Author:Yeshaia Blakeney

The Human Side of Treatment Behind the Opioid Epidemic: Ryan’s Story

I was working in residential treatment a few years back; one Friday night, a new resident, Ryan, approached me. He was a teenager, 5’6” with big, kind eyes, natural dark circles, and a face that turned red at every feeling or change in temperature. He asked, vulnerably, if he could speak with me. I took him to my office, we sat down and I asked, “What’s up?

I got out of Heroin detox two days ago. I’m 8 days sober. And I’m craving shooting heroin again.”

I could see that he was quite sincere and on the razors edge of going this way or that. I looked him in his eyes and asked him: “How are you going to use?” This question surprised him; I think he thought I was going to talk him out of it.

I’ll smoke it,” he said dryly.

“Do you have Heroin on you now?”

No,” he said.

I asked, “How will you get Heroin?”

“From my dealer” he responded, clearly getting impatient and annoyed.

I proceeded, “Do you have money?”

“Ten bucks” he answered.

I said “Give it to me,” and he did, and I put it in my pocket. “Do you have a cellphone?” I asked.

“No,” he was beginning to catch on to our game.

“How are you going to call him?” I pressed.

With some finality he said, “I’ll panhandle, get the money, I’ll call him from a payphone at the gas station, and get high.”

“So he will come drop it off and you’ll get high at the gas station?”

No.” Ryan said,  “my dealer doesn’t deliver, I’d have to take the bus to Inglewood and meet him.”

I continued, “After you meet him and get the dope where will you get high?”

“I’ll get some tinfoil and a straw from burger King and smoke it in the bathroom there.”

“And then what?” I asked accusingly.

“I’d be high,” he replied.

“And then what?” I asked.

“I’d go home,” he answered.

To your parents?” I asked.

“ No, they kicked me out. I’d come back here,” he admitted.

“To rehab?” I asked, “and then what?”

“I’d get sober,” he answered.

“You’d get sober? But you’re sober now!” I replied, too loud, revealing my inner judgement.

Yes but when I am High I really want to be sober,” he said.

Aha. “So let me get this right, in order for you to stay sober you have to get high?”


Two days later, Ryan was on the street getting high. Ryan wanted to be sober. But he wanted to be high, also. By the eighth day in treatment and sober, he had run out of motivation to stay sober. Why did Ryan need to get high in order to stay sober? When he went into his memory he realized that when he was high, he found the motivation to get sober; the crisis of addiction created an energy, a desire in him to get well. Ryan was cutoff, he was stuck in his own thinking, and his thinking was cut off from the world. He was stuck in a narcissistic bubble of addiction. Ryan was rational, but his reasoning was driven by an unconscious craving to get high. He didn’t want to get high, that’s why he asked to talk to me, but it was almost as if once he engaged me he was sleep talking, unable to wake up and stay where it was safe and welcoming. Underneath the mechanics of Ryan’s thinking there was something else going on. Ryan was numb, and underneath his numbness was pain, fear and sadness.

I wonder if I had been able to break out of my role in that moment: warm and clever counselor and instead become loving and vulnerable with him, would the effect have been different? If I had held his hand, been there with him 2 or 3 hours or however long was necessary, listened to his pain, given him a hug, could I have broken through to a different part of him and changed his trajectory? As it was, I believe we were both stuck in our roles at the time, him the out-of-control addict in need of saving and me the young-smart-(slightly)-distant counselor. Ryan recovered from his condition; I am still working on mine.

Ryan ended up in treatment two weeks later and has been sober ever since. So it turns out he was right, he had to get high in order to get sober.

Things I don’t like about contemporary treatment: A meditation from the inside

Dr. Erich Fromm, one of my teachers, inspires the title, and much of the content here.

There is a huge shift transpiring in the field of drug and alcohol treatment, it is happening rapidly and systemically, it will be for the worst and difficult to reverse. Warning: the field of treatment is being infiltrated by people who are emotionally disconnected and un-empathetic towards the plight of the people they claim to serve.

What the treatment industry used to look like: A group of people who had an experience of transformation becoming missionaries and willing to do whatever it took to help addicts and alcoholics. Twelve step, spirituality, new clinical techniques, whatever helped people recover it was done with spirit, intention and legitimacy. I am not idealizing the past, there were always unscrupulous operators, but they were the exception rather than the rule (with some large scale exceptions in the 80’s treatment bubble).

What’s happening now is something different: salesmen, hustlers, and young wealthy kids who want to show their parents they can be successful, open treatment programs, for the wrong reasons and with no experience. Many Drs. And psychiatrists enter into the field as consultants or hired employees and get tempted by money and use their degrees as cache to become owners and operators of there own centers, these too tend not to be missionary healers, but more business savvy narcissists. What’s happening now in treatment is systemic, a result of the breakdown of ethics and spirit in the treatment field. All of this has come together in a near perfect storm to create an industry that seems to have lost its way. The new breed of treatment centers is looking at how to maximize profits, buy and sell addicts care, and become as large and efficient as possible. It is the wrong approach.

One of the contributing factors to this shift is the influx of narcissistic and egoistic personalities that own and operate treatment programs. Every day I hear about the shenanigans of the owners of large “successful” treatment programs. It is clear many of the owners of private rehabs have not done their own spiritual work. Many of these owners are pathological. They tend to have the psychological profile of compulsive gamblers: Mildly (or majorly) anti-social, grandiose, charismatic, addicted to the cycle of winning and loosing, self sabotaging, self-absorbed and lacking in empathy.

What makes this situation deeply troubling, as opposed to another unfortunate by-product of profit-centered capitalism, is that recovery once was a sacred field, largely due to Alcoholics Anonymous.

