Sierra Tucson – Tucson, Arizona

Gazing down from the plane at giant irrigation projects in New Mexico, I was reminded of similar ongoing struggles to make the Saudi Arabian desert fertile. My Saudi memory was triggered again when I stepped out of the airport in Tucson and into the 40º heat of an Arizona afternoon. The desert plants, the Japanese cars, the scrap-yard for old planes and especially the dead straight roads all brought back mixed memories of the 1980s and King Abdullah’s kingdom. Most Americans I know would be horrified at the comparison, but recent Arizona legislation to hunt down, prosecute and deport illegal immigrants is a very familiar story to those workers from around the world who made their way to Saudi to earn a living and found they had to battle through and around the corrupt chicanery of the immigration system and indigenous racism.

Saudi Arabia, like everywhere else, had, and has abundant supplies of drink and drugs, and like the America of the 1930s it locks up those who are caught indulging in such degenerate moral turpitude. Rehabilitation and treatment centres are in the process of being planned in the Middle East, but the stigma and denial attached to alcohol and drug use, let alone the illegality of it, will prove an enormous hurdle in efforts to restore good health to addicts: a familiar tale worldwide.

Sierra Tucson is world famous for its bio-psycho-social-spiritual approach to pain management, addictions and mental/behavioural disorders and has been nestling in the cactus scrub beneath the Santa Catalina Mountains north of Tucson since 1983. I had particularly wanted to visit since I had read about their use of brain imaging technology in helping addicts visually perceive and understand some of the neural damage caused by substance abuse, but I was also attracted by my impressions of it being a ‘Rolls-Royce Rehab’.

To call ST discreet would be understatement. It is 30 miles north of Tucson, off the beaten track and marked only by an easily overlooked sign, so much at odds with the many glossy pamphlets and brochures that announce ‘more comprehensive services than any other treatment center in the country’. I pulled up at the CCTV monitored electronic steel gates, introduced myself and my appointment time to the ‘Speak Here’ box, and received my instructions on where to park and how to proceed. I suppose such security is understandable when one has a responsibility to protect the confidentiality of clients from the paparazzi et al, but to me it felt a bit oppressive and institution-like.

My trepidation was partially replaced by ego titillating amusement when I entered the reception building to find a welcome board with my name and profession on it; a feeling that dimmed a bit over the 15 minutes I had to sit and wait for my host to come and introduce herself. When she arrived I signed a confidentiality agreement to keep to myself all that I heard and saw at ST, and I received a written schedule that included sitting in on a Chemical Dependency group from 9.30 to 11.30, having lunch from 11.40 to 12.15 with the equine therapists (one of whom was the brilliantly named Kermit Firestone, a wrangler and horse expert who looked like a 1950s tanned, handsome cowboy actor… a rugged Ronald Reagan perhaps). And from 12.15 to 13.00 hours I would get a tour of ST. This package, because that is what it felt like, was delivered efficiently without much warmth except for in the chemical dependency group where six young addicts were coming to terms with their problems and sharing their experiences and feelings amongst themselves and with the facilitator and me. It turned out to be the most human bit of the day and interesting for me to hear the similarities and differences with their British counterparts.

Lunch was brisk. Too brisk for me to do justice to the dietician-designed buffet of beans, rices, pulses, proteins and greens that were enticingly spread out. Good nutrition is an essential starting point for chemical dependency recovery and there was plenty of it available here in the glorious wooden dining area with its picture windows looking out across the valley. Unfortunately my appetite was side-lined by my interest in the equine and group therapists’ conversation which followed my enquiries as to how management and therapists work together at ST, and how much of the profits were taken by shareholders and how much ploughed back into provision of core services to clients. I found myself a bit embarrassed by the openness of their quite hostile views on management and profit taking, and how as therapists they felt dispensible and under-valued. These weren’t the views I expected to hear as a visitor; and if I was hearing them, I wonder what goes on behind closed doors?

Whether it is a sign of the economic times, or some other factors, Sierra Tucson was operating with a roll-call of 73 patients on the day I visited; meaning that they had 79 empty beds. Not much profit to be had on figures like those.

In retrospect, it was a crazily optimistic venture of mine to hope to get anything more than the faintest understanding of what ST is about in a day, and in the end I only got a 3-hour ration and a big bundle of glosssy literature to take away with me. I wonder how different the feelings are for patients who leave after their 30 days?

