by Susan Juby
My friend gazed gloomily at pictures of ponds with fountains. “It would suck if the nicest holiday I ever had was to a treatment centre,” he said. Like a lot of people with substance abuse issues, he’d had a very circumscribed life. It definitely didn’t include any vacation destinations. He ended up going to a facility about an hour away from where I live, and on visiting day I got to see first-hand what sixteen thousand dollars for six weeks buys.
The Cedars is a treatment centre located in Cobble Hill on Vancouver Island. It looks like a cross between a meditation retreat centre and an exclusive summer camp. The architecture leans toward Japanese-influenced post and beam. There is a swell little yoga pod and miles of walking trails throughout the surrounding forest.
I pulled into the parking lot on Sunday afternoon and walked down a winding stone path and into the main lodge, where I joined a short lineup of mostly well-heeled, middle-aged people. We filed past a large table, where a staff person had us sign in and hand over gifts so they could be searched for contraband. It was a bit like visiting the most genteel of jails. The list of forbidden items included anything edible or mood altering, including but not limited to Almond Rocca and the board game Settlers of Catan, which I was asked to return to my car. In the room beyond, patients lay on leather sofas or stood, waiting awkwardly for their visitors.
My friend offered to show me around. He’d been in the centre for ten days and in that time had had no contact with the outside world. We visited the smoking area, clearly a central hub for most patients. If you’ve ever asked yourself where all the smokers have gone, treatment centre smoking areas may be the answer. Well, there and standing outside twelve-step meetings.
Even the smoking area had a faintly Japanese vibe. There was a sign posted forbidding men to outnumber women by more than one person and vice versa. I wondered about the origin of this rule. I had visions of multiple female smokers puffing away while a lone man was ravished by two other women, in the ferns at the edge of the lawn, just out of sight of the counsellors.
After our visit to the smoking area, my friend showed me the rest of the buildings and grounds, which really did feel very restful and healing. I began to resent that I hadn’t gone to treatment. Imagine how well I’d be by now if I had! Fluffy Sunshine expressed the same sentiment. When I asked her how she felt about not going to treatment, she said she hadn’t known much about it until she started going to meetings. She thought it was something only celebrities did. Then she went through a phase of being pissed off that no one had cared enough to send her. She said she still thinks treatment would be a good getaway.
As my friend and I sat at a cedar picnic table and basked in the weak winter sunshine, I had to agree with Fluff. The lawn underfoot was like a putting green. Around us small family groups visited and talked in murmurs. At exactly one-thirty, “the store,” a small room off the cafeteria, opened and people began to converge on it. The store was stocked with recovery books, inspirational slogans written on rocks, candy, potato chips, and, most important, cigarettes.
We bought some chips and candy, then went to the cafeteria to eat them. Then we walked around some more. Soon, we were back in the smoking area.
After I got used to the overwhelming sense of peace and structure, another vibration began to penetrate my consciousness. The addict hum, one might call it. I overheard snippets of the conversations in a gender-balanced group in the lower smoking area.
“Yo, dude. So I like fucking nearly ODed G! Sold my shit to live large. Yo! Thug life forever.” This was uttered by a young blond man who appeared to be approximately twelve years of age (though that was impossible because Cedars is an adult facility). He had on a baseball cap, worn sideways, and extremely roomy pants. He was apparently speaking to his mother, who looked tired.
When we went back to the TV room, we found a woman weeping disconsolately in front of a heavy-set man. I couldn’t tell which of them was the patient.
Kids ran around while their tense parents talked in hushed whispers.
It occurred to me that inpatient treatment centres have to provide calm surroundings just to balance out the rampant and cresting emotions, the endless drama and intensity that follow any group of addicts and alcoholics wherever they go.
It’s one thing to keep people’s behaviour in check for an hour-long twelve-step meeting. It’s entirely another to keep things from boiling over when dozens of newly sober addicts and alcoholics live together in a co-ed facility for six to eight weeks. Make no mistake about it. People in treatment centres, at least those in good treatment centres, are not on vacation.
There is very little “downtime.” Rules are to be followed, and each day is filled with activities and assignments, including group therapy, exercise, and lectures. Many of the activities are emotionally demanding and designed to help the patients break through accumulated layers of denial about their addictions. That’s about as fun as it sounds.
One of the things that treatment provides, in addition to one-on-one and group therapy and a highly structured environment that includes daily chores, assorted activities, proper food, and exercise, is insight into the science of addiction. I interviewed Neal Berger, the director of Cedars, and in a short space of time learned more about the science of addiction and recovery than I had in my previous nineteen years.
Like many people who sober up using the twelve steps, I didn’t spend a lot of time researching alcoholism. I decided my best chance was to trust the program rather than argue with it and find excuses for why it wouldn’t work. After all, the twelve steps had been effective for other people who were far more hard-core than me. Still, it was fascinating to learn, with the benefit of hindsight and my own experience, about how addiction and our understanding of it has changed.
