Tag Archives: adolescents

Full Metal Self

Had a few ideas recently, after watching the film Whiplash; made a few links, reignited certain determinations, sighed and resigned to my fate on a few other matters. The film stirred hope and–dare I say, inspiration–on many levels: firstly, I learned that the film had been out for nearly a year already, though it was only recently making a splash in theaters. I am reminded that promoting a film, like promoting a book, takes time, hard work, and no little amount of salesmanship. This parallels the story of Whiplash somewhat. Miles Teller plays Andrew Neyman, a young would-be jazz prodige, a drummer in a prestigious music conservatory band. Scouted and then selected by the school’s jazz maestro, Terence Fletcher, he joins a band that is further elite, and is initiated into rehearsals in a manner that is at once predictably brutal, yet also fascinating and entirely gripping. Actually, more so than any thriller or action flick I can think of, this film had me gripping my seat for almost its entire length, such was the tension created between the quietly narcissistic hero and his near sociopathic mentor. In scene after scene, I watched with mounting angst as Fletcher alternately seduces and then terrorizes the naive yet ambitious Neyman. He flatters him, telling the class he’s found his Buddy Rich; then, minutes later, he is tossing cymbals at Neyman’s head, mocking him for not keeping tempo, threatening to “rape him like a pig” if he fucks up his band. For my part, as non-musician, I had no idea drummers were this important.  Meanwhile, the Fletcher character brought to mind a few teachers from my past, sort of morphed with that terrifying drill sergeant character from Kubrick’s Full Metal Jacket.

About two thirds into the story, we get Fletcher’s rationale for being the way he is: modern jazz, like modern society, is in a sorry state, he says. The words “Good job” constitute the most harmful phrase in the English language (I’m paraphrasing). He’s an advocate of tough love, obviously; of the belief that teachers must push people beyond expectations in order to get the best out of them. The ends, as in the preservation (or growth) of standards, justifies the brutal means. The film’s counterpoint is to indicate casualties: a former prodige whom Fletcher had allegedly driven to suicide; the girlfriend whom Neyman dumps so as to focus on his drumming. Neyman’s father, a loving but feckless man, voices opposing values, decrying Fletcher’s abuse, challenging his son’s obsession, imploring him to slow down lest he (literally) die on the drumstool. Ultimately, the story seems a celebration of going for it; of not compromising standards. It’s just that it doesn’t ignore the costs.

Again, the film brought up a lot for me. I wonder how much of Neyman and Fletcher’s drama is transferrable to the world I inhabit. If you’re a would-be client of mine reading this, don’t worry. I have no plans to emulate Fletcher or the drill sergeant from Full Metal Jacket. However, I reflect on the opinions I expressed in Working Through Rehab, my book about adolescent drug treatment; sympathetic views about the dinosaur-like, similarly tough-love ethos of the much maligned Therapeutic Community Model. This week, I shall be teaching a short-term class on the Masterson Model at a community service agency in Marin, and espousing the value of, among other things, therapeutic confrontation, the importance of having boundaries, a therapeutic frame in which consistency, self focus–striving beyond expectations–are at least analogously observed. The dialectic I anticipate will mirror the drama of Whiplash, and maybe FMJ: principled agreement about driving people to their best, tempered with compassion for those who, for a variety of reasons, fall short.

As for myself, I go for it in my own way. Inspired by Andrew Neyman and the indelible image of his blood-stained drumkit, I might stay up late tonight, working on my latest manuscript: tightening the prose, adding pieces of subtext, changing a character or a plot point, correcting sundry mistakes in punctuation and spelling. I am well read with respect to my own books. I read them over and over again. It’s like combing the text, looking for tiny bugs. Sometimes I am satisfied; more often, I am not. Figuratively, I bleed. I have expectations.

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Games

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.

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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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Adolescents and brain development: “Naming an emotion can calm it”

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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

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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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What To Look For In Drug Rehab

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If you go to a 12-step meeting one of the slogans you’re likely to hear is “keep coming back”. It’s meant to welcome you, and be encouraging. And it is. But with respect to rehab, you don’t want to “keep coming back”. As a therapist of 20 years, I can’t tell you how many times I’ve heard something like the phrase “I’ve been going to rehabs for years,” from weary drug addicts who are still suffering, wanting to get clean. They are not so much unmotivated as stuck with something that is more than an attitude, and something closer to an embedded way of being: I want to feel better, not get better.

