Cracked: Putting Broken Lives Together Again - Drew Pinsky, Todd Gold (2004)

Chapter 16

IT’S AFTERNOON. I’M on my way to the treatment team’s weekly meeting when I bump into Pat, one of the two counselors, who is also heading toward the conference room. Pat is a talented, compassionate, but imposing recovering heroin addict. Even on hot days he still wears two long-sleeved shirts to cover the tracks and tats that remind him of his disease.

I’ve just left Amber’s room, and as we fall into step together Pat asks, “How’s she doing?”

“She’s having a tough time coming to terms with her powerlessness,” I say.

“She’s not the only one, is she?” He gives me a meaningful look. “Aren’t you feeling a little frustrated by her yourself?”

“Point taken.”

“You’ve gotta be careful with that one. We have to push her. She can handle it. We have to stop coddling. In fact, as soon as the meeting is done I’m going to review her first step with her to see how it’s coming. She’s going to keep sliding if we don’t stay on top of her.”

“I don’t know if I agree completely.”

“I can see right through her,” argues Pat. “I see her working you for meds all the time. She’s got so much shit in her. I know what she’s about.”

I walk into the meeting stunned by his comment. All the principals are already in the room, either seated or standing by the coffeemaker, waiting for a fresh pot. I turn Pat’s words over in my mind. He’s probably right. Each of us has our own response to patients, after all. I know I’m always taking on everyone else’s feelings as if they were my own burden, particularly women’s. Amber seems to have found a pathway into that primitive part of my makeup, and that’s what Pat has picked up on.

I know this is one of my weaknesses: I can’t always catch the complexity of my own reaction to a woman in pain. Of course, that fact itself only makes these meetings more valuable: By sharing our experiences with patients, we sharpen our faculties in debate, catch each other in mistakes, and use our experience in different professional disciplines to make each other better at what we do.

“So where’s Matty at?” asks Finley, directing his question to Pat.

“Well, you know, Matty is Matty,” he says. “He’s self-absorbed, not really interested in sobriety.”

“Did he do a first step?”

In our program, the first step, admitting powerlessness, is a requirement; so is getting a sponsor. We’d love to see them get through the second and third steps, too, but that takes weeks, and very few have the resources to cover such a lengthy hospitalization. We give them education and workbooks on the steps.

The goal is to bring about a new awareness of the extent of their disease, its effects on their lives, and the alternatives. Ideally, this leads to opportunities for patients to experience themselves on a new emotional level. If it were all cognitive work, I’d just have to convince them to change their thinking. But the change must be made in the emotional centers of the brain. This is experiential learning, and it takes time—a reality that insurance companies, among others, don’t understand.

“Yeah,” he nods; Matty took at stab at completing his first step—on the face of it. “But it was just so he could get closer to getting out of here.”

“How was it?” asks Finley.

“He was able to identify the consequences, but he still insists that he’s not powerless over drugs and alcohol. He kept suggesting he was going to use his will to overcome his drug problem. There was no sense of capitulation to the unmanageability in his life. He remains focused on people, places, and things. He insisted he’d let his boss and his girlfriend get to him—that that was why his use had escalated.”

“Very superficial,” says Finley.

“He doesn’t see the biological effects of the drugs,” I add.

“He remembers the anxiety and the agitation, but he’s got no insight into how manic he was when he came in,” says Alexi.

“It’s amazing how difficult it is for them to see it,” I say.

“Not really,” says Pat. “Lest you forget, they’re so fucked up they don’t know anything.”

“Point taken,” says Finley.

“He’s cooperative,” interjects Gail, the other counselor. “I had him earlier today. As a matter of fact, he went ahead and did a second step.”

The second step of Alcoholics Anonymous acknowledges belief in a “power greater than ourselves that could restore us to sanity.”

“That’s ridiculous,” says Finley. “We shouldn’t have accepted his first step. Don’t you think it should’ve been redone?”

“If you’re asking that question, you’re going to love this,” Gail continues. “He hasn’t presented his second step to the group yet, but I went over it with him. He insists his girlfriend is his higher power.”

The whole room giggles and groans.

“Fantastic,” I say. “Get him to redo his first step. Maybe if we can get to some level of honesty, we can deal with his concept of higher power.”

Finley leans forward. “Whatever his whim is in the moment—that’s his higher power,” he says.

For a split second, I imagine what it must be like to be Matty, and I flash on a scene I’d recently witnessed at the airport. A four-year-old boy began crying in the terminal as his mother walked to the ticket counter. He was clearly frightened by the crowd. Immediately, his father, a twenty-three-year-old version of Matty, yanked him close, put his face nose-to-nose against the child’s, and in a menacing voice said, “Shut up!”

The little boy cried even harder as his father walked away with him, and I cringed along with him. The boy was crying in the first place because he was feeling anxious and powerless, and instead of getting what he needed from an adult, he got rage, abuse, and separation from his mother—exactly what he feared in the first place.

That’s how it happens. Soon there’d be a wall built around his unbearable pain and powerlessness. Soon we’d have another Matty.

