out on the same duplicity. However, Weed, you might gather from the outset, has an edgy side to his character: not just pleasure seeking, not even profiteering, but something vengeful, something violent which subordinates a peaceful sensibility. In this way he still realizes his heroic potential, because the audience—his audience that is Jill or his peers, and perhaps you the reader—still like violence. Really. You don’t mind it, so long as it’s not entirely self-serving; as long as it stands up for something, for someone else, presumably someone weaker or less privileged, and doesn’t gratuitously inflate bank accounts. That’s how I cheated, in case you want to know. That’s how I wrote it, thinking you’d accept violence if you saw it in these terms, followed these rules. But please read until the end, because that’s where I change the rules
It also helps if my protagonist is an underdog, and a surprise underdog at that. Transcending his limitations—his un-athletic girth, his lack of Krav Maga knowledge, a reader’s prejudice borne of unflattering characterizations in CFTH—Weed shows that he is poised and capable in a fight; so much so that he inspires the supportive partnership of Jill who, despite her own nurturing front (she’s a nurse and habitual caretaker), activates her own aggressions (and she does know Krav Maga). That’s what circumstances often call for. That was the situation. That is the situation. But it’s not the way play ought to be.
Games
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Accidents
My twin novels, good friends Crystal From The Hills and The Situation (published 6/29) both begin with accidents—the same accident, but with different conclusions, different, uh, opinions as to what really happened on a last Wednesday in March. Someone died, says book number one, CFTH. Someone’s still alive, says the spoiling follow-up, bringing hope, or denial. Distortions. It’s a problem when two people experience the same event but come away with different ideas, different memories. What really happened? What really happens in drug treatment? In yet another book I claim to know the answer to that question. Who’s in charge? Who gets to decide the truth, the way things ought to be?
Accidents. They’re all accidents, the things that happen in life. They have to be, for to insist otherwise is to say that things are consciously determined: mapped out, overseen, foreseen, and taken care of. Are we being taken care of? When accidents happen, someone is meant to step in and mollify bad feelings, guilt and inadequacy—things we download somewhere between 2 and 5. Someone’s meant to step in and say everything’s okay when we break things or fall down. But what if they don’t? What if those grown ups are gone, or just preoccupied; depressed? We forget the early stuff, the wrongdoings of our bodies, the pre-sexual mistakes of bad touch, upsets in the crib; inexplicable, cosmic aloneness. Do we really want to grow up? Some, like my characters, don’t so they keep having accidents—violent, sexual, toilet-centered, water-based accidents—things that keep us young, hoping to be picked up and rubbed until feeling better. One protagonist’s parents gave him up early, passed him off to another couple, one that tried and still tries to love. The other one’s parents stuck around, but clearly had other things to do, and perhaps should have given him up, broken up with him like women tend to; let bossy yet formidable aunts take over; just disappear, maybe.
Give the kids a break. When they’re men, let them grow down and not up, just a little. “Gimme time,” says Chris Leavitt in hapless climax. It happens too fast, this life of responsibility and mission: like this opportunity that fell upon the lap of Bryan “Weed” Tecco at some point before the text of either novel. The flash drives, plural of drive, drove him to steal, and then head out on a doom-laden drive. Weed had a vision, just like Chris Leavitt, his friend, has visions, and the vision informed Weed that the video game he was expertly testing, “The Situation”, contained elements he recognized: these “Shadows” that the likes of he and Chris see on a regular basis, pointing out truths that no one is willing or able to speak of: about wrongdoings, what’s happening in the world; what ought to happen. Weed has a problem, a God-like problem. He foresees that fallout, the events that will unfold, subverting all that should happen. The problems start when Weed starts to plan: to steal the plans for “The Situation”; to lead his corporate security followers on a chase; to take his friend Chris with him for back up, as if that were something he needed. Maybe human beings should never try to plan things. You see, we don’t it well: planning. All things are just accidents…horrible, wonderful accidents.
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A Day in Symposium, Part Two
As I listened to several speakers champion the apparently threatened cause of drug treatment at the 2nd Annual Addiction Symposium in San Francisco, I wondered to what degree I was hearing cutting edge opinion. Conventional wisdom is that drug treatment should be thriving, with Parity Laws, Affordable Care Acts, and so on paving the way for expanded services: more spaces in outpatient programs; increased number of beds in hospitals. Third party payers must now think of addiction, or substance use disorders (as they are termed in the APA’s DSM V), as a disease, and therefore pay accordingly for its treatment. But programs aimed at specific professionals, such as doctors and nurses, are under threat, apparently. At least so-called “diversion” programs are threatened, though speakers thought the term “diversion” ought to be threatened (for reasons I didn’t really understand, I should add). Meanwhile, I wondered about the implications for a particular corner of the drug treatment industry, one in which I worked for fifteen years: namely, adolescent residential treatment.