            Find a program that does not collude with this misguided goal. Here are a few tips and explanations:

1.)    First of all, size matters: the size (as in number of beds, # of patients participating in activities); the size of a case manager/therapist caseload. If a program has more than six beds, or offers groups with more than 8 participants, the tendency is for treatment to become unwieldy, possibly unsafe. If a therapist has more than half dozen patients on their caseload, it is unlikely they will have sufficient time to devote to one individual or family. I’ve observed these phenomena over many years, and depict numerous examples in Working Through Rehab.

2.)    Secondly, ask questions about the influence of patients’ rights groups, community licensing bodies. Some programs are more answerable to external regulators than others, which isn’t necessarily a good thing. In my book, I chronicle several instances wherein outside agencies influenced program procedures, often based upon societal norms, and not for the better. Often, accommodations served to enable problem-behaviors of substance abusers, not protect individual’s rights. This is a similar view to that offered in Dr. Drew Pinsky’s 2004 book, Cracked: Life on the Edge in a Rehab Clinic.

3.)    Thirdly, observe the proscription of depth therapy in rehab settings. Note the tendency of programs to sell short-term models that address behavior and cognition, but not underlying feeling states, maladaptive patterns of relating to others—attachment difficulties, and trauma. For example, anger management skills and mindfulness training are well and good, but they don’t address pervasive distortions of self and others. Furthermore, dovetailing with item #1, if a therapist is too preoccupied with multiple staff meetings, producing rote documentation, communicating with collaborators on largely pragmatic matters, in-depth focus with any one individual or family is more or less squeezed out.

4.)    Finally, hear with some distrust the phrase “fun in recovery”. This language is pitched to teens in order to get a buy-in, but while teen programs should include recreational activities, make no mistake: recovery, or meaningful change, is not fun. If you are a parent looking to place your child in rehab, I suggest the requirement of “fun” has not worked, and reinforcing this idea may have you or your child coming back, again and again.

 

 

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Effectiveness of Therapeutic Communities in Drug Treatment

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In a January 2014 issue of the Journal of Child and Adolescent Substance Abuse, within an article entitled “Therapeutic Engagement as a Predictor of Retention in Adolescent Therapeutic Community treatment,” authors offer that Therapeutic Communities (TCs) are effective in so far as they lead to reduced substance use along with reductions of other types of delinquent behavior. This isn’t a new assertion, nor is the apologist follow-up that much is still unknown in terms of what factors increase the likelihood that an adolescent will remain, much less thrive in treatment. Strange, since the Therapeutic Community model has been around for just over fifty years, ever since Synanon was founded in the late fifties to address problems of addiction. One might think that fifty years was enough time to give the Therapeutic Community model some scrutiny, some thought, and to determine what aspects of this somewhat controversial model work, and what aspects don’t. Well, it isn’t strange to me. Actually, when I consider all the elements of such a model (drawn from my fifteen years working within such programs), I try to imagine how a truly comprehensive research study might control for all factors. Therefore, it’s not surprising to me that the consumer of services is left reading research platitudes that beg a plethora of further questions.

            The efficacy of the Therapeutic Community model is one of several subjects I tackle in my book, Working Through Rehab: An Inside Look at Adolescent Drug Treatment. For those unfamiliar with the TC model, it is described by one notable researcher as the following: a total milieu treatment (as in residential) that promotes positive peer culture and socialization, with confrontation as a staple technique of the TC approach. How does that sound? If it sounds good so far, then okay. But if you’re reading from the point of view of somehow who might soon be living in a TC, or from the POV of a parent wondering whether to place your son or daughter in a TC, you’ll likely want to know more. You might take a look at literature on TCs that came out of Australia in 2010, though researchers Foster, Nathan, Ferry are similarly cautious about what is truly effective in therapeutic communities. Alternatively, you might want to tour such a place, take a moment to sit in one of its dorm-style bedrooms, and take in the atmosphere, the buzz. I remember the first time I toured a TC as a would-be employee. It was Thunder Road near downtown Oakland, and it was the mid-nineties. I took in the harsh noise of the unit that first day, as well as its tense silences. The atmosphere was one of anxiety, the restlessness of kids addicted to drugs, risk taking in general; the barely suppressed rage borne of thwarted freedoms and deeply-rooted yet thinly acknowledged pain. Through my book, I give readers a first-hand feel of how a typical TC operates. I’ll sit you upon its time-out devices, the bench, and have you gaze into its affirmation mirrors. I’ll give you a pair of hospital scrubs and strip you of your clothes and other belongings. Before long you’ll be sitting in confrontation group, or in something called contract breaking. Later, you’ll be doing some chores to keep you and your living environment both literally and figuratively clean. Then you’ll go to a 12-step meeting, and after that, maybe a family therapy session. You’ll learn that these norms, methods, and that the principles that underlie them follow a rigorous structure, and have a long pedigree.

