Those of you following the blog may recall Jerri’s interview at Caramore Community back in October –the one cut short when she confessed she’d smoked crack the day before. Yep. Not one of her more stellar moments. If you’re new to the blog, you can catch up here.
I’m sort of crushing on Caramore. I know, I know. It can’t possibly be ALL THAT but what I’ve read and observed is truly impressive. Caramore is a structured, residential support program for adults with mental illness that uses a step-up approach to empower independence and community employment. Not sure why this is such a novel approach–but trust me, it is– no one else seems to be doing it. Caramore puts brain disorders in their place; chronic conditions to be managed as you get on with the business of living your life.
At first, participants establish a daily work regimen, 30 hours a week, as employees on Caramore’s janitorial or landscaping work crews which provide services to the community. The janitorial crew, for example, cleans churches, businesses, and homes. Participants live in Caramore apartments where Residential Advisors supervise and help them establish personal goals like sticking to a budget or improving social skills. There are 4 participants to an apartment. Everyone has his/her own bedroom, shares a bath with one other person, and shares the kitchen and den with all housemates. Chores are assigned and everyone contributes to maintaining the living space.
Participants earn minimum wage which is applied to their housing. Disability income goes into a savings account which after several months is enough for a deposit and first month’s rent on an apartment outside the program.
As you progress in the program, there’s gradual lessening of supervision and Caramore helps you secure employment in the community at sponsoring businesses. A HUGE shout out to Lowes, Target, Whole Foods, and UNC for being Caramore employers.
After 3 or more months of steady employment, participants move into community apartments. Many split the cost with housemates they met at Caramore. Slowly, Caramore’s services are reduced and eventually phased out. Eventually, participants “graduate” but can continue to network and get support from other alumnae.
Did I mention Caramore has a 90% success rate?
At first glance, it might appear Jerri doesn’t need this kind of program. After all, she’s already able to live fairly independently. She takes her medicine on her own, does her own shopping, pays bills, and has her own apartment. Still Caramore has a lot to offer. Jerri’s not great with money and spends it all within days of getting payed. Probably as a technique to remain clean (if she doesn’t have any money, she can’t buy drugs) and perhaps as a post-traumatic stress response (if she doesn’t have any money, no one can steal from her.) Caramore could help her work through money issues. Jerri is also ready to get a job but fears losing disability and the possibly of getting sick again. Caramore has experts in disability law and can help navigate this. On her own, she lacks the discipline to get up every morning and go to work. Plus she has a felony on her record and that makes it difficult to even find employment. Lastly, her social skills aren’t great. These are all challenges, Caramore can help address.
After the botched interview back in October, Jacob, the Admissions Director, said typically new admissions have to be clean and sober for 6 months prior, however, he would cut that to 3 months for Jerri and scheduled another interview for January 8th. Jacob has since had a promotion and on the 8th, Jerri met with Blake, the new director. The interview went well – no drama this time – and Blake scheduled a trial visit for Jerri to test drive the program.
That was this past week. Trial visits are supposed to be 5 days but with Martin Luther King day on Monday and the ice storm on Friday, Jerri’s visit lasted only 3. She worked on the janitorial crew mostly vacuuming and complained of backaches daily. She described the other participants as “heavily medicated” and likened the experience to “being in a mental hospital” because Caramore dispenses all medications and you have to take them while they watch. When I pressed for one positive thing about the experience, she said “everyone is really nice to me.” She also felt better about the visit after talking to her Residential Advisor for the week.
Yesterday morning, we sat down with Blake and discussed the visit. He said the 3 days really hadn’t been enough time for Caramore or for Jerri to fully assess whether the program was a good fit. Jerri is concerned she might not be physically able to vacuum for 6 hours a day, 5 days a week. (Ha! Who among us is?) So Blake asked her to do another trial visit, for a full week, starting Monday.
For my part, I’m trying my best to remain objective. To me, Caramore seems like a life-saver. On the other hand, what could possibly be worse than ending the relationship with Telecare (her current mental health provider), letting her apartment go (for which there was a waiting list to get in), and moving all her stuff to Caramore only to receive a call 2 weeks later saying it’s not going to work out? Jerri has said as much. “I want to be sure I can physically do the work before I commit.” She was seriously doubting herself when I picked her up yesterday.
“What will you do, Jerri, if you decide you can’t manage the Caramore program? Just go back to watching TV all day?”
“No. Catherina will take me to Vocational Rehabilitation and I’ll try to get back into work that way.”
She’s got good intentions – I’m just concerned about follow-through. And likelihood of success without more structured support than what Telecare can provide. I know, it’s out of my hands. God, grant me the serenity . . .
