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Craig's review: This book
is not easily pigeonholed. It centers on a critique of public policy issues
surrounding drug rehabilitation efforts aimed at “street” addicts, who have
no resources to apply to private treatment. But the author, Lonny Shavelson,
approaches his subject in such an astonishingly fresh, compassionate and
insightful manner that he manages to shatter a number of myths about
“Recovery” along the way.
Shavelson, a physician and journalist (and neither a
“recovery” professional, nor an academic, nor a reformed addict), spent
two years following the often-Kafkaesque journeys of five different
addicts (Heroin-2, meth-1, crack-1, alcohol-1) as they were dealt with by
the network of recovery facilities in San Francisco in the late 1990’s,
when that city initiated an “open door” policy promising the availability
of treatment for all who sought it. He found that the chaos of the
addict’s lives was replicated in the chaos of the rehabilitation system.
In many ways, the author shows, the “System” is
designed to weed out those who most need its help.
Dual diagnosed? Go to
the drug rehab centers and be told treatment is not available to those
with severe mental disturbance.
Rejected but not despairing, go across town to the mental health center
and be told, “sorry, we can’t help you until you stop taking drugs.”
Suffer a relapse? Be kicked out of most programs, as though the
ability to NOT use drugs is a pre-condition for admittance to a drug rehab
program. Homeless?
Conclude your rehab by being placed in a cheap hotel room in the same part
of town where drugs dominate life.
But there’s another level to this book.
Shavelson gives a voice to people rarely heard from: practicing
addicts. What we see is,
superficially, what we might expect, a group of screwed-up people But he
persists for a deeper look and allows their humanity to not just be
visible, but to shine through unforgettably.
What he reveals are people who are fighting as hard as they can to
survive even while they appear, to non-addicts, to be destroying their
lives. The addicts are
burdened by the results of their “choices,” but they also suffer daily
from the other realities that haunt their lives.
First and foremost is childhood abuse and neglect.
Add some poverty, some emotional distress, and a limited ability to
establish healthy relationships, plus lots of unresolved anger and a lack
of resources upon which they can draw.
The result is chaotic lives.
The goal of treatment is, or should be, to bring order, calmness and good
mental and physical health in place of this chaos.
But more often than not, Shavelson shows, all else is forgotten in
the quest for “order.”
In fact, the addict himself is often lost, as the “System” demands
conformity and rigid adherence to rules and procedures designed to serve
the needs of the system itself, rather than the needs of the addict.
“Hooked” is, among other things, a classic story of the nature of
bureaucracy.
In the end, Shavelson contends, the best hope for
these hardcore “street” addicts comes from what seems, at first glance, to
be the least likely source: the criminal justice system.
Drug courts (a recent innovation), he contends, EXPECT addicts to
relapse and are prepared to offer the sort of stern-yet-forgiving guidance
that is crucial to long-term success.
In fact, the twin poles of “stern-but-forgiving,” and “nurturing
and understanding,” he seems to say, are the real sources of treatment
success.
One thing missing from “Hooked” (thank God!) is any
discussion at all of AA. It’s
mentioned in passing, but it’s clear that the author considers it
irrelevant to a serious analysis of the issues surrounding addiction.
Marty's Review: Most people don't care enough
about addicts and alcoholics to pay attention to us, unless we crash a car,
break a window, hurt somebody, litter the sidewalk with our bodies, or
otherwise make a nuisance of ourselves. Lonny Shavelson is one of the
exceptional people who cares, really cares. He spent two years following the
lives of heroin addict Mike Pagsolingan, methamphetamine addict Darlene
James, crack and alcohol addict Darrell McAuley, alcoholic Glenda Janis, and
crack addict Crystal Holmes, as they struggled to survive and to get clean
and sober in San Francisco during 1998-2000.
He not only interviewed them and photographed them, he fed them and
gave them rides and carried their bundles and their messages and held
their babies and searched for them and advocated their cause before
counselors and other authorities in San Francisco's addiction treatment
and mental health bureaucracies. The result is a book full of heart and
wisdom about five remarkable lives, readable as an intensely human story.