            If you read studies about treatment models, you’ll likely come across terms like “completion rates” or “retention”. Within the literature pertaining to efficacy of programs, concepts like completion or retention are deemed tantamount to successful engagement of patients. If you complete a treatment of, say, 4-6 weeks (or longer), versus dropping out of treatment, then the treatment episode is implicitly effective, and a program looking to promote its services might refer to completion rates as indicators of success. Alternatively, programs might refer to studies (across programs) that demonstrate the efficacy of TCs in reducing substance use, though you might wonder about the methods of research. For example, if a person is said to be clean from substances post-treatment, how exactly is this determined? Is it through mandated submission to urinalysis testing? Or, are questionnaires being used: self-report essentially, from adolescents or their parental co-participants? Also, how long after treatment are the determinations being made? Are questionnaires being administered within 72 hours of discharge? Ninety days? Six months? I recall conducting post-discharge surveys for three different programs over the course of my fifteen years. The average length of time passed before conducting the surveys was about six weeks.

            Imagine your information is used for such a study (not that your name would be revealed). Think what it would be like for you if your treatment program was deemed successful because people like you completed the required number of days, or because you volunteered that you were still clean after eighty nine days. And even if that’s true, what if you relapsed on day ninety two? A program might benefit from the statistics, but what consolation would this be to those who slip back into old habits, and perhaps worsen from a previous baseline of addictive behavior? Many who go through drug treatment do so on multiple occasions, at great personal as well as societal cost. In future articles, I will address the problem of repeat customers in treatment, and argue for practices that aim for long-term change versus band-aid solutions and a low-bar, common denominator of treatment success. Long term, as in sustained change is what the consumer of drug treatment wants, after all. And it will take hard work, not to mention patience if treatment programs are to meet these standards. Studies of treatment efficacy that track change over time are few and—of course—far between. Exhibiting a quality that is perceived in most addicts, consumers of drug treatment research follow an ironic yet understandably urgent pursuit. They want the immediate gratification of fresh information, the latest studies. They cannot wait.

 

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Working Through Rehab: opening salvo

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So, you’re thinking of placing your kid in rehab? Or, maybe you’re thinking of getting a job in such a place, as a counselor, social worker, therapist, or whatever they’re being called these days. Do you know what it’s like being in rehab, or working in one? Have you visited a drug treatment facility, or heard stories from your neighbor who sent their kid to an out-of-state boarding school the previous summer, and later discharged just in time to begin senior year in high school. Are boarding schools the same thing as rehab? You wonder. A doctor outlines options: suggests therapy for a troubled teen, or an assessment at a nearby hospital, which boasts detox facilities and an intensive outpatient program, committing kids and their families to eight weeks of group and family therapy, ten hours a week, not counting the 12-step meetings that counselors will ask participants to attend on the weekends. A residential admission is the next level of care. It is the last resort as far as professional intervention is concerned—the last stop on the treatment ladder.

            Do you want this? Need this? Does a kid getting referred to rehab even have a choice: Meaning, is a court presenting rehab as an alternative to incarceration? Or are the parents the mandating authority? Perhaps your kid’s best friend has called you up, or texted you anonymously, warning that he or she is drinking or smoking much more than you realize, or “experimenting” with some other, supposedly more hardcore drug—one that will really scare you. You notice the kid’s grades are going down, and that more time is being spent with sedentary, seemingly anti-social activities: marathon spells of video-gaming; the vague notion of “hanging out”. What happened to that kid that seemed vibrant a year or so before: polite, energetic, and gregarious. Is this normal adolescence? You worry. How long do you wait to see what happens?

