Cracked: Putting Broken Lives Together Again - Drew Pinsky, Todd Gold (2004)
“HOW’D IT HAPPEN?” I ask. “One minute two patients are here, and the next they’re gone. Who was doing the accounting? Who saw them last?”
It’s the next day, and Wendy and Matty have disappeared from the unit. I gather the staff, and they know I’m upset. According to everyone’s recollection, Wendy and Matty were at breakfast and attended morning group. They also ate lunch and had a smoke on the patio, where apparently they spoke to each other one-on-one for the first time.
Though Wendy hasn’t caused any problems for us since being admitted roughly four days earlier, we take her disappearance as a serious health risk. Even at her best she’s unable to control her impulses, and she’s hardly at her best. In the throes of withdrawal, she’s in danger of hurting herself. Of course she’s not legally bound to stay at the hospital, but if she’s here we’re obligated to make an effort to find her and keep her safe.
I double-check Wendy’s room. It’s empty. I glance around quickly. The room is as messy as it was when I was in there the day before. I open the closet, in case she’s hung herself and nobody’s thought to look. I’m not being morbid. Since most patients suffer severe depression during withdrawal, all have to be considered suicide risks. It wouldn’t be out of the question for someone with Wendy’s issues. Fortunately her closet is empty, except for a pair of men’s flip-flops that must’ve belonged to a previous patient.
Before I close the door again, though, I notice a window in the back of the closet. I guess it’s left over from the last remodel. The view is of the back ninety, our nickname for the large stretch of undeveloped chaparral behind the hospital. A hazard of dirt, brush, and trees, it’s our danger zone. We regularly catch patients out there either using or scoring drugs. Now, with the sun starting its descent in the west, it’s a field of light and shadows. I scour the scene intently, and after a few minutes I see something move. Maybe not. I try to focus on the spot, but I can’t tell for sure. Shit.
Darting out the door in the adjacent room, I scramble across the dirt. About twenty-five yards out, I hear the sound of a man’s voice. A second later, a woman’s gentle laugh helps me narrow my search. I wonder if they’re smoking grass or trading hits off a crack pipe. Then I see Wendy and Matty. He’s naked. She’s still wearing her tank top. They’re having sex.
What happened to Wendy’s knee pain? Did it suddenly clear up?
No, she merely discovered that sexual arousal gratifies her addictive biology the same way drugs do. She wasn’t able to stop herself, wasn’t able to manage her feelings. Her addict brain had taken over. The temporary relief it provides is enough to get her through the moment. The act is also something she has relied on for validation her whole adult life. Losing herself with someone she perceives as a powerful male makes her feel safe, though ultimately she chooses men who reenact traumatizations and reinforce her shame, guilt, and her sense of herself as a victim.
I shout at Wendy and Matty, telling them to get dressed and meet me in their rooms. Then I return to the unit and let everyone know I found them.
Everyone knows Matty and Wendy fucked up. The two of them also know they violated their treatment contracts. We don’t try to keep the incident quiet. The gossip grapevine among patients in a chemical dependency unit is spectacularly lively. Within minutes, all the patients knew what had happened.
The counselors deflect the buzz by reminding patients of the behavioral contracts they all signed. They drive home the point by reviewing them again.
Alexi can’t contain her amusement. “These people are too much,” she says.
“So smart, yet so dumb,” I say. “Just proves how much they’re in the grip of this thing.”
They may be powerless, but we aren’t. Both Wendy and Matty have to be dealt with—separately, of course. First, though, I want to prescribe some postcoital contraception for Wendy.
“To my knowledge, she’s not on birth control,” says Alexi.
“If the pharmacy has it, I’d prefer the levonorgestrel-ethinyl estradiol combination,” I say. “Two pills now. Repeat them in twelve hours.”
“Also, please debrief Wendy and see if she feels in any way that she was coerced into this encounter. If so, we’ll have to send her to the ER for a forensic exam. You should also explain to her that postcoital contraception prevents her from ovulating. It’s not an abortion. If she’s ovulated within the last twenty-four hours, in all probability this won’t work and she’ll still get pregnant.”
“What about Brad Pitt?”
“I’ll take care of Matty,” I say.