These portraits -- all too familiar in many ways to anyone who has
experienced addiction from the inside -- must deeply touch even the
non-addicted with the pain, the obstacles, the gallows humor, and the
extraordinary determination and survival skills of its subjects' lives. By
profession an emergency room physician, Shavelson also has credentials as
a journalist, author, and photographer, and he writes concisely and
vividly, with an eye for the graphic detail and the telling anecdote.
Mike shooting up with one hand while driving his pickup truck on the
freeway, Darlene withdrawing into a tarpaper cave dubbed the Opera Boxes
under the freeway after Public Works bulldozed her homeless encampment,
Darrell losing his beloved dog while double-parked outside a bar to get a
drink, Glenda cheerleading her program's basketball team, Crystal trying
to scam the Drug Court judge -- these and many other scenes and stories
make for a rich tapestry that kept me turning the pages.
Shavelson succeeds as a biographer in showing his people as
three-dimensional, contradictory, believable, alive, intelligent, and
worthy of your interest and compassion; and you may find yourself, as I
did, crying over Glenda, and anxious to learn Mike's court sentence, and
proud of Darrell, and laughing and cheering with Crystal, and wanting to
rage and storm at the mistreatment of Darlene.
If there were nothing more to Shavelson's book than these deeply felt,
vivid and memorable five characters -- faces we can see on the City
streets every day -- the book would be well worth buying, reading, and
sharing with friends. It is so rare that anyone takes addicts, especially
hard cases, seriously enough to get close and pay attention and write
well.
But Shavelson's book is not merely a biographical study; it is also, as
its subtitle indicates, a brief for reform of the substance abuse
treatment system. Each of Shavelson's people has a series of encounters
with one or another island in the archipelago of San Francisco's more than
130 drug treatment programs, and the author sticks with them before,
during and after, tape recorder and camera in hand.
 A
highlight of the book is the story of Mike's journey through Walden House,
perhaps the premier rehab program in the city. Walden House is a
Therapeutic Community inspired by Synanon and based on the premise that
all the addict's old habits, behaviors and thoughtways must be torn down
and rebuilt along clean, structured, disciplined lines. A tight schedule
of groups, meetings and chores with few if any free moments, a thick book
of written and unwritten rules, a system of public penance for any neglect
of duty or infraction, and unquestioned obedience to staff members make up
the recipe for creating an overpowering community aiming to reform and
rebuild the individual addict from the ground up.
Walden seems to work for Mike; he works hard, stays clean and seems to
be developing into a model participant who is assigned to mentor
newcomers. But on his last day he drops a note that says "I love you" in
the laundry basket of a female member, in flagrant violation of Walden
rules, and he is called into a House Meeting. There he sits alone in the
center of the room on an old hardwood chair, facing a godlike staff member
in a padded armchair, and surrounded by the assembly of residents. The
staffer barks a command, the residents snap to attention and chorus "Thank
you." Then comes an ordeal of confrontation, accusations and vilification
hurled at the violator, renewed with each response, until he breaks down
in shame and humiliation.
In this case, Mike is allowed to remain a Walden member, but he does
not last long. Soon he is shooting heroin again, and when he is found out,
he is kicked out of the program, banished from its services, and
ostracized: no member may speak with him or even acknowledge him on the
street. The author asks: what kind of medical treatment stops and kicks
the patient out on the street just when he most needs it?
 Darlene's
odyssey through treatment begins in a Central Intake Unit where counselors
are supposed to find treatment slots for them within 48 hours. But Darlene
is not only homeless, she hears voices, and nobody has been able to find
out whether her auditory hallucinations came before her drug addiction or
are one of its symptoms. She not only needs drug treatment, she needs
mental health treatment. Most of the drug treatment programs don't want
her because of her voices, and the mental health system doesn't want her
because of her drugs.
Despite author Shavelson's energetic and informed intervention on
Darlene's behalf, she gets ping-ponged from one closed door to the other,
and Public Works repeatedly rips up her ingenious and cozy self-made
refuges until she ends up sleeping in doorways. Shavelson's last-ditch
effort to find her someone who will help her takes them to the
Haight-Ashbury Free Clinic, where her case touches off a war within the
staff over the proper role of treatment. Darlene in the eyes of the
treatment system is Trouble; yet, as Shavelson points out, Darlene is also
very typical. If the system can't help Darlene, it isn't doing its job. If
the system can only help the easy cases, what good is it?