When speaking of access to treatment for doctors, airline pilots, nurses, as well as adults in the general public, advocates tend to speak against discrimination issues: the problem of individuals being discharged from treatment programs because they relapse on drugs, or because they otherwise break program rules, fail to comply with medication regimens; because they exhibit the symptoms of their disease. The mocking that is directed at such intolerant discharges—the would you turn away a heart disease patient who has a heartattack? arguments—remind me of the similar yet more detached observations of journalist/physician Lonny Shavelson in his book Hooked. He likewise decried the strict rules of Therapeutic Communities, and lauded drug courts for working more flexibly with society’s most difficult cases, its most inveterate users. However, it’s strange to me that given the ubiquity of sanguine opinion at the level of medical leadership, that principals of adolescent programs, especially residential programs, don’t weigh in with some counterarguments: most notably, that relapsing substance users don’t just disaffect themselves as they continue to use drugs or refuse to take pills or go to therapy. Sometimes they spread drugs in a program, or threaten people, physically hurt people; harass people, verbally abuse people, staff and peers. Problem? Of course it’s a problem—a problem of safety. And it’s not a problem that can be resolved with a brief course of motivational interviewing, and so discharging—that “discriminating” act against the incorrigible—is not only appropriate for some, it’s necessary.
This issue of how to make treatment safe for everyone (especially kids) is one of the most important topics in my book, <em>Working Through Rehab: An Inside Look at Adolescent Drug Treatment</em>. Who am I to offer opinions? Who do I need to be? I am not a physician. I’m not a recovering drug addict, nor am I a long-suffering parent of a troubled teen. But I am a psychotherapist, and I worked for fifteen years in this complex rehab business that defies soundbites, pat summaries of phenomena. I compiled memories and opinion, and now offer for a concerned readership a nuanced view of what really happens in an average drug rehab.
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A Day in Symposium
Last weekend I attended the 2nd annual David E. Smith symposium on addiction medicine in San Francisco. It was a treatment star-studded event, featuring doctors mostly, plus a few therapists, addiction treatment advocates of various kinds, all congregating (and I sort of mean congregating) to celebrate Dr. Smith, who founded the Haight Ashbury clinics in the sixties, and to reflect upon trends in the addiction treatment industry, many political in nature, and dominantly extolling the disease concept while ignoring anything to do with harm reduction. From Dr. David Mee-Lee, there was an overview of addiction medicine placement criteria: a system designed to help providers assess afflicted individual’s needs and therefore place would-be patients in appropriate levels of care: residential, intensive outpatient, day treatment, etc. There were overviews of the history of addiction treatment and the various models of care, both medical and not, which featured familiar chestnut complaints: the “discrimination” that addicts experience across the spectrum of services, thus adversely impacting treatment outcomes; the ability or even the desire of individuals to access services. I’d heard much of this rhetoric before, which is not to say that it’s incorrect. Doesn’t society realize that addiction is a disease? Would you turn away or impugn patients who presented with cancer, just because they were manifesting the symptoms of that disease: denial, compulsive behaviors(s). You get the idea.
On day two, much focus was given to a review of programs specifically aimed at physicians and nurses: meaning, programs specifically designed for medical professionals who present with substance use disorders (“abuse”, dependency, and the range of “axis II” disorders are no longer indicated by the latest version of the APA’s diagnostic standards manual). Dr. Gregory Skipper cited his and others’ studies of the last decade (roughly) which indicated through 5-year follow up measures that these programs are quite successful in terms of treatment outcomes and lasting abstinence from substances. The program standards, as well as the profile of patients, are notable: taut definitions of relapse that provide behavioral guidelines and compel abstinence; urinalysis testing to provide accountability; workplace “monitoring” to assure lack of substance use in the workplace (which many doctors/patients found oppressive, if follow up surveys are anything to go by); mandatory attendance at 12-step meetings; physician-specific support groups to discuss things like the evils of medical boards, the terror of losing licenses.
One presenter joked that doctors don’t make good patients in drug rehab. Well, actually they do if these studies are an accurate reflection of what’s happening in these programs. At the symposium, these studies and these physician-specific programs were held up as models for how services might be aimed at the general population. They also serve as a rebuke to skeptics who claim that drug treatment does not work. As I listened to later case presentations, including a fascinating, psychoanalytically-influenced treatment of an adolescent in residential care, I wondered about the application potential of the physician-specific model. Adolescents, for example, have less power in society than adults, much less physicians. Dr. Michael Wachter and a therapist colleague of his spoke of a privileged and “pseudomature” teen whose parents seemed to have abrogated caretaking responsibilities, “empowering” their son with the rights of an adult versus placing age-appropriate limits. Treatment presented a childlike regression, but a reality-check in another sense—a watershed moment that disoriented the parents and teen, but which enabled subsequent growth. The rigor of treatment grounded the family in reality: “This is a 16 year old meth addict,” the therapist kept saying. Still, I asked Wachter if anyone thinks that what works for doctors might work for everyone else: can you imagine installing program elements akin to “workplace” monitoring for teens? What would that look like? Or, can you picture a homogenous interest or vocation-based support group for a population yet to decide upon its future—yet to feel what it has to lose?