The overall atmosphere was more hospital/clinic than rehab, and there was a brusque efficiency about all that I saw outside of the group therapy session. One thing that delighted, surprised and reminded me of hospitals was the bookshop that opened up at lunchtime. Here you could buy addiction and other mental and physical health literature, stationary and toiletries… but no postcards or chocolate unfortunately!

There is no denying or deriding Sierra Tucson’s place at the top of the treatment league as they deliver a certain kind of first-rate service to those with the money to pay. Not only is this delivery very professional, but their research and commitment to new technologies (as evidenced at the centre and in some of their bio/psycho literature and on the web) is something we can all learn from. Their facilities include a detox unit, a swimming pool, a labyrinth, an adventure playground and all manner of therapies and therapists situated in a magnificent and very private location; but as one of the young men in the therapy group said to me: ‘I’m looking forward to going to Prescott (another treatment centre) because 30 days isn’t enough for me.’

The understanding that time is the most vital component in successful recovery is perhaps the greatest gift that he takes away from Sierra Tucson.

The Ranch – Nunnelly, Tennessee

Addiction is a strange and far from fully understood condition, and the further I travel the more variety I find in its treatment. Not only do the ‘experts’ fail to agree about whether it is a disease and whether it is genetically inherited or environmentally developed, but they also interpret and define recovery in different ways. And the different ways have been starkly illustrated to me in my small journey around central Tennessee.

The clinical environment at Cumberland Heights,  the homely recovery houses of YANA,  the detention centre of DC4 and the therapeutic retreat at Onsite are all differing responses, within 50 miles of each other, to the same condition of addiction in its many guises; and my trip to The Ranch gave me yet another perspective.

Crossing the Carolina to California 2500 mile Interstate Highway (I 40), with its evocative signposts to Nashville and Memphis, I crossed from a hilly, forested and old mining region into a more agricultural belt of cattle pastures and rolling hills; and there beside the Piney River lies the 2,000-acre working horse and cattle ranch that is The Ranch, Alcohol and Drug Rehab.

Pulling off the country road and into the dusty parking area I saw the first cows I had seen in America. They were big! I thought I was in the right place, but wasn’t entirely sure because there was no sign or name plate and work teams were on the roofs making the place look a little like a building site, or a rehab in recovery itself! I asked a ‘new age’ old lady who was getting out of her big black shiny 4x4 whether I was at the Ranch and she confirmed I was and offered to take me to the Director, Cheryl Brown, who has 30 years of experience in the field of recovery; much of it in Sierra Tucson and Cottonwood, two treatment centres on my itinerary in Arizona.

Cheryl explained the work going on as being the result of the Great Tennessee Flood of May 2010, (which I heard variously described as a once in a 100, 500 or 1000 year occurrence), and she told a horrible tale of being stranded in California unable to fly into Nashville, and being kept up to date by phone on the devastation being done to her rehab. As it turned out, only one of the four residential houses had to be evacuated, but the uninsured losses to the Ranch were significant. Not only were the central admin and therapy buildings swamped by a 12-foot deluge, deleting at a stroke all the sensitive and confidential paperwork and computer files a medical facility must maintain, but all the kitchens, stores, vehicles and livestock facilities were ruined. Cheryl described how a nephew of hers opened up the stables and animal sheds to allow the animals to escape, which the horses and cows did. The 300 goats however refused to leave the shelter of their home and suffered the ultimate consequence.

The treatment emphasis at The Ranch is on healing: physical, emotional, mental and especially spiritual. The range of disorders treated is impressive. Trauma/PTSD, Eating Disorders, Codependency, Personality Disorders, Substance Abuse/Dependency, Mood Disorders, Love and Sex Addiction, Depression, and Anxiety are all approached through a normally three-month, occasionally six month, programme. That is an ambitious schedule and it interesting to see how ‘simple’ drug and alcohol recovery has expanded in its scope as more and more conditions are discovered to lie behind the obvious symptoms of uncontrolled alcohol and drug use.