Maybe this isn’t your story. Maybe you’re a parent who has struggled with your own substance use. Maybe you’re an addict, and it seems like your kid is following suit. You don’t know what to do, or even if, given your own history, you have the aptitude or even the right to speak your concerns. After all, did you listen to adults when you were a teen? So, your kid is staying out all hours, has joined a gang, become a dealer as well as a user. Involvement in the juvenile justice system seems imminent, if it hasn’t happened already. You’ve already had several phone calls from Child Protective Services; one or two home visits. You and a couple of county social workers are on a first name basis.

Maybe you’re a fledgling member of the mental health profession, and working with troubled kids seems like a good idea: a stepping stone to a career as a social worker, a teacher, or, if you’re really stupid, a psychotherapist.  You’re a tweenie that’s looking for a job while in school. Or you’re a journeyman counselor that’s just completed requirements for certification as a drug and alcohol abuse counselor. An adolescent drug treatment program, attached, say, to a larger hospital, will offer steady employment, some modest benefits, if not a particularly competitive wage. You’re okay with that, maybe…for the time being. You want to reach young minds, work with those who may be more flexible in their ways, feel more hope than the adult addicts you’ve known. It will be less depressing, you think, working with kids.

Now that you’ve read the brochures and the websites of various programs, or taken tours of their sterile, hospital corridors and dorm-like accommodations, settle in for a first hand look at what happens in adolescent drug rehab programs, from the ground up, because that’s where I started. To do this properly, I have to go back in time to give some history, some context for what is happening today, especially in residential programs, for while some things have changed, others have not. Along the way, there are markers of change, nodal moments in my working life that in my opinion reflect trends in the business as a whole. If by the end of this text, the reader still wants to enter this field, or admit his or her child to a rehab like the ones I worked at, I’ll have no complaints. Just consider this the longest informed consent form in rehab history.

** opening of Working Through Rehab: An Inside Look at Adolescent Drug Treatment

 

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The Mirror Defense

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Within the branch of psychotherapy that is self psychology, which is derived from Object Relations Theory, which in turn is derived from classical Psychoanalysis, Heinz Kohut was pioneering. He was the first to emphasize the clinical manifestations of a grandiose self and an omnipotent object representations of a narcissist personality disorder. He also suggested the existence of a ‘healthy’ narcissism, and posited psychotherapy as a restorative exercise in which afflicted patients receive “correctional emotional experiences” through what Kohut termed transmuting internalizations.

He prescribed the technique of mirroring, in which a therapist repeats back what a patient has said, then amplifies its importance to the individual. The therapist doesn’t necessarily elucidate the defensive purpose, which was a problem in places like Thunder Road, the adolescent drug rehab in which I worked for fifteen years, and which I depict in my book, Working Through Rehab.

At Thunder Road, the first order of business was the containment of acting out behaviors, especially destructive behaviors like drug abuse and violence. Mirroring alone wasn’t sufficient to contain this acting out: it failed to acknowledge reality, both of the consequences of destructive behaviors, and also the reality–meaning, the thoughts and feelings– of other individuals, including that of helping professionals. I mean that therapists aren’t fantasy parents. They reject, disappoint, criticize, as anyone does. Sometimes they love, but they don’t really correct. The Kohutian therapist focuses on the inner experience of the patient, more or less ignoring the possibility that what is “needed” may be a distortion, a need with a defensive purpose, such as an expression of helplessness, which may in turn justify apathy. If the therapist doesn’t confront this response (which might be a behavior as well as an internal event) the defensive purpose may be reinforced and treatment may reach an impasse. As a therapist in a residential milieu, it is easy to become overwhelmed, consumed with the day-to-day lives of patients, the hand-wringing, fretful concerns as to whether these individuals will “make it”. This plus the volume of work is the reason that many burn-out, or so management assumes. In my opinion, it’s not. The reason there is high turnover among staff in drug rehabs is the sense of objectification and futility: the experience of being used by patients, and by management, for the mirroring of their insatiable needs. It is the sense that problems never stop, that business never stops, and finally, that some interventions are iatrogenic–not only unhelpful, but also counterproductive. The whole process seems a reenactment of an insidious, circular pattern begun long before treatment started. For the concerned and astute helper this is demoralizing. In actuality, it’s this that leads to burn out.

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