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Crystal Surreal
As my next novel, The Situation, becomes available today, I step back two years to reflect upon its predecessor, my much maligned Crystal From The Hills. You don’t have to read CFTH to get The Situation. It’s easy enough to follow the action, infer the major events of the previous novel, if not its subtext, and get involved in its story. What you might miss is the contrast between friends pictured above–the paths defined by different needs for both characters and readers: for mere consciousness on the one hand, for heroism on the other–for empathy above all. Who are you? Where are you in your life, and what do you want from drama? Here’s a few thoughts from November 12′:
I’m not sure what an example of surreal fiction is. When I think of surrealism, I think of painters like Salvador Dali, or filmmakers like Jean Cocteau, or Luis Bunuel. I’m told Jacques Lacan is the man for those following the unconscious. Not sure that’s true. The author Polizzoti writes that Freud and the surrealists were nonplussed by one another, especially Andre Breton, who reportedly met the Viennese physician and was underwhelmed. These writers were poets, stylists of the 20s and 30s, contemporaries of the absurdist Dada movement, and men who reported interest in the unconscious, and went about the task of creating images that simulated dreams. For what it’s worth, I’ve tried a modest and similar tact with Crystal From The Hills, having read some of Lacan and Breton, and then staring at that remarkable painting by Magritte: the one that frame a woman’s naked body within the contours of a feminine hairline. ‘Le Viol’ it’s called: the rape. Simplicity and genius. And horror.
Mine is a story that begins dreamily on the streets of Oakland, with an ambiguously aged man holding a sign that reads, “Hungry White Trash” as he panhandles by the side of a freeway. You might get the idea that it’s a joke, but not entirely. In fact, there’s a history to the joke, and horror: a serious underpinning. Chris Leavitt has suffered an accident. That’s the pitch, the beginning of the story and the forerunner to a back-story. There will be a few accidents depicted if you read on, as well as deliberate action, malevolent and kind. There is no hero per se (heroism comes later), just a hapless everyman riding a string of bad luck, making several wrong decisions, struggling to act like an adult. He’s playing with life. He has a girlfriend, sort of. It’s Jill Evans, ten years before her stints playing support character in Living Without Blood, and almost twelve years before she takes the lead in The Big No, my second novel. Jill gets around, and here she goes back in time, getting younger, lucky girl. I have a villain of sorts, a guy who’s not around, but who gets talked about a lot. He’s Weed, a drug dealer, video game star, con artist—a bad, absent, abandoning guy. His influence is balanced by Sweet, Chris’ other friend, who is even more childlike than Chris, yet affable and easy to have around. He sticks around. There’s an aged yet autocratic aunt—Chris’ only surviving relative, an endearingly caustic woman. Others in the story are lawyers, doctors, police, employers, street thugs, ghostly figures (dubbed “Shadows”) that hang around with hallucinatory menace: not all bad people; just people with seeming power and a willingness to use it.
CFTH is a story that concerns itself with many ideas. It relies on continuity and the experience of ideas, fragments that have been indicated previously in the text. If you read a few pages then put it down for three weeks, then I’m sorry if I bored you. If that’s not the case and you’re just dilatory in your reading habits, then I’m afraid you may miss out. A good read is like good therapy. You don’t go once a month, like it’s a check up. You’re supposed to remember bits and pieces, like it’s embedded in your experience, and just know where you left off—no bookmarks are necessary if it works. There are associations to be made along the way. Don’t look for patterns, just experience the sense of revisiting as you note terms, phrases that appear to get repeated in the novel; themes that seem to link to one another. This is a story about accidents; personal, physical, even sexual, and habitual. It’s a story about rejection: also personal, and also institutional. There is trauma involved, and the problems related to poor memory and dissociation. You might feel what my characters don’t: that’s the point. Chris doesn’t remember much in the beginning, but builds his story along the way, and tells others, and you, what’s happening in his own time, on his own terms. His friend Sweet has an even worse memory than he does, but low and behold, it is he that becomes the chronicler of events in the end; the witness. Trauma victims need witnesses. That’s written somewhere. Above all there is a problem with reality, regressions in time, age. Characters aren’t sure what’s happening. They lack real perspectives, real goals. They don’t even use their real names. Despite all this, CFTH is actually not a confusing novel, in my opinion—not if you’re present, that is. It’s not all in Chris’ mind: things actually happen.
Bad things happen. Evil lurks, as in any good action movie or pulp mystery novel. Darth Vader types hover, and towering infernos exist. Read the novel some of these cheeky references will make sense. Meanwhile, like the “Shadows” of Chris’ imagination or psychosis, the author and reader are witnesses to all that goes down. CFTH is a novel that may move you, or it may leave you cold, or I suppose—just to cover all bases—it may leave you feeling something (?) in between.
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Feel Before You Think Or Do
Think before you act. That’s culturespeak—dominant culturespeak, some say—for a certain brand of lay-counseling that infiltrates business and industry, schools, anger management classes, parent-child conversations, social cliques, young and old. Feelings? That’s a therapist word. Therapists are often counseling individuals to express feelings, use “I” statements that gird the framework for feelings, the growth of intimacy. Feelings.