The office for Caramore Community was not what I expected. Think non-profit, low budget, scuffed up, battered furnishings, cracked and sterile floor, walls badly in need of paint. Instead, the office appeared interior-decorated. There were two large seating areas with comfy chairs surrounding over-sized square coffee tables. The walls were painted a warm caramel with matching plush carpet. Magazines and plants were scattered about. The receptionist desk was a long white affair that stretched across the length of the room. We were greeted promptly by Samantha who quickly found Jerri’s appointment and brought her coffee.
After a short wait, Jacob, the admissions director, greeted us and escorted us back to his office. He stepped out to get a copy of Jerri’s application giving us a chance to check out his digs. On the wall behind his desk was a portrait of someone who might have been Andrew Jackson. It was hung upside down. To the right was a credenza stacked about a foot high with piles of paper. Above this hung 8 to 10 apple green paper plates as if they were china. Above these, a bathroom scale had been hung and it took me a minute to realize it wasn’t a clock. On the opposite wall, a tree branch reached into the room, it’s base framed with an ornate white frame. Interesting!
Jacob, himself, was soft-spoken but exuded a sense of purpose and authority. He began the interview by saying this was an opportunity for us to learn about Caramore and for him to learn about Jerri. They are very protective about their community. They have limited space and receive hundreds of applications a year. They only have space for 30 individuals in their residential program and there is a 4 to 6 month wait-list. They only accept individuals who are not a threat to the community – you must be stable on medications, no history of violence, clean/sober for 6 months, ready and willing to work. He told Jerri that he would request records from Telecare and it was important that what she shared with him aligned with Telecare’s records. It was important for her to be completely honest with him because dishonesty was a warning flag and would raise concerns about allowing her into the program.
He asked if she wanted me present during the interview or if she would be more comfortable if I waited outside.
“My sister can stay. She knows everything about me so there’s no reason for her not to,” Jerri replied.
He asked about her diagnosis and how she was first diagnosed. Listening to Jerri tell her story was hard – it brought back a lot of difficult memories and all the emotions I’d felt at the time washed over me again. I don’t remember some things exactly the same way Jerri does, but I have a lot of gaps in my memory – things I imagine I’ve blocked because they are just too painful. Jerri talked about repeatedly running away and our parents checking her into Mandala, a private hospital, when she was 15. One of Mom’s friends had a daughter, Connie, who had “acted out” like Jerri and Mandala had helped her. Mandala diagnosed Jerri as having mental illness – the actual diagnosis is unclear – but my parents never accepted the diagnosis. She did not get medication or counseling.
After that she started using drugs and skipping classes with a 38 year old woman who hung out at the high school, buying drugs and alcohol for the kids, and taking them home. Debbie sexually molested Jerri – at the time Jerri thought herself in a relationship with Debbie. She believed she was discovering her true sexual orientation was lesbian. But as an adult, Jerri recognizes Debbie was a predator. Jerri was so desperate for attention and affection, she was willing to go along with Debbie in order to feel loved.
Jacob then delved more into the substance abuse. “When was the last time you used?”
“Four months ago,” she said and explained the situation.
“If that is true, and I have no reason not to believe you, then you don’t mind doing a drug test today, right?”
Silence. Jerri looked at Jacob and said nothing for what seemed like eternity. Her hesitation was a dead give-away. Finally she spoke. “You’ll find crack in my system. I smoked it yesterday.”
Ayyyyyyyyyyyyyyyyy! I could just strangle her. Why would she do something so STUPID? She knew Caramore required 6 months of sobriety to get in. She read it on the website and even talked to me about it beforehand. Did she really not want in the program? Was this some twisted passive-aggressive way to get them not to accept her? Was she purposely sabotaging herself?
Jacob closed his folder and said, “I’m going to end the interview now. If I continue the interview it’s not going to go well with you and could prevent you from ever getting into our program. I’m going to reschedule the interview for 3 months and you will need to provide evidence of 3 months sobriety in order for the interview to occur. It concerns me greatly that when I asked when you last used you said 4 months ago which was not the truth. The truth is you used yesterday. Maybe you lied because you want into the program so badly. But if that is the case, the way in is through sobriety. This development delays when you could be considered for the program. If you are serious about changing your life, I’ll see you again in January. There are some people I’ve worked with for years to get them ready for the program. This is not a ‘no’. It’s a ‘you are not ready.'”
I could learn a lot from this man.
He refused to accept any of Jerri’s excuses. She said, “I don’t crave drugs any more. I wouldn’t use if people weren’t knocking on my door offering it to me for free.”
Jacob’s response: “No one held you down, forced the pipe in your mouth and made you inhale. Even when they bring it to your door, you have to take responsibility and say no. Even in Carrboro, crack is available. It will always be accessible no matter where you live. You can’t use that as an excuse. You are lying to yourself when you say ‘I wouldn’t use if I lived somewhere else.'”
As you might imagine, the drive home was a bit strained. Jerri couldn’t explain why she’d done it. I could feel myself disassociating.