Neal Berger has worked in treatment services since the seventies. His position as an in-demand addictions consultant takes him all over the world. He’s also uniquely gifted at using plain language to explain complicated things like how brain processes are affected by addiction.
I asked him about the current prevalence of treatment and what effect it has had on the numbers and types of people in recovery.
Surprisingly, he feels that there was more and better treatment available in the late seventies and early eighties when the idea first gained hold that addiction was a disease and, as such, was treatable. During that period, there were many centres and they had decent success rates. Then insurance companies started to get ideas about how addicts and alcoholics should be handled, and unqualified people started to get in on the act, and the level of care, he feels, began to falter.
Still, most people who achieve long-term abstinence today undergo some sort of treatment, either as an inpatient or an outpatient, and just as the type of people going into treatment and their conditions have changed over time, so have treatment facilities. There are treatment centres that cater to celebrities and the very rich. These are wildly expensive and lean toward the “spa” end of the scale. Other treatment centres, such as the Betty Ford Center, are costly but relatively stark. There, clients stay in plain, dorm-style rooms and there is little of the pampering found in the more spa-like rehabs. There are bare-bones government-sponsored treatment centres in both the United States and Canada. In Canada, some treatment centres operate using a combination of government money and donations. Patients may be asked to pay part of their care (forty to fifty dollars per day and up). For those on assistance or with employment insurance, this amount may be subsidized by the government. While they are unlikely to be mistaken for summer camps or meditation retreat centres, subsidized treatment centres can be extremely effective. The average length of stay in government-sponsored centres is twenty-eight to sixty days, but some programs allow patients to stay for ninety days or even up to a year in some cases.
For-profit centres in Canada cost between $13,000 and $17,000 for a forty-five-day program. Costs go up the longer the patients are in treatment. In the United States, costs vary widely. Some of t
he best-known centres charge between $30,000 and $120,000 for thirty days. The expense of malpractice and liability insurance helps to explain why for-profit centres are more expensive in the United States, but the extra costs are also connected to the level of luxury and name-brand recognition.
The type of care and success rate between centres also varies widely and is not necessarily tied to the cost of the program. In the United States, there is a growing preference for evidence-based treatment. This is an attempt to introduce standard guidelines and measurements as well as desired outcomes. Evidence-based therapies may include pharmacotherapy to manage withdrawal and reduce cravings, and various therapies, such as psychosocial interventions, motivational interviews, behaviour modification and psychotherapy. Other treatment centres use a harm-reduction approach. This approach may not necessarily emphasize abstinence, but rather support a measurable reduction of harm to both the alcoholic/addict and society.
Whatever the approach of the individual residential or outpatient treatment program, the reality is that many more people need treatment than get it. By some estimates, only a quarter of the people who could benefit from treatment actually receive it. In the United States, state and federal governments spend more than $15 billion, and insurers spend over $5 billion, on substance abuse services for four million people. In Canada, most government-subsidized treatment programs and many for-profit ones have long wait lists.
The treatment centres with the best outcomes tend to be those with longer programs that include an aftercare component. Aftercare refers to ongoing meetings with other graduates and counsellors and, in some cases, halfway or extended-care houses that support patients as they start to work and re-enter society. I’ve met many people who’ve “graduated” from Cedars or Edgewood, a renowned treatment centre in Nanaimo, who’ve moved to town to stay near to each other and their treatment centre. It’s obvious from watching them that these connections are important.
Some patients undergo voluntary monitoring, usually administered by the treatment centre. (Doctors, nurses, and airline pilots, among others, are required to do this.) These follow-up measures are combined, in most cases, with participation in a twelve-step program as the foundation of long-term recovery.
A final comment about treatment centres. Each has a different philosophy and approach. In the past, treatment centres were often based on a form of confrontational therapy in which addicts were “confronted” with their delusions. This can be extremely effective for some patients, but for others, among them those who grew up in abusive alcoholic homes, it can be risky.
It seems that children who grow up in such environments may suffer from a form of post-traumatic stress disorder. As George Vaillant, author of the groundbreaking study A Natural History of Alcoholism, observes, “Outside of residence in a concentration camp, there are very few sustained human experiences that make one the recipient of as much sadism as does being a close family member of an alcoholic.”* This background may make children of alcoholics or addicts harder to treat than other patients. The defence mechanisms that help them get through their traumatic childhoods also allow them to tolerate extraordinary circumstances. Neal Berger refers to the most common of these coping mechanisms as “psychic numbing” and notes that children of alcoholics and addicts have a four times higher rate of relapse than other patients. The brain disconnect they engage when stressed makes it tough for them to grow emotionally, and these patients have to be handled carefully and made to feel safe. They might survive a confrontational program, because they’ve proven that they can get through anything. But they often won’t get much out of it.