Why are feelings important, actually? Many people, especially left-brain bullies who extol the virtues of logic, or compulsive survivalists who ever assert the need for action, often ridicule those who draw attention to an affective (emotional) underpinning to any given issue or conflict. Others still consider that giving weight or time to feelings, especially negative feelings like fear, guilt and shame, is an indulgence—an exercise in what some term “navel-gazing”. Given certain contexts (do I really need to enumerate them?), the weight given to thinking or action is appropriate, but all too often the ethos is extended, given inappropriate width, while underlying feelings are either dismissed or given pat, superficial meanings, such that individuals, couples and families—the world—can move on. The person who exhibits rage, behaves with violence, is likely someone who, when later asked about their feelings, speaks pridefully of feeling “disrespected”, but makes little (if any) space for the likely truer feelings: fear, hope; desires for closeness, the experience of danger or abandonment.
I’d like to give readers a practical example of why acknowledgement of negative feelings is important, and why the sustaining of feeling is also important. It’s a story of a couple that struggles to slow down and really communicate: In this anecdote, a struggling pair has made room in their busy schedules for a “date night”, which will include, among other things, a night of sex. Problem: their evening is intruded upon by one of the countless distractions in their lives. The woman receives a text—someone from work needs a call back. The husband, anticipating (based upon actual past events) that the interruption will be prolonged, sarcastically gripes, “Well, so much for our so-called night of intimacy.” The woman, feeling “disrespected”, assures him she will not be long, but resents his attitude, which she casts as “entitled”. Later she returns to him, and finds that he is pouting. The “date night” proceeds, sex included, but without the earlier goodwill and spontaneity.
In speaking to this couple, I challenge both to recall, possibly experience, consider and then lead with feelings, rather than focusing singularly upon “what do we do.” I challenge the husband to say what he felt when he first learned of his wife’s seeming distraction. “I was disappointed,” he says. Upon some expansion, I ask “What kept you from saying that?”
“I did,” he remonstrates fully believing he’d done all he could to connect with his wife on the night in question. “No you didn’t,” I argue—respectfully: “You made a sarcastic complaint to her, and later ‘pouted’ when she returned, saying little if anything about your true feelings.” He shrugs, transforms his voice into an affected whine, and says, “What am I supposed to say, ‘gee, I’m really disappointed that we’re not having sex’. I can’t say that.”
“Why not?” I counter. This is where the therapy really begins.
“Because that’s not the way I am; not how I was raised, to talk about my feelings.” Note the distancing of opinion, plus the excuse, the implied helplessness: I can’t. For the moment, I ignore the historical dimension (and the affected expressions) and stay in the present.
“Why can’t you say that you’re disappointed, if that’s your true feeling?” After one or two more fumbling replies (this man is at a loss), he says, “I don’t know.”
“What do you mean? You don’t know why you can’t express your true feelings, your full experience?” The man shrugs. I choose to help…this time.
“You were disappointed that a planned evening of intimacy was disrupted. That’s understandable. There was an opportunity to say you were disappointed; to point out that your wife had agreed to devote the evening to a date and not work, and that you were anxious that work seemed more important to her than working on the relationship.”
The man nods, understanding, but looks defeated. “I can’t say all of that. Or, I couldn’t remember all of that. I’m not that articulate. Could you say it again so I can write it down?”
“It’s not about being articulate, or memorizing lines,” I reply quickly. “It is, however, about being in the habit of recognizing your true feelings, staying with them long enough so that thoughts and eventually words, may follow. (BTW: I level a similar confrontation at the wife) You experience a feeling—disappointment, and beneath that, the pain of rejection—and because that feeling seems so difficult to experience, you move to get rid of it as soon as possible. Thus, you use humor, aggressive humor, to distance yourself from both your wife and, more importantly, your own experience.”
** this example is a fiction in one sense, but in another, a coalescing of exchanges noted over time.
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An Argument for Depth Therapy in Drug Rehab
You might think that drug treatment with adolescents and psychoanalysis are terms that don’t go together, and you’d be right…sort of. Actually, a psychoanalytically-derived therapy is precisely what James Masterson, considered by many the father of adolescent psychiatry in the United States, intended for a residential treatment of troubled youth. His 1967 book, The Psychiatric Dilemma of Adolescence, offered the view that troubled kids do not “grow out of” problems of anxiety, depression, and acting out behaviors, as many of Masterson’s contemporaries appeared to assert. In this review, Masterson found that upon five years upon initial evaluation, over 50% of the adolescents previously treated in hospital settings for psychiatric conditions remained severely impaired. Although symptoms of anxiety, depression, and delinquent behaviors achieved modest reduction, some psychiatric disorders, such as pathological character traits, had not been touched upon in treatment at all.
