Tag Archives: drug treatment

And sharks do not eat gas tanks

 

It’s not as though suspension of disbelief isn’t a thing. In Ian McEwan’s The Cement Garden, the reader has to believe that three children, whose parents have both died of separate illnesses in quick succession, can live undetected by neighbors, schools, police or social services, for several weeks, even as corpses rot in their home’s basement. In Jaws, that trauma-inducing film of my youth, the viewer must accept (or not think too much about) if wanting an optimal thrill, that sharks might leap across boat decks or swallow gas tanks.

In my novel, Venus Looks Down On A Praise Vole, there are numerous events, plot points and situations that stagger credulity to one degree or another, though none are fantastical in nature. Somewhat mundanely, the reader is meant to believe that my protagonist, Dr. Daniel Pierce, a psychologist, can pursue a career while regularly drinking in between sessions; that he could spend several hours in the company of a transgendered individual (admittedly in a pre-op stage) and not notice the person’s transformation; that he could forget names and patient details, not maintain adequate records, stop listening to people, actively dislike some of his patients, and still be a practicing clinician.

Well, that’s why he’s taking a break from his practice. Daniel Pierce goes on hiatus. That’s the opening plot point: his recognition of his falling apart, his need to stop working and deal with issues, some bad habits, and some losses: the estrangement of his son, the recent passing of his wife. But before he’s even fashioned a plan of restful inaction, his working life pushes back, or rather pulls him back into a working stance, only it will be a much different day on the job, what happens next. It will suspend his disbelief, make him think before the adventure’s done that he’s being seduced, patronized, rescued, recruited, chased…scapegoated.

Perhaps the most difficult event to accept is Pierce’s meeting of a former client in a sober living home. Kirkus reviews made this complaint, thinking it unrealistic that a psychologist would drop out of society, drop into a rehab-like environment, and meet one of his former patients, and even have the man as a roommate. Even if I hadn’t given cursory hints that this might happen—indicating that my unnamed setting is a small town; a hackneyed statement that the world is small—I’d grumble about this critique. After all, what’s so hard to accept? That a mental health professional would have a drug or drinking problem, need treatment or a retreat? That he wouldn’t take special care to avoid contact with his client base? Perhaps my reviewer isn’t aware that certain professionals—doctors and airline pilots, for example—do require or demand segregated, occupation-specific services, precisely because of this concern. It’s actually quite strange that the accommodations that are afforded these professional groups aren’t made for psychologists and other professional counselors.

But for me, this rather ordinary discussion misses an important point: namely, that a strict adherence to what is orthodox or realistic isn’t the most important aspect of a fiction; hence the term fiction. I had Daniel Pierce leave the structure he was in, or the rut he was in, because in order to regain his vitality and sense of mission, he has to leave not only his comfort zone, but almost his entire frame of reference. That’s an equally important axiom of drama, surely. Therefore, he has to perform an impromptu therapy in the most unlikely of circumstances; he has to not conform, challenge authority in ways he never has before. He has to observe ugliness that he’d previously been sheltered from; rethink gender, justice, his oldest notions of fitting in. In being responsible, being anything close to a heroic figure, he must consider that he may be right or wrong about the judgments he ultimately makes, but make his decision anyway.

 

 

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As dark as it gets

 

“Around ten o’clock, Andrew revealed a surprise: he’d been in therapy before, as in before he’d ever called me. And not even therapy, but analysis: for two years. He left because he didn’t like what he started to feel, a parallel between his drug addiction and emerging sexual compulsion. Though tired, I perked up, sensing something coming. Andrew spoke theoretically, about chasing highs, going back to an original experience. It felt like a prefacing explanation, his talk of addiction, its bedrock principles. Then he told me about his first time, the predictable, clandestine grope with an older girl, when he was eleven, she fourteen. The dreams of that girl, and his lust for teenage girls in general had never gone away, but he wouldn’t tell me more, not while there were legal issues pending, files not yet written. With that stuff looming, I wondered why he’d tell me anything, but then, I am ever struck by the desire to be known, by someone. Andrew’s loneliness gripped my heart, even as he retreated from memory, back to theory. He had an idea about pedophilia, he said, lowering his voice. It related to that original experience, that primal desire to be a child, experience pleasure as a child—natural, he argued. Shortly thereafter, his face broke, as if the pain in his soul had just hit him: that unsolvable clash between ancient fantasy versus the demands of growth.”