Finley picks up another chart, glances at the front page, and shakes his head. “So our friend Mark Mitchell is back,” he says. “He’ll make us feel better.”

Alexi doesn’t look up from the papers in front of her. “I’m concerned about him,” she says. “He doesn’t have many more of these left in him. He’s developing muscular wasting. His liver enzymes are way up. He has enlarged red blood cells. His nutrition is horrible. Each time he gets worse. His binges are longer, and his withdrawals are more intense.”

“How’s he doing now?” asks Finley.

“Finally through withdrawal,” she says.

“He was in group this morning,” says Debra. “But he was still out of it. He just sat there. Actually, he slept through most of it.”

“Enjoy that,” cracks Pat. “It won’t last. Soon he’ll take over.”

“It pains me to say it, but I’m not sure this guy’s ever going to get better,” I say.

“Agreed,” continues Pat. “This is his fifth treatment. He never follows through. He always manages to weasel out of our recommendations.”

“He went to Sober Living after the last treatment, right?” asks Finley.

“No. Not even close,” I answer. “He split when we started pushing him to meet his behavioral goals.”

“So unlike him,” says Alexi. “That’s why I’m worried.”

“He went directly to live in the apartment of another patient, a female,” I say. “Both of them relapsed.”

“He’s never capitulated,” says Alexi, who turns to the two counselors.

“We need to point out he’s never gone beyond the superficial,” I say. “He’s the kind of guy that, if we could just get him to stay sober long enough to get to a fourth step—”

I notice Finley and Alexi staring at me in disbelief. I stop talking.

“Okay, then,” says Finley. “Back to reality.”

Sort of. The last point of the meeting is almost beyond belief, too. Linsey has made progress. After hurrying through the details of her medical status—which is stable, including her eating disorder—Pat reports that she did her first step. Since these weekly meetings are my only involvement with a patient’s steps, I listen intently for the reaction. Was it honest? Strong? Emotional? Superficial? Complete and accurate? Still romanticizing the life?

My eyes are on Pat, who describes Linsey’s delivery as “one of the most powerful steps I’ve heard in a long time.”

“Really,” I say. “Good for her. What happened?”

“She sat down with twelve pages on her lap. I thought, oh boy, she’s just going to read it? We’re going to have to push on her to get something out of this. But she sat down and began to read, and poured out so much emotion. She tried to make herself so small in her chair, but she climbed right out of it.”

“What were some of the details?” asks Finley.

“She told about going to boarding school at fourteen and discovering pot while hanging out with the kids who did drugs. At a party, she sat next to a guy she thought was cute, a high schooler, and he put his hand up her dress. ‘And that was the first time I was raped,’ she said. I got a chill.”

“And her use escalated after that incident?” I ask.

“Right,” says Pat. “God bless her, she didn’t leave anything out. Rape. Trading sex for drugs. Abusive relationships with other addicts. Her parents’ neglect.”

“Beverly Hills is such a nice place to grow up, isn’t it?” snickers Alexi.

“You know, before she came here, she was dead,” continues Pat. “They revived her at Century City. She discussed her ambivalence at having survived. Now she very much wants to live.”

“How’d her peers react?” I ask.

“They gave her terrific feedback.”

Good news comes in small increments, but you learn to be grateful for whatever you get. It inspires the whole staff, as well as the patients. It’s a phenomenon unique to this sort of medicine. Nowhere else can one patient’s successes in recovery have such a profound effect on a group of other patients. They see their disease operating in their peers.

In reality, many patients are so preoccupied by their own shame and suffering that they won’t hear a word of a story like Linsey’s. But one or two might find themselves so profoundly affected that it helps them find the courage to do their own steps in a genuine and honest manner.

That’s how it works. The twelve steps of AA are simply empirical structures that have proved useful for getting addicts to engage slowly in a therapeutic process. Fundamentally, they are a structured journey into a healthy, intimate relationship. There are numerous theories about why addicts are able to connect with one another in this process. Most believe they connect around a common experience of pain and powerlessness without the fear of exploitation. Their pain is so raw and tender that getting them to start the process requires them to be convinced that their pain will be understood. They’re all people with extreme trust issues, and the only people they’ve ever trusted are other addicts. They understand each other. (Interestingly, doctors have discovered that survivors of torture have similar reactions to treatment. They don’t open up unless they’re around others who’ve been through similar horrors, as though the pain of being misunderstood would be too great of a risk.)

That’s why patients present their steps to their peers. The staff determines whether the step is acceptable, but the real feedback comes from their peers. Sometimes the insights they have are brilliant. They’re so attuned to one another’s bullshit, they can sniff out a lie before it’s halfway uttered. They know when someone’s in trouble. They also sense when someone is making progress. Unless you’ve been through it, you don’t know.

Pat reminds me of that point after the meeting. I can’t put myself in Amber’s shoes and make her do what I want. “It has to come from inside her,” says Pat.

“We’ve had good talks. I thought I sensed her coming around.”

“If you ask me, I think you’re responding to her pathology. And some very pretty eyes.”

“You think I need to pull back?”

“Boundaries, Doctor.”