Subsequently, Masterson was invited to take charge of adolescent inpatients at the Paine Whitney Clinic connected with Cornell University, which later resulted in his seminal text, Treatment of the Borderline Adolescent, in 1972. This book introduced the stage progression system of movement through a long-term residential program, intended to mirror the child development stages of separation-individuation as observed by Object Relations theorist Margaret Mahler. In this book, Masterson describes an initial “testing” phase of treatment in which patients relentlessly break rules or challenge staff, testing the limit-setting capabilities of staff, substituting them as parents (alloparenting, some call this), unconsciously determining who cares enough about them to maintain said limits and thus provide safety. The job of the therapists in such a setting is to convert patients from “actors and non-feelers” to “feelers and talkers”. Twenty years after this text was published, I began my career working in the field of adolescent drug treatment, though it was a further ten years before Masterson’s ideas really sunk in.
During my early years at Thunder Road in Oakland, a Therapeutic Community whose structure once bore a distinct resemblance to that described at Payne Whitney, I adapted to a cohesive treatment structure that more or less supported the Masterson approach (though few referenced him specifically), while adhering to the psychodynamic underpinning. Staff commonly used terms that were of psychoanalytic pedigree, such as “containment”, “splitting”, and “failure to thrive”; interns such as myself were repeatedly encouraged to observe transference (feelings in present relationships that are unknowing reflective of past relationships) meanings in the behaviors of patients, and more importantly, to attend to countertransference feelings in ourselves that may impinge upon therapeutic goals. Even staff not trained or educated in psychoanalytic concepts appeared to observe unconscious process in patients; in confrontation groups, counselors would routinely call out the negative behaviors, tease out the secrets of “acting out”. Then, upon the dropping of defenses, staff would zero in, often compassionately, sometimes not, upon the deeper meanings, the unacknowledged feelings.
For many in treatment this seemed not only fruitful, but also necessary, even exciting. They appreciated feeling understood. Furthermore, it seemed like common sense, this in-depth approach. Firstly, the adolescents lived in the facility and were kept clear of substances (at least, much more so than they otherwise would have been). There was clearly an opportunity for multiple therapy sessions per week, in various formats: individual, family therapy, and group. Even daily meetings were possible, and so the table was set for an in-depth therapy to occur. But the truth is that psychoanalytically-derived therapies, which call for an exploration of attachment patterns, links between family of origin memories and latter day behaviors, is frowned upon in many community mental health settings, even rehab settings wherein the intensive structure would seem tailor made for an in depth approach. There are several reasons for this, in my opinion: most concern either expediency or cost, but other reasons constitute a pronounced, if subtle devaluation of not only adolescent capacities, but also the dedicated staff that typically comprise drug treatment teams.
One assumption is that shorter term therapeutic orientations, solution-focused or cognitive behavioral therapies, for example, are easier to train to newer professionals. Their elements are easier to bullet point, sound-bite, and thus install into memory, left-brain functioning, versus the more unwieldy task of integrating a fuller experience. This is why many patients leave rehab centers armed with jargon, making glib pronouncements as to how they’ve changed; promises that all too often they cannot sustain. Often, these patients haven’t changed—not really. They’ve learned some “tools”, can parrot some phrases, maybe a few 12-step slogans. But their complex feelings haven’t about themselves and others haven’t changed, much less their understandings about those feelings. A second reason for the proscription of in depth therapy is that it is presumed to be cost-ineffective. But short term methods mean short-term outcomes, in my opinion, while short-sighted research conceals long-term effects, the attrition of growth that leads people back to rehab without understanding why earlier lessons didn’t stick. Reading this, a proponent of brief models would likely break out the sales pitch language and declare short term models “evidence-based”, and imply that psychodynamic models are not. This is untrue. Don’t believe me? Check out University of Colorado professor Jonathan Shedler’s comprehensive, 10-year meta-analysis research of over 70 studies upon the efficacy of psychodynamic models. It was published in the March 2010 issue of American Psychologist. It’ll open your eyes.
Regardless, especially in my latter years at Thunder Road, I experienced the unfortunate devaluation of psychodynamic models of care, and heard that similar things were happening at other programs. Managers began making philistine comments in staff meetings, deriding psychodynamic models as “that Freud stuff” while unknowingly using psychodynamic terms to reference current and longstanding practices. Few around me seemed to know or remember who James Masterson was, much less perceive his legacy within adolescent psychiatry. Borrowing models concurrently used in schools, clinical managers began using language connected with the Strength-based movement, which presumes a normative population of youth as the focus of care, emphasizes encouragement of adolescents’ strengths versus what is disparagingly termed a deficit-based approach. Thankfully at least, short-term models with worthy methods are coming to the forefront, muscling into the competitive arena of ideas. Most notable are the mindfulness-based therapeutic approaches, which are teaching affect (affect roughly corresponds to feeling) regulation skills (Important note: addiction is increasingly understood as a problem of affect dysregulation, not faulty cognition!), which draw their principles from advances in the area of neurobiology.