— a passage from Venus Looks Down On A Prairie Vole

Several points here, will touch on just a couple for starters. In this chapter, Daniel Pierce, my troubled protagonist and therapist, has serendipitously reunited with a patient he’d A.) thought he’d lost after a bad intake session, and B.) is the man whose privacy he is being pressured to violate by a rogue former prostitute and later, lawyers. Check out my novel and you’ll find out why.

The above conversation happens in the “privacy” of a shared room in a sober living environment–both men’s retreat. What Andrew (alias Derek) reveals here he would likely not have in the structured, orthodox forum of the therapist’s office. The thoughts Andrew shares are of a kind that few, in my opinion, share unless a near-profound alliance has been established. The reference to analysis, as distinguished from therapy, implies the depth divide between models of care, and further suggests what Daniel and Andrew tacitly have in common: they both tend to leave before the going gets tough.

 

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Saving Thunder Road

In a recent article in the Contra Costa Times, journalist Malaika Fraley writes that Thunder Road Adolescent Treatment Center in Oakland is scrambling to stay open. She reports that TR’s longtime operator, Summit Medical Center, has been planning to sever ties with the program for two years, due to annual running costs of the residential drug rehab and plus facility in excess of $6 million, yearly deficits of $800,000, and declining admissions. Well, I think that conversation’s been happening for much longer, actually.

I worked at Thunder Road for fifteen years, between 1996 and 2011. I chronicled my time, what I observed, what I think treatment for substance abuse and teens entails, both from a research and personal perspective, in a book I published in 2013, entitled Working Through Rehab. Among other things, I remember that threats to the program’s viability started around 2004, and continued periodically thereafter. When I left TR in 2011, I’d worked most clinical positions in the program, seen various changes to program structure, tweaks of philosophy and methods, etcetera, and held the view that TR had been “scrambling” for some time. I am sympathetic to its latest bid for survival, and for the prospect of retaining “the only program of its kind” for Bay Area, and especially East Bay, Alameda residents.

But what is the meaning of this latest, perhaps most threatening of crises? If the community wants drug treatment for youth; if it believes that drug abuse, gang violence, physical and sexual abuse, child abandonment, are ills damaging the community, where is the ongoing support for programs like Thunder Road? Why were admissions declining? Where is the city leadership, the rally of business sponsorship that would spare a thirty year old institution from this desperate position? At the risk of disparaging efforts that may yet come to fruition, I wonder if there is enough conviction to save Thunder Road; if there exists a muted rejection of drug treatment in the community as a whole.

An overview survey from 2014 by the National Institute on Drug Abuse (NIDA) reveals some interesting trends. Use of illicit drugs has generally declined over the past two decades: decreasing use of alcohol, cigarettes, the misuse of prescription pain relievers; stable rates of marijuana use among teens, but perhaps more importantly, changing attitudes about the perceived risk of harm associated with marijuana use. 36% of adolescents say that regular use puts users at great risk compared to 52% just five years ago. In other words, a majority of teens no longer think marijuana use is significantly harmful, which begs the question: what becomes the pretext for treatment, especially a residential admission, if this attitude prevails? Aundrea Brown, who runs Alameda County’s public defender’s juvenile division, states that Thunder Road is an essential placement alternative to juvenile hall (according to the Times article). The Save Thunder Road petition site says something similar. But I suspect many citizens of Alameda, the county that TR now dominantly serves, might reject the implied dichotomy. They’d surely rebut that neither alternative should exist; that a society moving towards legalization of currently illicit drugs, and that deems K2/spice, painkillers, e-cigarettes (according to NIDA, the only major substance whose use is on the rise) as effective, acceptable mood-altering substances, should leave well enough alone.

I hope the county is able to broker financing for a provider (or coalition of providers) to take over care of Thunder Road from Sutter. On balance, I believe what the program brings is a valuable service to the community, though it undoubtedly needs reform. But a broader question needs to be aimed at the community, in schools, churches, within board meetings and without: what do you really want to do about drug use?

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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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An Argument for Depth Therapy in Drug Rehab

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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

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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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