A year into his research, Shavelson encounters Glenda, a Lakota woman
of 37 who looks 70 and has been getting drunk since she was a teenager on
the reservation. There is a Death Prevention Team in the City, a
six-member crew of probably the most dedicated and pragmatic city
employees in the urban jungle; they make the rounds of the alleys and
empty lots at night, trying to save lives. Glenda tops their list of
homeless persons most likely to die.
 Unlike
Darlene, Darrell and Mike, who desperately wanted treatment, Glenda only
wants to drink; she wants nothing to do with rehab programs of any kind.
One afternoon, stretching the rules considerably, the Death Prevention
team lures Glenda into a taxicab and basically kidnaps her into treatment:
first the emergency room, then detox, then to Friendship House, a Native
American drug rehab. Against her drunken will. But after two sober weeks
at Friendship House, Glenda begins to heal. Her numerous scars have begun
to close, her eyes are clear, her voice is calm and soft.
Surrounded by affection, by culturally familiar foods and symbols, and
showered with positive reinforcement, Glenda begins working through her
load of pain and discovering the beauties of life as a sober woman. After
three months, she is beginning to look like a transformed person. Her
graduation ceremony is a moving ritual of rediscovery and renewal.
The next day the program throws her back into the same infested hell
where she came from. The program has a 90-day funding limit and there is
no appropriate clean and sober housing available for her. Within weeks she
relapses; months later, she dies. What point is treatment, even excellent
treatment, if it stops just when it starts working, and if there is no
aftercare, no coordination with housing and other social services?
Crystal, a small time crack dealer and user, also enters treatment
involuntarily. Busted for possession, she finds herself in San Francisco's
Drug Court, which refers her first to outpatient treatment. Street-smart
and a con-artist, she goes along for the ride but soon relapses and lands
back in court. After two more relapses in two other programs, Crystal
begins to realize that she has a more serious problem than she thought,
and asks for, and gets, full-time inpatient treatment, and eventually
becomes a proud and successful Drug Court graduate.
She is one of the lucky ones. Most of the other addicts have nobody who
follows their cases through thick and thin, who can refer them to the
appropriate program, find them social services, mental health services,
housing, medical care, education, whatever may be available and whatever
would help her stay straight. She has all of that and more, in the person
of a Drug Court judge. Part actor, social worker, teacher, doctor,
psychiatrist and priest, with the threat of state prison as a backup, the
Drug Court judges emerge as the real therapeutic heroes of Shavelson's
book. It is an irony, not lost on Shavelson, that the clinical ideal of
continuous case management, matching, referral, coordination of services,
and follow-up, toward which the civil treatment system theoretically
strives, is a living reality only in this narrow sliver of the criminal
justice system, the Drug Courts.
Shavelson argues that his five individuals are broadly representative,
and that their experience with the treatment system in San Francisco is
typical of or better than the national picture. Of course, Shavelson
only saw and his people only experienced a relative handful among the
scores of programs in this one city. Still, Shavelson brings a
formidable array of statistics and authorities to the case. The nation
today has fewer addicts, but they are worse off. A high proportion,
perhaps a majority, have dual diagnoses: trauma, psychosis, bipolar
disorder, and other psychiatric disorders. A tiny proportion of substance
abuse programs and an even smaller number of mental health programs are
qualified and willing to treat such addicts.
Getting bounced from one system to the other without help from either
one, as was Darlene, is the rule rather than the exception, according to
knowledgeable professionals whom Shavelson quotes.
Cutting addicts off from peer group contact and from services just when
they need them most, after a relapse, is the iron rule at Walden House
and, in one form or another, at many other treatment centers.
Connecting the addict with other social services, even just following
up the addict after treatment to see what happens, is exceptional. Only a
highly visible program such as Walden House maintains some kind of
follow-up statistics, and they are not encouraging. True, of those who
spend two years in the program, 75 per cent achieve stable recovery; but
90 per cent drop out before graduation. The less prominent programs,
typically, have no evidence-based idea what happens to their
clients/patients after they leave and no supportable claim whether what
happens within their walls "works" or not.