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The Accident
I wasn’t even running late. At a quarter to five, I had about a half hour to get to an office that was just over a mile away. The thing is that I had multiple things on my mind, such as the limited number of checks at my disposal that week. I’d just ordered more, but in all likelihood they wouldn’t arrive before several bills were due. Then there was the form I was to fax off to the hospital: my wife’s healthcare plan. Would I have time for a quick trip to Kinko’s? I wondered.
Driving alongside the high school, I glanced to my left, then to my right. As my eyes passed over the digital clock next to the steering wheel, I noted an SUV about thirty yards ahead of me, but thought nothing of it. It was a twenty five mile per hour zone, or thereabouts, not that everyone adheres strictly to that limit. I was going around thirty, possibly a bit faster, and the SUV? Okay, maybe it was slowing down, obeying the speed limit, being more attentive to the distractible teens ambling along the sidewalkless road. Meanwhile, as my thoughts converged on a narrowing lane of consciousness, one more managed to squeeze in: wait, is that car even moving? I was still traveling at thirty plus miles per hour. The SUV, my disbelieving eyes notwithstanding, had ground to a halt with its indicator light clearly on, signifying a turn it was patiently waiting to make.
There was no way, I thought—no way I’d avoid a collision. I was about ten yards away, and at the speed I was going, contact was imminent. Still, I slammed on the brakes, thinking I’d turn my car to its side and crash into the back of the SUV with my driver’s side door leading the plunge. Less damage, I figured–to the car? me? It didn’t happen like that. Moments later, after a split second wherein I’d resigned myself not only to a crash but also personal injury, the front of my car hit the bumper of the SUV, the impact jolting the vehicle forward as I came to a shuddering halt. There was little if any time to feel anything: no pain, no relief for not having pain; no time, even, to process the sound of metal crunching. Immediately, the driver of the SUV, an middle-aged man wearing glasses who resembled the haunted leading man of Breaking Bad, exited and marched—no, he strode—towards me. As he reached my door he stopped and looked down through my window, staring at my face. He flinched like he was tempted to reach out, grab the door handle, and then pull me from my car. Instead, he waited, chomping on the bit to say something unpleasant.
“I’m sorry, are you okay?” I managed miraculously as I rose from my car.
“I’m pissed off and feel like kicking your ass,” shouted the man, his glasses shaking. I was shaking too. Had I looked down I might have seen his fists clenched, held in check by his side, but poised to strike at the slightest provocation. I didn’t look down. There was none of that looking up or down, so to speak—none of those provocative right brain gestures. Instead my eyes glanced off his face and into the distance with fleeting connection. It was a reptilian act, this look of mine: aversive, escapist; seeking the still territory. Peace.
“Please don’t,” I simply replied. Other words came to mind, don’t get me wrong. Talking to others since this incident, I speculate that some combination of intuition and training, my attachment gifts or pathology, depending on one’s point of view, clicked in and took over. You see, there were rules afoot in the above described moment: rules that may apply to men and women, but especially to men. Rule one says that if you want to not escalate a dispute following a threat, you must not counterthreat. This isn’t difficult to understand. It’s somewhat harder to execute, of course, again depending on your point of view. Rule two, however, is more obscure, much less talked about, and in my opinion, almost exquisitely difficult to execute. Rule two says that if you want to diffuse a threat, you must not state or even imply that the aggressor cannot do what he or she threatens. In order to proceed safely, as my loved ones (especially the women) would demand, I had to bite down—as in bite down hard—on the following type of answer: oh yeah, why don’t you give it your best shot?
Call it fear. Call it training. Call it empathy. Call it self preservation. Something moved me, quite consciously I might add, to be short, reasoned, yet uninflammatory in my response. Over the next minute or so, the other driver and I exchanged information while my body decompressed, my nerves rattled, and my shame—my shame at being a bad driver, that is—percolated. My adversary was soon quieted, possibly disoriented, and five minutes later he was on his way, muttering that he or his insurance company would “be in touch”. Another kind of threat. On the one hand, he too may have seen the wisdom of not escalating: why risk trouble for an assault if a judgment of my fault regarding the accident was impending? Secondly, upon noting his own lack of injury plus the relative lack of damage to his vehicle (his got scratches; I got the worst of it), he may have been decompressing also, not to mention feeling relieved that he hadn’t lost control and struck me. As I proffered my license and policy, he may have felt my defeat, my two-fold humiliation: my implied acknowledgement of fault; my swallowing of his threat without reprisal or counter-provocation.
Within the confines of a subculture that places value, real value, upon the undefended experience of fear, I can feel unjudged, held, perhaps even admired. It’s one of the perks of being a therapist, the immersion into this kind of sensibility. Some will comment that by appealing for no harm, for myself at least and possibly for the other driver, I had demonstrated real strength. I had presented myself with dignity, acted like the bigger man.