We have reached a moment in the field of treatment where events and industries have conspired to create the perfect storm. The issue is greed.

Treatment, when done correctly can be a profitable business, and treatment with a focus on profit (over care) can be insanely profitable. Treatment has now become an attractive field for those looking to make a quick buck. On some level what is happening is no different than what happened in the mortgage industry in the early 2000’s. The treatment bubble began to attract these characters (en masse) with the introduction of mental health coverage from insurance in conjunction with the capacity for huge online marketing efforts on Google.

How has this happened? There is a lot more money in the field than there was ten years ago. There is also, unfortunately, a growing customer base, as our country is in the midst of the worst heroin epidemic it has ever seen, and it is an epidemic affecting not only the lower, but also the middle and upper class that can afford to spend more on treatment. This has not gone unnoticed by venture capitalists, real estate investors, huge multinational corporations; they all see treatment as an industry they can capitalize on.

One of the reasons this works is that when families or clients choose to come to treatment all they know is the marketing, not the treatment itself. Unlike a restaurant, customers cannot just try the product and decide if they like it and go somewhere else. Rehab is a big investment. From the outside (or the website) there seems to be no difference between genuine experience legitimate treatment, and large commercial insurance farms. Financial success in this industry has little to do the quality of treatment and everything to do with marketing. The more one can focus their resources on marketing the more clients one will get. It has become a marketing game to fill beds. As a result you see the greediest operators achieving enormous success, putting marketing first (over care). The clients who don’t get the care they need don’t have a voice because they disappear back to where they came from, or sometimes, tragically, die. No one takes responsibility, and the most vulnerable among us are being exploited.

And, we now have the recovering community itself getting involved. Which in many ways is a great thing, but when a recovering person in the first couple years of recovery without much experience or know how opens a treatment center, the core of the treatment matches the core of the founder: shaky, compromised and not yet fully integrated.

So what does good treatment look like? A good treatment center is one that exemplifies healthy living, strong ethics, strong boundaries, expertise (through experience) and lots of love. The men and women in the trenches of their recovery, with an interest in transitioning into the field of recovery, become counselors, therapists, techs; they go back to school learn their crafts and 10 years later they have worked their way to positions of power, legitimately.

The best of us in the field are those who feel an obligation to our fellow person, see ourselves in the people we help, recognize our own limitations, can empathize deeply with suffering, and have the strength to help create a safe and sacred place for those in need to recover.

The other day I was visiting with a young man who just opened a new treatment center. I was speaking with him and the clinical director for longer than I had anticipated.   It was clear he was excited about his new business and also clear that he was excited to be helping those who need it. We talked about ethics, spirit and fighting the trends of our industry. Treatment programs like his and mine, are becoming the exception. We are people first, we’ve done our own work, we have experience, we are small, smart, and we are values based. I am having these conversations more and more (with colleagues, with parents, with clients, with peers); there is a small underground group of us forming, perhaps a specter is haunting the treatment field: the specter of integrity!


Beyond the “Unbroken Brain”

In Maia Szlavavitz’s new book “The Unbroken Brain” Maia articulately lays out a subtle and nuanced idea: Addiction is a developmental disorder. It is a beautiful (although not new) idea that bridges the gap between the brain disease model of addiction and the idea that addicts are selfish amoral people “model” of addiction. The idea that addiction is developmental in nature accounts for the vast majority of what we see in the addicted populations. Addiction as a developmental disorder posits that there is correlation between addictive behavior and a stuck or disordered learning process. It also posits that the solution for addiction is growing, learning and changing. This is spot on and would seem obvious, except for some reason this view has not spread or been articulated well to the mainstream. It is important to not that this theory does not account for why some people who get stuck along the course of healthy development, also get stuck in a cycle of addiction, and others don’t, this remains a mystery.

The interesting question to ask about addiction as a developmental disorder is what type of developmental disorder is it (i.e. in what areas are people stuck and or split?) Is there a construct that can account for the diversity and totality of the stuck states we find in the addicted population? In fact there is: The Developmental Integrity Theory of Addiction. Dr. Charles Blakeney a Harvard psychologist (and proudly my father) and researcher hypothesized in 2002 that clients suffering from addiction were suffering from a state of dis-integration. The idea was that people with addiction had underlying developmental disturbances that kept them stuck in addictive cycles, put simply they weren’t whole. This dis-integration was due to certain parts of the self becoming stuck (not growing) in the course of development. When one part of the self is growing and another is not, it creates a split, a developmental disturbance that essentially if unaddressed manifests as stress, pain, anger, anxiety or cut-offness. The Developmental Integrity theory posits that people are medicating their splits with drugs, alcohol and other escapist behaviors. The theory goes beyond the Unbroken brain hypothesis, and articulates specifically what types of developmental disorders lie underneath the addictive behaviors.

Integrity is when the parts of the self fit and flow, have a strength in character, and the potential for transformation. Underneath all addictive states is a dis-integration, a lack of fit flow, a lack of transformative potential. Dr. Blakeney engaged 700 people in the addicted population, and all 700 had the predicted dis-integration. It is important not to understate in a 10 yr. longitudinal study 100% of people who were tested coming in to treatment had these predicted states of developmental spits or delays. The theory is quite revolutionary because for the first time there is a construct that accounts for the diversity we see in the addicted populations. It also gives treatment a whole new way to understand and treat addiction. The test can pinpoint clients underlying issues and prescribe the correct therapeutic approach.

Unbroken Brain has begun to popularize the idea that the causes of addiction are developmental, the question becomes, now that we are beginning to understand this, what are we going to do about it?