Nor, despite all the millions of public funds that are disbursed to the
more than 40 entities that run more than 135 drug rehab programs in San
Francisco, is there any oversight, accountability, or coordination. In an
afterword, Shavelson writes that his experience in writing the book
hammered certain conclusions into his consciousness. They are:
- Relapse: When an addict in rehab gets worse and heads back to
drugs, the programs must increase treatment, not withdraw it.
- Detox: Each and every rehab program must be required to have a
formal, structured association with a drug detox center where it can
send relapsed clients.
- Humiliation: Abuses and humiliation in the name of therapy must
cease. Cities must establish an ombudsman to monitor the rehab programs,
and addicts must be allowed to access the ombudsman without
repercussions.
- Psychological counseling: All rehab counselors must be trained to
recognize and treat the multitude of addicts who also have psychological
disorders, and refer them to appropriately intensive additional care
when needed.
- Case management: Cities must establish a comprehensive case
management system to guide addicts through the maze of programs and
services. The case managers should not work for any particular rehab
program, but rather represent and advocate for the addicts in the
overall system.
- Oversight: Government agencies that provide funds to the programs
must assure that addicts are receiving comprehensive and effective
treatment.
- Funding priorities: Federal funds and efforts must be shifted
from drug interdiction abroad to drug rehab at home.
Summing up, Shavelson asks himself, "Does drug rehab work for those who
are most disastrously addicted?" and answers:
I still don't know. In the two years of this investigation I
rarely saw rehab done well enough to learn if it might work. What we
today call drug rehab does not provide consistent and coherent help to
the majority of addicts who come seeking it. It may well be that the
nature of the beast of addiction makes effective treatment of addicts a
pie-in-the-sky dream, even with the best that rehab could offer. Or it
may be that the frustratingly unimpressive treatment results we see
today with those most intensely addicted are merely what happens in a
rehab system that is as ill as the addicts themselves.
Rehab can work, he stoutly believes, based on the glimpses of good
treatment he saw here and there, but not in the way that it is put
together today.
This is a book that ought to stir the public and lead to a
thoroughgoing reform of the treatment industry, much as Charles Dickens'
novels led to reform of poorhouses and boarding schools, as Upton
Sinclair's The Jungle led to the cleanup of the meat packing
industry, or Jessica Mitford's expose helped reform the funeral business.
Shavelson's documentation is thorough and well-informed; his human
characters are compassionately drawn and real; and his agenda is on the
table.
His book corroborates the principal findings of the Hester-Miller
Handbook of Alcoholism Treatment Approaches, reviewed here
earlier, but much more vividly, with more passion, and as a gripping,
colorful human story.
Like any sincere and well-intentioned reform effort, Shavelson's
proposals will draw fierce opposition from entrenched interests in the
treatment industry, who thrive in the present climate of non-oversight and
non-accountability, as well as from political conservatives, who see all
treatment, even when enforced by Drug Court judges, as so much "coddling
the addict."
The ideas that addicts should have access to an ombudsman, and that
case managers should advocate for the addict rather than for the
institutions, although commonplace in other medical contexts, are still
considered almost seditious in the addiction setting, where blame for the
failures of deplorably bad treatment is routinely thrown on (and accepted
by) the addicts themselves. But when an author makes the case as vividly
and persuasively as does Shavelson, perhaps the public will listen and a
reform of the treatment industry will finally commence.
I want to add as a postscript some of my favorite little snippets from
the book.
As a LifeRing speaker and activist who frequently advocates in a
treatment setting, I am keenly interested in how the professional
practitioner approaches the addict. Does the practitioner define the
addict as "one hundred per cent zero" when it comes to the power to
recover, so that only an external force can bring change, or does the
practitioner look for the inner struggle, the internal voices of desire
for recovery, the native resilience and survival instinct, and build on
that?
I was tickled to read the dialogue between Darlene and Dr. Pablo
Stewart, the resident psychiatrist at the Haight Ashbury Free Clinic, one
of the several clinical Good Persons in this book.
Darlene, in her first interview, is telling Dr. Stewart that if an
addict doesn't want to get off drugs, "you can just talk at them until
your eyes turn blue, and they'll just tell you to fuck off."