Who knows if my now absented adversary will think of these things, process notions of masculinity alongside the experience of trauma, mine or his? I hope he will. From within my fantasy, I hope that he will recall the rage with which he initially approached me; the transformation in him that seemed to take place as he observed my shaken, non-threatening demeanor; my disarming yet unprideful statement to him. In my book, Working Through Rehab: An Inside Look at Adolescent Drug Treatment, I write about kids who might not even conceive of the lessons I draw from this accident. I write about kids with severe attachment pathology, long histories of violence, substance abuse to medicate feelings like fear and shame; a habit of psychic equivalence wherein feeling equals fact; a baseline bias towards survival in which time and perspective is shortened, split seconds become nanoseconds, and empathy—that capacity to feel into another and step outside of oneself—is forsaken. Observe the following passage from WTR:
“On the surface, it seemed to me that kids got into fights not so much because of gang rivalries or social marginalization, but instead because of more plainly interpersonal conflicts, such as that incident with Eddie and his hapless rival. Someone gets looked at the wrong way, and feels disrespected; someone’s shoulder gets bumped, and feels threatened, at risk of being a punk. For those feeling a surfeit of frustrations or humiliations in their lives, and without a place, the aptitude, or even the permission to speak openly of these stressors, “stupid stuff” becomes inflated in meaning. Seemingly trivial stressors are the proverbial straws on camels’ backs. As a result, thousands of clients have struggled their way through Therapeutic Communities walking a knife edge.”
**photo by Helnwein
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Adolescents and brain development: “Naming an emotion can calm it”
Putting aside for now questions confidentiality and containment, matters of how to confront or otherwise engage kids about addictive use of substances, let’s turn to some research about human development which helps us understand child development and the implications for drug treatment. Last year, Daniel Siegel, renowned psychiatrist and neurobiologist at UCLA, published Brainstorm: The Power and Purpose of the Teenage Brain, a book seemingly aimed at an adolescent readership.
Siegel’s book touches on many subjects which affirm assertions I make in my own book, entitled Working Through Rehab: An Inside Look at Adolescent Drug Treatment. Firstly, Siegel explains the adolescent’s susceptibility to such things as novelty seeking, risk taking, the seeming observance of positive outcomes of behavior, coupled with the seeming disregard of negative consequences—all of which are characteristics of an addictive personality. He points out that during adolescence there is an increase in the activity of the neural circuits utilizing dopamine, a neurotransmitter central in creating drive for reward. A drug, alcohol for example, can lead to release of dopamine, and users may later feel compelled to drink further so as to re-trigger a dopamine release (the addictive cycle). When alcohol wears off, dopamine levels decrease, and those who become addicted experience withdrawal symptoms, and are then driven to use more of the substance that spiked the dopamine circuits (tolerance). Through phenomena such as pruning and myelination, humans are able to integrate functions of various areas of the brain—the cortex, limbic system, and brainstem—render it more efficient, and in particular consolidate skills around that which is repeatedly experienced.
And therein exists the problem for many who become addicted or otherwise troubled. Alluding to problems of attachment in early childhood, as well as social conditions that exacerbate feelings of disillusionment and disconnection, Siegel observes that many seem to become arrested in survival modes of thought and behavior, and therefore strain to develop skills that serve collaboration: so-called pro-social behaviors, reflective thought, and above all, empathy. They become prone to what psychoanalysts call psychic equivalence—the inner sense of conviction as to what others are thinking, leading to impulsive action. For the individual lacking what Peter Fonagy calls mentalizing skills (the ability to reflect upon another’s mind), even another person’s neutral responses are filled with hostility. Therefore, not only must those individuals not be trusted, they must be defended against, at all costs.
These were among the qualities that I observed repeatedly over my fifteen years working in adolescent drug treatment, in kids and sometimes parents; especially at Thunder Road, the Oakland facility wherein I worked until 2011. There were distinctive patterns of thought, feeling expression, and behavior that I observed, and which I depict and chronicle in my book. Siegel writes about many of these phenomena from a largely theoretical point of view. He describes the tendency for troubled kids to avoid their feeling states, to feel anxious but “get rid of the feeling”, rather than being open to learning about those feelings. In the dynamic between parent and child, he reminds us of feedback loops: the cycle wherein kids act out in some manner, producing negative consequences; adults react severely, exacting consequences that further stifle adolescents, who in turn rebel against the restrictions with further, perhaps even more egregious behaviors (BTW: I see this playing out with adult couples, also). Implicitly, Siegel affirms the premises of both drug treatment and psychotherapy (sometimes compatible entities, believe it or not) by indicating that in the brain, naming an emotion can help calm it. Here the psychiatrist is encouraging something that many resist. Indeed, hardly a week goes by without someone in my practice asserting that the problem is not so much “not talking about it”, but rather “talking about it.” The solution, according to the addict not in recovery, is not a sustained emotional release, but rather the opposite: silence and isolation.