Having followed instructions, he is waiting for me in his room. His roommate, an alcoholic in his fifties nearing the end of his stay, is out. Matty is a big, competitive guy. In such situations, it’s usually prudent to bring a nurse into the room, too. I didn’t. I don’t know Matty well enough to anticipate his reaction. I don’t like such confrontations, so I keep my talk short and to the point.
“We try to be a supportive program,” I say. “I’d like to give you a chance to come clean with us.”
“Have you been doing any drugs this morning?”
“No,” he says.
“What’s your sober date?”
“Eight days,” he says.
“Nothing since then?”
Matty tosses a little piece of paper he’s been playing with into the trash can, and gestures like an NBA player when it goes in.
“What’s the big deal?” he says.
Irritated, I open his chart and take out his treatment contract. I make sure he sees his signature, and then I point to a paragraph midway down the page. It’s the paragraph that explains that sexual contact between patients is not permitted, and furthermore is grounds for discharge.
“Do you recall that?” I ask.
“I thought that meant, like, rape,” he says. “That chick was really into it.”
Matty has to go. If I had any doubt, his last comment erases it. He hasn’t gone to groups regularly, another violation of his contract. His constant flirtations with women on the patio have stirred up the other patients. Now this incident. He’s toxic, a danger to other patients. We don’t have enough structure to contain him.
I tell him that it’s not working out. “Let us help you transfer to a more structured unit,” I say.
After hearing that, Matty finally gets what’s happening, and he reacts in the way I feared. I can see him literally wrestling with a buildup of stress. He starts to argue, listing the ways the program is helping him. Matty’s not the kind of guy who wants to be told anything. It triggers his feelings of helplessness, and makes him feel out of control. He can’t handle that. It triggers aggressive feelings that guys like Matty can’t regulate. I know what’s coming.
“Matty, you’ve got to call your girlfriend or your mother and have one of them pick you up,” I say. “We’ll give you referrals to Cry Help, Impact House, or another excellent facility.”
He slams his fist into a pillow. “I’m paying cash for this program,” he says. “I put down five thousand dollars, and I’ve gotten lousy care. You guys haven’t done shit for me. I haven’t seen a doctor. You don’t give me enough medication. I keep telling you I need more. This morning Alexi wouldn’t listen when I told her about my back pain. This is some kind of a ripoff. How much of that money I’m paying goes to you?”
After that outburst, I tell him to make his phone call and then I leave. As I leave I hear him throw something, probably a book, against the wall and scream, “This is bullshit! You can’t discharge me. I haven’t done anything. I’m calling Patient’s Rights.”
I’m for watchdog organizations like Patient’s Rights, but in practice they can end up empowering the most manipulative and disruptive patients. Generally, Patient’s Rights assumes a patient is right and the caretaker is wrong. Our only defense is impeccable documentation. It seems we’re always filling out forms. Since there’s never enough time to complete all the paperwork, patients like Matty may get their way, to their own detriment.
In progressive states like California, patients aren’t obliged to follow their doctors’ instructions, the rationale being that to force them to do so would infringe on their rights. It’s against the law for me even to suggest that we might stop him from calling Patient’s Rights. It’s like a criminal suspect asking for a lawyer. In fact, if he wants to, I have to offer him the opportunity to call. Matty’s behavior has been so outrageous that I want to believe even Patient’s Rights would see through him. But if he wants to pick up the phone, hey, I can’t stop him.
I end up triggering a silent code, an alarm that gathers staff from throughout the hospital to provide a show of force to a patient who is or might become violent. This is as opposed to a more urgent Code White, which is an emergency call for help issued over the entire hospital through the P.A. system, a call for help with a patient who is an imminent danger and must be immediately restrained.
Within seconds of my silent alarm, staff convenes by the nursing station. I’m especially grateful to see the half-dozen large males who show up. The group, about fifteen strong, follows me into Matty’s room. Bewildered by the show of overwhelming force, he asks if this is an intervention. In a way it is, I tell him, except the upshot is that he must leave the premises.
“Give him referrals to Cry Help and Impact House,” I tell Alexi. “Let him use the phone in the consultation office. If he doesn’t want to set up a bed at one of those facilities, have security escort him off the grounds. He needs something more structured. And long-term. Six to twelve months minimum.”
About two hours later I pass him in the hall, tell him he has what it takes to get better if that’s what he wants. He mutters something about being a New Yorker and being misunderstood. Of course, it’s all out there, nothing that he is responsible for. “I don’t need any of the bullshit anyway,” he says. And that’s the last I see of him.