The Ranch has a strong spiritual basis that has evolved from the 12 Step Programme and now incorporates shamanic wisdom from the Toltec civilisation that followed the Aztec Empire in central America a thousand years ago. Cheryl gave me a book called The Four Agreements by Don Miguel Ruiz, a ’nagual (shaman) from the Eagle Knight lineage, on which various recovery practices here are based. The agreements are: be impeccable with your word, don’t take anything personally, don’t make assumptions and always do your best. A tall order.

But through practice, prayer, awareness of the wisdom of the Great Spirit, meditation, structured ceremony in a therapeutic sweat lodge and contemplative and reflective use of a medicine wheel, the labyrinth and a 12-Step walk through the trees, The Ranch develops something it calls Spiritual Recovery. Here in the lovely Tennessee countryside, flood damaged or not, it is easy to believe that people can “experience themselves beyond the programmed limitations of belief, as aspirational beings who are free to love, free to live, free to be happy.”

At $15,000 a month, that must sound attractive to a lot of addicts.

Onsite – Cumberland Furnace, Tennessee

If your substance abuse, relationships, traumas and various other mental health issues have not robbed you of every penny, then here's a suggestion on where to go to restore ‘‘the peace and balance you desire’’ and ‘‘discover the best in yourself and your relationships’’.

Onsite is an hour out of Nashville in a tiny hamlet called Cumberland Furnace. The name is not a reflection on the weather but a reference to the first iron ore production in Tennessee that went on here in Dixon County through the 19th and early part of the 20th century. Onsite today run their experiential therapy workshops from the beautifully restored 1868 mansion, Drouillard House, that was built as a summer retreat by the wealthy Southern belle and inheritor of the iron ore business, Mary Florence Kirkman, and her Union army captain husband James Drouillard.

Onsite is not a rehab in the accepted sense but a retreat, and its longest programme is six and a half days. They do deal with substance abuse, but only within the context of self-empowerment and self-realisation and acceptance, for which they use a combination of talking and experiential therapy. I was lucky to make my visit at a time on a Friday after the departure of one set of residents and the arrival from the airport of the next, which gave me the chance to be shown around the building and grounds without interrupting any therapy.

Several different workshops can run at the same time within the retreat as Onsite contract in various expert therapists from around the country to lead programmes such as: Living Centred, Coupleship, Couples Intensive, Learning to Love Yourself, Insight, Healing Trauma Issues, Healing Sexual Issues, Healing Money Issues, Family Intensive and the Equine Programme. At roughly $3,000 a week these workshops are not expensive by US standards but they are designed for a ‘top-end’ clientele, often people who have been, or still are, in therapy at home, and who want to tackle their problem in a concentrated and intensive manner in a very beautiful, relaxing therapeutic retreat setting.

I was lucky enough to be offered a session of equine therapy which gave me a lot of insight into how horses can be used to mirror/reflect back to us some of the feelings and behaviours we experience every day without realising their effect on ourselves or others.

I loved this place. It has history and atmosphere and is so far off the beaten track that my self-esteem rose by just finding it!

DC4 – Nashville, Tennessee

If you had told me a year ago that I would be sitting down for lunch with a Tennessee judge in the board room of a Drug Court Residential Program in Nashville, I would have assumed that your journey into rehab and recovery was imminent. But that was how my visit began.

Developing Character During Confinement in Davidson County Drug Court, or DC4, is the brainchild of Judge Seth Norman, a Korean war veteran and Tennessee judge since 1990 who recognised that there was a population of people appearing before him who were in the ‘revolving door’ syndrome and that substance abuse lay behind their offending behaviours.

There are six criminal courts in Davidson County, Nashville, and each court is handling about 2,000 cases a year. Of these, 80% involve some kind of drug and alcohol abuse and 60% of those charged have a chemical dependency problem. With a very high recidivism rate and nowhere for these men and women to get treatment outside of the prison system, Judge, as everyone from professionals to the residents call him, decided to try something different.

Structured and closely monitored drug rehabilitation, administered and directed by the court, was the model they decided to try.

Initially, the drug court was set up to run after the close of daily court sessions, Judge Norman presiding, and was aimed at individuals who were on probation or non-custodial sentences of some kind. The results of the close monitoring, urine testing, and the programme of education and recovery were encouraging and successful, but didn’t help those incarcerated people who needed treatment the most.