This is hardly news to Dr. Stewart, and he has an answer. Holding up
his thumb and forefinger pinched together, he says, "Just possibly, that
person who you're speaking about may have the teeniest of desires" to deal
with her drug problem.
Darlene joins in the game, holding up her fingers and pinching them
together harder. "Well, what if that person only has the teeniest,
teeeniest, tiniest wanting to be off drugs?"
"Then," says Dr. Stewart, standing up and offering her his hand, "I
would think that such a person would do very well in this clinic."
Here the doctor knows that telling Darlene she is powerless over drugs
or that she has an incurable progressive fatal disease is a sure way to
drive her out of the clinic. What keeps her coming back is his solemn
acknowledgement that something within her, something of her own, no matter
how concealed and tiny, is right and good; and he bonds with that quality
in her, no matter how fragile, and builds the therapeutic relationship on
it. That seems to me an example of the LifeRing way: finding,
acknowledging, reinforcing and ultimately empowering the sober place
within the addicted person, rather than shaming and humiliating the person
for displaying the symptoms of their affliction, as so frequently happens.
Another example of what I think of as the LifeRing approach shines
through Glenda's remark about her counselor in Friendship House: "Evelyn
tells me, 'Glenda, you're a strong, wise lady.' She says all kinds of
things about me that make me feel really good." The counselor Evelyn is a
strong, wise lady herself, and she knows that focusing on Glenda's many
deficiencies and shortcomings would be a pointless and abusive therapeutic
exercise. Glenda has been beaten up enough. Healing cannot come by
reopening the wounds that her addiction has inflicted on her; it must
begin with recognizing and reinforcing her positive, sober side.
Another gem, in my view, is Shavelson's conversation with Drug Court
counselor Marillac after observing her run a meeting. He thought Marillac
would be tougher with the Drug Court patients, because they were mandated
to be there.
Marillac shakes her head. 'It's just the opposite.' She smiles. 'I
have to be more relaxed with them here. The fact that they're mandated
to be in rehab doesn't make their treatment easier, it makes it harder.
They have to show up, but then I have to win them over to wanting to
change their lives. If I act tough, all I get is an addict who's pissed
at another authority figure. So I've got to grab at what good they
have inside of them, and they have to see me grabbing it, bringing it
out - accepting them.'
It's ironic, Shavelson observes, that rehab in the coerced setting of
Drug Court turns out to be more compassionate than rehab in many voluntary
programs. Not only compassionate, but more pragmatic and more likely to be
effective. "Grabbing the good" that is inside the addict, bringing it out,
accepting them because of it -- these methods awaken and mobilize the
inner motivation to get clean and sober, without which no treatment
approach has the slightest chance of success. That, too, is to my mind a
"LifeRing" type of approach.
Also very true and significant in my eyes is Shavelson's observation,
made after watching Mike stay clean and sober on his own for weeks while
waiting to get into treatment, that "the fierce power of an addict's
obsession with drugs is matched, when the timing is right, by an equally
vigorous drive to be free of them." Linking up with and mutually
reinforcing that vigorous inner drive to be free is, basically, what our
LifeRing self-help groups are all about. That vigorous drive for freedom,
if given peer support, can do more than match the obsession for drugs, it
can overpower it, break it, and pen it up harmlessly for life. Shavelson's
observation ought to be made into a poster and hung in every treatment
room, where it might do far more to promote recovery than the disabling
platitudes typically found there.
There's much more to like in this gem of a book, which ought to win its
author big awards. If it has one flaw, it's that it ignores the big
elephant in the center of the room. By far the greater part of the rehab
industry that Shavelson finds misguided and inadequate is of course
erected on the 12-Step model. Shavelson, however, maintains a diplomatic
silence about this whole topic. However, the fact that he quotes all
of his subjects by their full real names and publishes their photos, with
their express consent, speaks volumes. This book is a powerful
manifesto calling for more effective alternatives, by someone who
passionately cares about people.
Photos: Mike Pagsolingan in Walden
House, Mike in relapse; Darlene James with her shopping cart, Darlene in
treatment with Dr. Stewart; Glenda Janis on the street, Glenda with
counselor Evelyn at Friendship House. By Lonny Shavelson, from the
book.
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