Meanwhile, Wendy is in her room and falling apart. Alexi has already spoken to her and reported back to me. She had a nurse help Wendy clean herself up after her romp in the dirt. She doesn’t know how much of Wendy’s response is dramatic effect and how much is real.
“We’re just four days into it with her,” says Alexi. “This girl is like dead rats in the window.”
“It’s Slav.” She laughs. “No matter how nice the merchandise in the store, if you see dead rats in the window it tells you what’s really going on.”
I take a deep breath before going into Wendy’s room. Laying on the bed, her face buried in her pillow, she’s still sobbing hard. I notice she’s turned down the photos on her nightstand. After talking a bit, she sits up and apologizes. She couldn’t control herself, she says, and I know that part is true. Unlike Matty, she seems to be taking some responsibility. Then again, she could also be playing me. I don’t know.
“I want to get better,” she says. “I don’t like living like this. I don’t want to go on spending every minute thinking about where and how I’m going to score my drugs. I fucked up. I don’t know why I do these things. I know they aren’t right. I need help. Please let me stay.”
“How many second chances have you asked for?”
“I don’t know,” she cries. “Too many.”
“In order for me to let you stay here, you have to be willing to follow all the rules to the letter,” I say.
“I will. I swear.”
I hand her a brand-new treatment contract, containing additional and more rigid restrictions, and tell her to read it carefully.
“All the rules are right there in black and white,” I say. “We’ll be holding you accountable for everything. If you have questions you should ask them now, because telling me later on that you didn’t understand won’t work.”
Wendy nods. Still, no matter what I tell her, I suspect we’re going to have more problems ahead. If she’s going to have a chance, she needs help dealing with her impulses. I restrict her to the unit. She appears to accept the news well. She doesn’t argue. Nor does she balk when I tell her that she can’t abuse the staff, have any inappropriate contact with her peers, or miss any groups.
“I also expect you to participate in group,” I say. Group, I explain, might allow her access to the emotional material that’s driving her need to escape. “No more bullshit. Be on time to all groups—no exceptions.”
I sound like a teenager’s parent. Of course, she’s acting like a teenager. This is a lot of information for her to absorb. I know three-quarters of it passes right through her, untouched and undigested. But part of my job is to repeat it over and over again until something does stick.
A little later I get concerned and check on her. Call it a bad premonition. Luckily, it’s nothing. Though still in her room, Wendy is calmer. I don’t know what kind of issues she might have regarding family or insurance, but I sense that she’s scared. Part of her doesn’t want to blow it, and part of her simply doesn’t know how to be anything but out of control, and yet inside she’s a cauldron of roiling emotions. “I know you feel shame,” I say.
She’s silent; she looks right at me, but I notice a cold emptiness to her eyes. She is struggling with the powerlessness over her disease and the shame this creates. And she’s dealing with it in the only way she has ever known—by dissociating from her feelings. This is her escape when there is no escape.
Dissociation is the activation of a primitive region of the brain that we share with lower life forms. It’s basically the remnant of the mechanism that’s responsible for an animal’s feigning death when threatened. In this state, Wendy is reliant on behaviors like sex or drug use for relief from her feelings. The look in her eyes sets off a cold chill in my spine. I feel a need to reach her.
“The shame sets off a domino effect inside you that ends in catastrophe,” I continue. “Trust me, feeling your feelings won’t destroy you. You might feel helpless right now, but you aren’t helpless. If you were helpless, you wouldn’t be at this facility. We’re all here to help you. We know what works, and your job is to follow directions. It’s time to listen.”
“I have too much in my head to listen,” she says. “You talk about feelings, but I don’t know what I’m feeling.”
“You’re feeling intense anxiety,” I say. “Fear. You don’t want to use, and yet your brain is saying you won’t be able to manage if you don’t use.”
She grits her teeth and growls. It’s the sound of frustration. “What’s going on?” she sobs.
I turn over the two photographs Wendy had placed facedown. Once again the little girl in the two pictures is smiling into the room. Wendy steals a glance and then lays down on the bed, pulling a cover over her and shutting her eyes. I know she’s probably lied to me, but when she wakes up she’ll see that the person she’s hurting most is the one looking back at her, and maybe then she’ll start getting the message.