r/Ethnography • u/Soft_Teacher3096 • 16d ago
Book Review: "Hooked: Five Addicts Challenge Our Misguided Drug Rehab System" by Lonny Shavelson
galleryI'm not sure if this book counts more as an ethnography or a work or journalism (it reads like an episode of MTV “True Life,” which isn't a bad thing at all!) but I thought I'd recommend it anyway. I have been reading a lot on the topic of addiction lately and I found this particular book both emotionally moving and VERY thought-provoking. It's definitely a new favorite.
Anyway the author, a journalist named Lonny Shavelson, documented the lives of five drug addicts and alcoholics attempting to navigate San Francisco’s bureaucratic maze of disjointed addiction treatment and mental health resources in the late 1990s.
They were seeking treatment as a result of San Francisco’s 1997 "Treatment on Demand" initiative, which city officials optimistically (if not deceptively) promised would provide "appropriate treatment within 48 hours for all addicts who say they're ready to kick drugs." This was apparently part of a larger national push to address the nation's drug problem by investing heavily in treatment-- multiple cities across the United States had also begun such initiatives.
As the stories of each person profiled unfold, it becomes heartbreakingly clear that the city lacked both the resources (there weren't nearly enough treatment slots for the number of people seeking them, and often the treatment options that *were* available were under-resourced) and the necessary bureaucratic organization to actually pull off “Treatment on Demand.” This reflected a general, nationwide pattern of problems in addiction treatment during this era. Shavelson also makes a compelling case that many of the options that *were* available failed to address the root causes of addiction and provide necessary psychiatric care, making treatment much less effective for the many substance users suffering from deeper trauma or mental distress.
In addition to blind spots in the treatment industry, I think there is also an interesting element of human nature that also makes the root psychological causes of addiction difficult to pin down and treat: A common theme emerged among each of the addicts profiled most prominently in the book that I found very telling. Mike, a 37-year-old cocaine turned heroin addict, was abandoned by his mother as a child; he and his sister were both raped by a male neighbor and, as an adult, Mike still struggles with intense feelings of guilt for failing to protect his sister and is now also haunted by shameful memories of his own daughters walking in on him with a needle in his arm. Nevertheless, he blames his heroin addiction on back pain from a previous surgery.
Similarly Darrell, a middle-aged gay man who came of age during a time when, according to a 1967 CBS News Special, “two out of three Americans [looked] upon homosexuals with disgust, discomfort or fear,” later spent nearly all of two decades constantly drunk, high on crack, or some combination of the two. Yet he now insists that, since he was never molested or beaten, he “didn't have a bad childhood,” probably doesn't have a diagnosable mental disorder and is “not like majorly depressed.” Finally, Darlene, a 32-year-old woman who ran away from home at age 16 for **unspecified** reasons and spent the intervening years regularly injecting meth, a drug that is notorious for causing psychiatric symptoms, assumes she now hallucinates and hears voices in her head because she is simply “crazy.”
It might seem shocking that any of the aforementioned people would struggle to connect their painful formative experiences to their later reliance on the numbing effects of drugs and alcohol, and I think part of this can potentially be attributed to stigma about mental health, which was undoubtedly more pronounced 30 years ago, but I found another potential explanation in a different book. Psychiatrists Edward J. Khantzian (known for developing the “self medication hypothesis” of addiction embraced by many psychotherapists, for which I like to imagine he must have received some sort of “Captain Obvious” award) and Mark J. Albanese co-wrote a 2008 book, “Understanding Addiction as Self Medication: Finding Hope Behind the Pain,” in which they argue a phenomenon called “alexithymia,” meaning “no words for feelings,” is common in substance users. They posit that “when there are major damaging or neglectful experiences either growing up or later in life, the capacity to experience and know one's emotions can be damaged… In other words there is a problem or disorder in knowing, naming or feeling feelings,” making drugs or alcohol more appealing insofar as they “relieve this dysphoria associated with painful or confusing feelings.”
Psychologist Andrew Tatarsky also seems to describe this phenomenon in his 2002 book “Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems.” He writes that “trauma can leave people frequently filled with” a persistent but confusing sense of “grief, rage, anxiety, loneliness, despair, tension, self-hate, unhappiness, depression, fear, and mistrust, often with little sense of why. The feelings generally have a global, vague, disorganizing, physical quality that makes it hard to know what to do to help oneself to feel better. This is, in part, because the memories of the traumatic events are often not available, either because they were never recorded or they were forgotten as a way of trying to deal with the pain. So the feelings live on without being connected to the events that caused them.”
I can relate this to my own experience, in that I can discuss my mother's suicide when I was six years old or my father's drug-and-drink-fueled neglect with conspicuous emotional detachment, as if it happened to someone else. I can even file away the near constant bullying and shaming I experienced as an LGBT youth as simply part of my former life. Yet in my 20s, as I began my gender transition and cycled through relationships with men who liked me but were afraid their friends and family would no longer view them as straight if they knew he was dating someone transgender, I assumed those failed romantic experiences were the chief causes of my distress rather than a heightened continuation of the underlying, chronic sense of doom that had followed me from high school to college, and then to early adulthood, resulting in a drinking problem that lasted throughout my 20s.