And so a residential drug court system was inaugurated on land formerly used by a state mental health facility in buildings that were extremely dilapidated and nearly untenable, or ‘filthy and dismal’ as Judge puts it. He went to the jails to talk to prisoners who were known to want drug treatment and found six volunteers who were willing to work on the premises in exchange for a recovery programme; and with a combination of scrounging, scavenging and a small grant from the state, enough furniture, bedding and food were acquired to open the doors in 1995.

The project was considered successful enough that when Dell Computers wanted to relocate to Nashville they were sold the drug court land, and a new $3,000,000 residential drug court facility was built to house up to 76 male and 40 female non-violent felony offenders. (A felony in the US is a crime that carries a sentence of 366 days and above on conviction.)

DC4 is no ‘fancy’ rehab and its simple block construction and dormitory accommodation to sleep 30 per room gives the place a very institutional feel, but there are no warders with keys, and there is a daily recovery programme run by by the director Janet Hobson and her staff of assessors, seven counsellors, a psychiatrist, a community service coordinator, a teacher and several court related staff and some volunteers. To qualify for treatment each offender has to have a chemical dependency, educational, employment and medical assessment and has to plead guilty to whatever charge has been brought against them, and has got to want to do something about the causes of the offending behaviour.

The initial six to eight weeks is the Assessment and Orientation period when a treatment plan is set up and only trips to the hospital or court are allowed. The next period is called Stabilisation and Rehabilitation and can take up to a year to complete. In this stage, cognitive behavioural therapy and motivational interviewing combined with the 12 Step programme and various educational and therapeutic groups take place; with five AA/NA/CA meetings a week, vocational training and the completion of 200 hours community service seen as part of the programme. The third stage is the Re-entry and Employment phase where education, vocational training and work options develop prior to departure to transitional housing and six months compulsory after-care.

Throughout the whole process random urine testing occurs and Judge Norman sits twice a week in the courtroom set up in DC4 to review progress and deal with infractions. Judge told me that there are men in there at the moment who would have got 10 to 20 years in jail had they not chosen to go the drug court route, and that since they started, the quickest anyone has gone through the system and back into the community full-time has been in 14 months. A resident told me two years was a realistic target for him.

Given national and local sensitivities and perceptions that criminals are getting an easy ride from a member of the State Democratic Executive Committee and a 1968 delegate to the National Democratic Convention, at the expense of the ‘hard-working American tax payers’ (a phrase I hear daily in these electioneering days), Judge Norman wants DC4 to be as close to self-supporting as possible. To this end residents grow most of their own vegetables and a surplus for sale, do all the necessary building and vehicle maintenance on site, and contribute 66% of their wages earned in stage three towards the running costs of the programme.

This residential model is the only one of is kind in the USA and is considered highly successful and the statistics from the website make interesting reading:

‘‘Since the program was established in 1997, 365 offenders have successfully completed the program.  The recidivism rate for persons successfully completing the program is approximately 25%. The retention rate since program inception is approximately 65%. On average, participants had more than 8 previous drug charges, and had been previously incarcerated from two to four years.  By using this approach since May of 1997, the Davidson County Drug Court program has accomplished the following: diverted approximately 1,057 people from the current criminal justice process, maintained a negative drug test rate of 97%, provided the community with over 50,000 community service hours annually, maintained a 100% employment rate for graduates, and 5 drug-free babies have been born. All of this has been accomplished at a cost of $38.00 per day as opposed to $45.00 to $55.00 per day in prison, representing a savings in excess of 30%.’’

That last statistic was the one that Judge Norman was keen to stress to me, as that is the one that carries the most weight in these troubled financial times to those to whom he is accountable. If he can convince the US population that jail is not only less effective than treatment for a large percentage of the prison population, but more expensive too, then he may be going a long way towards treating a lot of crime as a symptom of an underlying condition known as addiction, not as moral failure. This would be a big, not to say revolutionary, change to current thinking and practice.

I wish I could say that lunch with the Judge in Nashville had finished with mint juleps and cigars on the veranda discussing the works of Tennessee Williams. It didn’t. It had been a working lunch, made and served by recovering female residents learning the catering business; with a busy and enlightened man who has a belief and mission to match his powerful personality. To my eyes his project works well and is a model that could be exported around the world. Let’s hope so.