Memoirs about drug addiction and alcoholism are full of shocking, fascinating, and often entertaining stories about treatment programs. They are places where the high drama and low comedy of addiction take centre stage. They are also, sometimes, places where miracles happen. That said, those who are honest about treatment and the outcomes it can provide admit that it takes more than a good program, insightful staff, and scientific knowledge. It takes a willing and motivated patient as well as ongoing care and support. People who start out resistant to treatment may end up doing the best, while “treatment all stars,” as Jerry Blackburn, the admissions director from Edgewood, calls them, may relapse as soon as they are released. No one yet knows how all the pieces come together. Somewhere along the line, however, it seems that addicts and alcoholics must gain the humility and grace that allows them to give up their preconceived misgivings and to trust that somehow, their beaten hearts and minds can be healed.
* George E. Vaillant, The Natural History of Alcoholism Revisited. Harvard University Press, page 22.
23
Aftercare
ON A RAINY NIGHT in February, I met with a group of young people, most of whom were part of an aftercare program for Cedars. We met at the office of Sue Donaldson, who runs Pegasus Recovery Solutions in Victoria, B.C. She’s a petite woman with short blond hair who exudes confidence and warmth. It’s a mark of her personal charisma that she was able to get so many of her clients out on a Friday night.
The assembled group ranged from nineteen to thirty years old and had anywhere from two months’ to two years’ clean time from a variety of substances, including alcohol, cocaine, crack cocaine, and heroin. All had been to treatment at Cedars, except for a young man named Don who had gone to treatment in Maple Ridge.
The difference between the people with longer-term sobriety and those who were new was obvious. Nick, a muscular twenty-four-year-old who’d been clean for two years, chewed absently on his gold chain as he listened. He had sponsored at least two of the younger guys and was well-spoken and forthright in a way that was never overbearing. Abbie, a client who bore a startling resemblance to Rebecca DeMornay, worked part-time in a treatment centre. Her words also seemed to carry a lot of weight with the others.
We pushed back the comfortable furniture to accommodate everyone. As I looked around at the group, I felt slightly inadequate, partly because the group was so young and healthy-looking. I introduced myself and my project and said I was trying to get a picture of young people in recovery and what, if anything, has changed since the late eighties.
First I asked if anyone had tried anything other than treatment to deal with their addictions. There were some mutterings about “willpower,” spoken with the same sort of conviction a non-health-food person might use to say they took a few vitamins to deal with their advanced cancer.
Don, who had earlier volunteered that a few months before he’d been dealing crack out of the hotel located behind the office we were in, mentioned that he’d tried hypnosis to quit drugs. They all laughed. He said he was looking for a silver bullet. Several of the others had tried quitting on their own, but most had found it impossible and had resigned themselves to early deaths.
I asked about how familiar they had been with NA and AA before they went to treatment. Very few of them knew much, although all were now involved in one or both.
Reid, a twenty-one-year-old, mentioned that he’d gone to a couple of NA meetings and found them inspiring. “That one meeting ruined my using because I knew there was another way,” he said. Even so, he wasn’t able to stay clean and sober until he went to treatment. Most had been to see multiple alcohol and drug counsellors, starting in high school.
Kelli, a tiny woman with enormous blue eyes, said that when she was twenty-five she had been sent to meetings in Los Angeles by the courts, as part of a drug deferment on criminal charges. As soon as she figured out that there was no way to trace back the signatures she was supposed to collect to the people who gave them, because AA and NA are anonymous, she got her friends to sign her forms.
She was a heroin addict, and she talked about how she thought she’d never get clean and was sure she’d die an addict. It was only after she detoxed in treatment that she realized that she might actually have a chance. Kelli noted that her heroin use wasn’t fun any more and that she spent her life just trying to get from high t
o high. She ended up in treatment in Canada as a way to avoid jail time in the United States for trafficking.
I asked how many of the rest of them had gone to meetings before entering treatment. A few had, but none had stayed. For some, the language of recovery was a barrier. For others, it was the age of the other participants.
Most of them had gone into treatment hoping only to quit their most destructive substance, generally cocaine or heroin, but they had planned to continue drinking and smoking weed. I remembered a similar plan for myself, only mine involved stopping drinking entirely and using drugs only on very special occasions.
As they spoke, the thing that stood out was their enthusiasm about recovery. I’ve seen the same thing in people I’ve sponsored. Once they finish detoxing, get into a program, acquire a few friends, and are no longer sick to death, they often become exhilarated. But their exuberance is usually tempered by some misgivings.
Kelli admitted to initially feeling ambivalent about the idea that she was a person “who has to go to a meeting to feel better” but said that she’s over that now. All of them expressed an early fear of being “lame” or “uncool.” In Tweak, Nic Sheff’s heartbreaking memoir about his methamphetamine addiction, I was struck by this conversation between him and one of his drug buddies. He tells his friend he wants to get clean, and his friend replies, “You only get to live this life once. I’d rather be blissed out for a short time than fucking bored and miserable until I’m like ninety or something.” Then he goes on, “This is life … this is living. Every day is an adventure.” And Nic Sheff replies that it seems like every day is the same thing. He’s grabbed hold of the truth there. Addiction is cyclical. The same thing happens over and over with poorer results. The group in the aftercare program seemed to have grasped that as well. The thing that convinced them to keep going to aftercare and self-help meetings was that they started to get better so quickly.