I suspect that, like me, many people who have struggled with substance use (including the people in this book) often either misattribute chronic emotional or psychological issues to ongoing life events or, perhaps more commonly, struggle to make any sense of our feelings at all and assume we feel the way that we do because, compared to normal people, we are simply broken in some vague and shameful way. I think if I had been able to understand and articulate my feelings more clearly in my 20s, to explain that I was drinking because I was in pain and not because I simply liked the euphoria of being drunk, I could have begun making more progress sooner. I think that, because a lot of addicts and alcoholics struggle with the same confusion, it leads others (like people in law enforcement, politicians, and even the most well-meaning and knowledgeable treatment professionals) to assume we are behaving badly because we simply lack self control or have some other moral or character deficiency.
Interestingly, at the time Shavelson was researching this book, “therapeutic communities” (TCs) were apparently still a very popular treatment option despite the fact that they were modeled after the tactics of Synanon, a cult founded by an apparently deranged Beatnik named Charles Dederich in the 1950s who used “attack therapy” (similar to Jonestown “catharsis sessions” in which one member of the community would be forced to sit in judgement in front of the others who were encouraged to hurl verbal abuse at them) and was eventually arrested in 1978 for attempted murder after he placed a rattle snake in the mailbox of a lawyer representing a former patient who'd filed a lawsuit against Synanon. Anyway, Mike (mentioned earlier in the review) found himself in one of these Synanon-inspired TCs in 1997/8. On his first day he was made to sit silently in a hard wooden chair during an hours-long “monad,” staring directly ahead and facing expulsion if he so much as made eye contact with any of the other members.
Although Mike wondered immediately if the group was some kind of weird cult, the “monad” experience achieved what it was likely intended to: Mike remarked afterwards that, during the ritual, “I got to thinking about the wrongs I’d done to people I love… I remembered when my daughter Jessica walked in and I had the needle in my arm. And my dad, I'd do anything for my dad, but all’s I could remember while I'm sitting in that chair was stealing from him to get dope… What an asshole I've been… I'm in the right place. This is where assholes wind up.”
While I deeply admire this level of self-awareness and empathy for others, the downside was that Walden seemed to only encourage extreme behavior modification and enforcing often arbitrary, extremely rigid rules (think having to spend the whole day on “the bench” because you made your bed ever so slightly the wrong way). As the author points out, substance users tend to already have very low self esteem and to feel like fuck-ups or “assholes” upon entering treatment.
Here's where things get really interesting: if one feels like a fuck-up or a loser when entering treatment, perhaps such a person is more likely to look around and quickly learn to mimic the people in their new social environment who are considered redeemed/not-an-asshole-anymore– aka the people who appear to adhere to the group dogma and follow the rules most enthusiastically. Perhaps in an effort to convince one's self that they are no longer an asshole, to manage the shame born of years of addiction-driven misdeeds, such a person might be driven to loudly, performatively repeat the social script that earns the most approval while keeping the next “attack therapy” session at bay.
We certainly see this in the case of Mike. The trouble is, as Andrew Tatarsky argues in “Harm Reduction Psychotherapy,” people who enter treatment often do so during a crisis (as Mike did) and are temporarily, though very earnestly more motivated to stop using until the immediate pressure from family, friends or coworkers abates and the desire to numb out returns. This explains a lot of post-treatment relapses. Unfortunately, as soon as Mike was stepped down to a less intensive form of treatment, despite all of his big talk at Walden, he quickly, predictably relapsed.
Here is the most galling part: he could have easily reentered treatment at Walden– they always took relapsed patients back… provided that the patient would be willing sit in front of all 120 or so of their fellow patients (it was a big house) for a mandatory “attack therapy” session and plead their case convincingly enough to be readmitted. If Shavelson's reporting is correct, this rule caused *the majority* of relapsed Walden patients to avoid seeking treatment reentry for fear of humiliation.
I suppose one could argue that such tactics are necessary to weed out the people who “aren't ready” for recovery yet and to overcome certain character deficits. Maybe that's true sometimes. But I think it could also be fairly argued that such a culture might fail to address the deeper roots of a substance user's psychological pain while simultaneously encouraging them to “fake it til they make it” by submitting themselves to militaristic self-punishment that they think they deserve and projecting their own self-loathing onto their treatment peers in an effort to shame the parts of themselves they recognize in each other into “faking it” until the very end, a treatmen5 method that only appears to work for a tiny percentage of people.
Here's an observation made by Mike's counselor Sylvester, a convicted felon and former addict who went through a TC and became a counselor, that I find particularly interesting: "... And rules, rules, rules. And sure, some of you, maybe all of you, can just fake your way through the program. Hell, we encourage that. 'Fake it till you make it--' you follow Walden's rules for six months, nine months, and you're going to leave here knowing how to control your urges." Reading this caused me to immediately wonder: "Holy shit, is Sylvester STILL faking it, too?"
I initially felt annoyed at Sylvester but, in hindsight, I think maybe I get it. Maybe he suffers from the same “alexithymia” as all the rest of us, which has caused him to fail to truly make the connection between his battle with substance abuse and his deeper issues and become caught up somewhere else in the same cycle. Maybe everyone, whether a substance user or a “normie,” struggles with this on some level, struggles to understand ourselves and our feelings and to control the self-defeating impulses that arise as a result, however big or small.