YANA (You Are Never Alone) – Nashville, Tennessee

SOB are not the most flattering initials to carry around with you for life. Not if you're an American. And especially not if you are an American woman.

Susan O. Binns was given her moniker by her mother more years ago than you would guess looking at her, and she tells the tale of her grandmother sewing the initials onto her school uniform with the obvious result that she was tormented by her peers and classmates. Whether that traumatic start, or the drunken and abusive family background that followed in childhood, Susan was well on her way into alcoholism by her early twenties when she found herself the victim of more  domestic violence, this time from her husband, while trying to bring up her family. She finally had to throw in the towel and went into rehab more than 30 years ago.

Such a background, that she recounts with openness and sardonic humour, makes her the ideal person to run YANA, which she brought into being in 1996 with the help of the Music City Recovery Resources Foundation in Nashville. Susan understands the particular pressures that women face in recovery, not least the all too common dilemma of them wanting to return to the place where the children are living, which is also where the source of the domestic violence (and often drugs/drink) is located. YANA does not accept children, because as Susan tells me, ‘‘We believe women need time to heal and will not focus on themselves if the children are with them 24 hours a day in the beginning.’’

Susan designed a programme of ongoing support and structure for the initial 6 women who moved into her first safe sober recovery house which she ran with volunteer staff; and so successful has it been that she has recently opened her fifth house and has a roll of approaching 20 women living there today.

The houses are small and made of wood and sit in a cluster close to each other and a picturesque stream in a quiet western suburb of Nashville, and there is a lovely, cosy, log cabin feel to them all. Pictures produced in art therapy are on the walls, and big bean bags sit on the floor in the therapy room where I would expect to find chairs.

YANA today demands that the women have completed a detox or primary programme in a rehab before coming to the community, and once there, they are offered bi-monthly counselling, relapse prevention and process groups, art therapy and yoga, as well as help in developing general life skills.

The primary goal of YANA is to provide a safe and substance-free living environment from which to work towards reintegration into the world of work and healthy positive relationships, and under the watchful, challenging and caring eye of this unlikely ‘mother superior’ this goal is being achieved one day at a time.

Cumberland Heights – Nashville, Tennessee

 

When you need to raise money for for your rehab in Nashville, what better way to do it than by hiring the former Grand Ole Oprey House, asking one of America’s finest musicians to play and then charging a hefty ticket price that more than covers all expenses? If the treatment at Cumberland Heights even comes close in competence and professionalism to their fund-raising activities, then people are going to get well, and get well right.

None of my research had prepared me for the size, scope, quality and natural beauty of the programme and facilities I found down beside the Cumberland River in 170 acres of peaceful early autumnal rolling wooded countyside they call a ‘campus’. Again, like IBH in Akron, the favoured architectural style is of single-storey, ranch-like buildings, some with verandas, painted white, which give an atmosphere of openness and accessibility so at odds with so much of urban America’s building brutality. For a sick, stressed and depressed addict, such bucolic tranquility can only give a breathtaking first impression and so provide further impetus to the process of change that is the object of all addiction treatment.

Over the 45 years of its existence Cumberland Heights has developed and grown, and claims to have ‘touched the lives of 200,000 people’, and from my vantage point it is hard to dispute their claim to be one of America’s pre-eminent recovery centres.

The ‘detox’ wing, first stop for many, has large comfortable en-suite rooms that are more hotel then hospital, though missing a television and mobile phone, and a 24-hour fully ‘womanned’ nursing station, with state of the art computer equipment, sits at the hub of this quiet and purposeful wing. Full medical and psychological evaluations and assessments are done here and treatment plans developed for the normally 30-day minimum length of stay for most programmes. There is, however, great flexibility around length of stay as ‘patient’ needs and resources differ, and often it is the insurance company, not the ‘patient’ or CH staff that determines just how much treatment is going to be available. The quality of the treatment at CH is without question of the highest standard, but the determination as to whether someone can fully access that quality is more often than not a question of money.