Dan Siegel’s book, Brainstorm, is a useful affirmation of several ideas promoted in Working Through Rehab, though don’t get me wrong. I’m hardly claiming originality. In keeping with my sense of being a droplet in huge reservoir of information, my book contains well over a hundred references and endnotes. In the fourth of these articles devoted to adolescent drug treatment, I shall explore the territorial battle between theories of psychotherapy, and in particular, upbraid the narrow-minded, cynical, and even corrupt disregard of long-term, psychodynamic models of psychotherapy. As a preview, I’ll return again Siegel’s thoughts. In Brainstorm, he challenges the adolescent reader to reflect upon his or her past—the early attachment experiences—which are a staple of long-term, psychodynamic (as in psychoanalytically-derived) practice: “It makes sense for you as an adolescent to make sense of your life history so you can be as fully present as possible in your relationships. What this means is reflecting on your relationships in the past in your own family life and asking yourself how those experiences influenced your development.”
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Servant of the Process: Team v. individual approaches in drug treatment
What process? You mean the process of addiction? Do you mean the process of working with teens in a rehab setting? There are several elements of Working Through Rehab: An Inside Look at Adolescent Drug Treatment, that bear explanation. One of the more important features is this whole question of whether to treat the substance dependent individual (teen or otherwise) through a team approach or through the model of individual therapy. In a hospital-based drug treatment program, professionals assert that they work as part of a team which may include a variety of collateral contacts, each of whom may come from differing disciplines: therapists, teachers, doctors, psychiatrists—you get the point. If not characterizing a team approach, practitioners may use synonymous language, and describe their work as “systemic”. Among other things, it means that information drawn from patients, in individual, family, or group therapy formats, is shared with all members of a treatment team, in or outside of a program. The idea is to contain destructive behaviors, including but not exclusive to the addictive use of substances, and to uncover discrepancies in reporting by the patients. The premise is that addicts lie so the information they share with individual therapists is not reliable. As a result, traditional rules of confidentiality are loosened, especially with patients mandated through legal authority, such that the priority task—interrupting problem behavior—is more likely achieved. The argument goes something like this: since patient disclosures are unreliable, the traditional ethos of treating disclosures as sacrosanct is misplaced. Therefore, in a hospital or group home setting wherein therapists are operating from a “team approach”, individual counseling sessions aren’t really what they appear to be. There are invisible parties in the room.
For the most part, I have supported this therapeutic stance, especially on occasions (more numerous than not, actually) when it seemed obvious that patients were not truthfully reporting either cravings or continued using behavior. It has often seemed that if programs are to really intervene with a pattern of drug use, then it is necessary to maintain a skeptical position with a patient; to not get caught up in a patient’s denial system, and to consult with others—in short, to not get fooled. To work in a rehab setting and learn the ropes is to have the experience of being played by slippery drug addicts, over and over again, until this lesson is learned. Problem? To share information with colleagues and collateral contacts risks stalling or undoing the fragile trust-building that all therapists must achieve with their patients. So what, I hear the average drug counselor saying, especially those of the so-called old school variety. That trust-building isn’t happening anyway, they’d argue. After all, it is the addict, not those who live or work with them, who fail the exercise of trust. It is they who fail to trust others, family, friends, and helpers, by repeatedly not sharing the truth.
These are sound arguments that routinely bully therapists who otherwise hope to not waste their time with reticent, untrusting patients who will likely resist the spirit of help being offered. Despite my overall support of the “addiction model” ethos, I nonetheless think the arguments of individual therapists, particularly those working outside the addiction model, make compelling counterarguments regarding the loss of confidentiality. From this tradition, derived from a plethora of psychoanalytically oriented therapies, the patient in therapy must be assured that their disclosures will be treated confidentially. To do anything less would compromise trust and inhibit disclosures, rendering therapy an exercise in compliance—not meaningfully different from a relationship with a teacher, probation officer, or some other obvious figure of authority. Trust-building is a long-term task that can and should transfer to personal relationships, enabling meaningful dialogue about difficult subject matter over a lifetime. Trust-building isn’t simply a therapeutic nicety that will allow a therapist to have cordial exchanges with a reluctant patient. Secondly, and perhaps most interestingly, some argue that the containment bias of addiction model proponents sets up an artificial situation, one that is ultimately unhelpful to addicts and their loved ones.
To explain: one of the most difficult things for a loved one to say to the addict is something like “I don’t believe you. I think/feel you’re lying.” Fundamentally, it feels unempathetic and disrespectful to confront someone in this manner, and therapists usually feel a parallel dilemma: how to confront with tact while not rupturing the therapeutic bond. Paradoxically, many therapists have found that when they do confront lying behavior in patients, tactfully or not, it often improves the bond as opposed to disrupting it. Some of the best moments at Thunder Road occurred when committed staff, on the back of a solid bond with a difficult kid, pronounced its belief that the patient/addict was lying. This action, fraught as it is with anxiety and risk, enables the therapist to more fully empathize with the oft-gaslighted loved ones of addicts, those whose entire lives seem to revolve around similarly painful dilemmas: what can I say when my gut tells me something’s not right? What’s the easiest way to say I don’t trust you, don’t believe you?
No model of care is perfect or even close to being perfect. Addiction models and traditional psychotherapeutic models are not mutually exclusive, and don’t believe anyone who tells you they have evidence of what works and what doesn’t. They’re lying.
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Graeme Daniels Psychewriter 