 

The breadth and variety of services available at CH is awe inspiring for this English treatment professional brought up within the cultural limitations of nationalised health provision. On the main campus there are 125 beds and over 200 staff to care for the patients. There are residential programmes for adult men, adult women, youths/adolescents from the ages of 13 to 18, and professionals/executives. All of these programmes  run on the understanding that a sometimes considerable period of after-care is part of the process of recovery, and the CH ‘outpatient’ treatment follows the intensive residential element with a schedule of up to 6 weeks of 3-hour sessions held four days a week. Additionally, up to a year of of continuing care at weekly aftercare groups to supplement regular attendance at AA/NA meetings is offered.

Cumberland Heights is nothing if not comprehensive in its approach to recovery and it has taken its outpatient services far and wide across central Tennessee to better allow access to former residential patients. They have facilities and groups for both patients and and families running in the towns of Hermitage, Smyrna, Franklin and Jackson, and for those who cannot, or do not want to, return to their former homes they have transitional living houses available for stays of up to four months.

Of all that is on offer at CH,  a few pertinent elements resonate strongly with me.

Firstly, that a youth/adolescent taken in for the primary 30-day intensive programme is encouraged to stay for an extended period of a further 90 days, during which time the new knowledge and experiences of recovery are internalised and new cognitive patterns developed to replace the old self-destructive versions. They are also offered enrollment at the state-approved private high school, River Road Academy, where two former state school teachers put them through their academic paces to try to help them catch up with some of the schooling their addiction has ensured they have neglected.

Second, the emphasis on addiction as being a family disease, and therefore in need of family treatment, is clear and direct. Normally in the third week of residential treatment for the patient, the relevant, close family members come to River Road for a four-day intensive programme aimed at improving lines of communication and becoming part of the loved-one’s solution rather than problem. This is followed up in the the outpatient programme which allows for three hour weekly group and/or one-to-one sessions with a counsellor for up to six months.

This belief that family treatment is ‘essential to total recovery’ is taken very seriously at CH, and at other US treatment centres, and it is something that is too often missing or neglected from the treatment plans currently running in the UK.

The third pertinent point that strikes me about CH is that the whole highly successful philosophy of the recovery here is based on the world-wide abstinence model of the 12 Step programme of AA/NA that addresses the physical, mental, emotional and spiritual elements of the disease of addiction. Family reintegration is seen as part of spiritual growth, as is the ego deflating concept of there being a power greater than self; and the emphasis on connectedness with others, and within community, works pretty much the same here in this beautiful corner of Tennessee as it does in the tenements of Tower Hamlets in London.

Finally, and I could go on for a lot longer singing the praises of Cumberland Heights, I come back to the one crucial difference between ‘normal’ residential English recovery and this version of Tennessee recovery: money.

Though prices vary for the various programmes, a back-of-the-fag-packet calculation of a $1000 dollars a day for the 30-day basic ‘product’ is not far off the mark. The small print in the best insurance policies quite often results in the companies paying only 80% of this cost; and how many people have this level of insurance?

One of the most unfathomable mysteries in addiction recovery has always been how to know who is really ready to make and sustain the profound changes required for long-term success. No one ever knows for certain, though the wealthy have the luxury of being able to shift the odds in their favour by paying for what is usually thought of as the best available treatment. Cumberland Heights, despite being a profit-making organisation, is not devoid of charitable instincts, and can make certain ‘arrangements’ with certain clients that can enable access to those less able to pay; but in this unfair world of ours, the decision on who gets the help and who doesn’t is never fair.

The view of the skyline from the 20th floor of the downtown Nashville office block that hosted the Cumberland Heights pre-Lyle Lovett concert cocktail party, threw the outline of the AT&T headquarters into clear relief. It is known locally as the Batman Building due to the curious hooded ‘ears’ that stick up and out from the top floor, and it made me wonder what it is about the citizens of Nashville that made them give this odd looking building a nick-name so connected to the greatest crime fighter of my generation.

Given the $250 a ticket price tag for the concert, ‘Robin’ may have been a more apt choice on this evening, or OT&T, but the great and the good folk of Nashville who came to see, and to be seen, were generous in their support for this very Tennessee recovery centre. The much ‘therapised’ population of the USA think differently to that of the UK, and there was a sense of ownership and pride among the Southern cocktail party crowd that their local treatment centre was putting on such a show. How many of them have had personal reasons to be grateful to Cumberland Heights it is impossible to say, but the estimated $1,000,000 that the whole evening raised through silent auctions, gifts and ticket sales will go a long way towards spreading recovery.