“Here’s the thing, Jerri,” I said. “If you really aren’t interested in Caramore, you should have just said so. I took half a day off from work for this interview, and believe me, come January, I will not do it again if you use at all between now and then. What you did was inconsiderate of everyone – you, Jacob, and me.”
“I knew I’d made a big mistake the minute I did it. I don’t know why I did it. I was just so surprised when he handed me the pipe. I didn’t know how to respond so I just took it.”
“Jerri, the way your life is now is the way it will always be unless you choose to change it. That is if you’re lucky because right now you are dependent on the government and they could pull funding at any moment making your life even more challenging. You need to be dependent on you. You need to make a choice – do you want simply to exist? Or do you want to live? No one can make that choice for you. Only YOU can prevent forest fires.”
That’s right. Everything I ever needed to know about personal accountability, I learned from Smokey the Bear.
Many of the bad things that happen in our lives are a direct consequence of choices we make. I’m not saying that we are responsible for EVERY bad thing that happens. Bad things happen all the time to good people out of no fault of their own. Last time I checked, 100% of us can expect to experience something devastating in our lifetime. The untimely death of a loved one. Debilitating illness. Estrangement. Divorce. Bankruptcy. Down-sizing. A crime against us. Abuse. We live in a broken world and no matter how good we are, how religious, how smart or careful or risk-adverse, there is no magic formula. Bad things happen, period.
But some bad things are avoidable. If I make my car payment, my car will not be repossessed, for example. I won’t lose my job because I don’t have transportation to get there. Smokey teaches me that if I don’t light a match and throw it into the woods, I won’t start a fire that may eventually consume me.
“If God wants me to get into Caramore then He will make it happen,” Jerri said.
Really? Because I don’t think so. God forgives but I can’t think of a single time that he supernaturally revoked the consequences of someone’s bad choices. He’s not going to, for example, plant the notion in Jacob’s head to rescind the sobriety requirement just for Jerri.
So the visit to Caramore did not go as planned. Jerri continues to talk about the program as something she wants to do. We’ll just have to see how the next three months unfold.
Jerri once said, “You look at me and see a problem. I’m not a problem—I’m a person!” Ouch. Granted, she wasn’t well at the time and she was really, REALLY angry about me refusing to drop everything and wrap my life around her current crisis. Still. If I’m honest with myself (and most of the time I try to be, unless I’m hormonal, and then I tend to listen to that small but obnoxiously loud inner voice that hollers “You can’t handle the truth!”), she was right. My entire family has treated Jerri as a problem that needs fixing since she was about 14 years old.
But it’s not just Jerri. I have this uncanny ability to spot problems everywhere. It’s as if I’m viewing the entire world through a cracked lens. No matter where I look, there is stuff that needs to be fixed. My mind seems to hone in on that which is broken. I don’t know how I got to be this way, whether it’s innately who I am or a way of thinking learned from my parents. But I do know this. No one wants to hear about problems unless you’re offering solutions. And you need to make sure your conversations are sprinkled with positives or people will avoid you like a friendly raccoon in broad daylight. (Rabies for you city peeps scratching your heads.)
My boss recently reminded me of this. Not about raccoons (although that does sound like a conversation we might have) but about refocusing on the positives.
I’m currently working on the-project-from-hell (literally, that’s what I named the folder where all my project docs get filed) which appears to be totally jinxed, I mean, if anything can go wrong on this project, it will and it has. It’s as if the whole universe is conspiring against me. I’ve known for quite some time my life is harder than everybody else’s :-). But, really? I’ve brought issue after issue, challenge after challenge to my boss’s attention so he reminded me during my semi-annual professional development discussion that what I’m working on is, in fact, STILL an awesome project. It is STILL very worthwhile and something we should be doing as a company. We have made a tremendous amount of progress and it’s important to remember and to celebrate what we’ve accomplished. And we need to make sure upper management hears about the good stuff and not just about what sucks.
The same is true with Jerri. Not that she’s a “project” but like all of us, she is a work in progress. We have both come a long way since she moved here in 2010. It’s been hard. It’s been challenging. It’s been bang-your-head-against-the-wall frustrating. There have been times I thought I’d hyperventilate. Or get in my car, keep on driving, and never look back. But in a weird almost twisted way, its also been rewarding. Like Glinda (Wicked), who can say if I’ve been changed for the better? But I have grown. And I have been changed for good. (Don’t hate me for identifying with Glinda here—remember, Elphaba turns out to be the hero.)
I’m limited. Just look at me – I’m limited
And just look at you. You can do all I couldn’t do, Glinda
So now it’s up to you. For both of us – now it’s up to you…
I’ve heard it said that people come into our lives for a reason
Bringing something we must learn.
And we are led to those who help us most to grow If we let them
And we help them in return.
Well, I don’t know if I believe that’s true
But I know I’m who I am today because I knew you…
I completely understand why many siblings, maybe even most siblings, want nothing to do with brothers and sisters with brain disorders, particularly those who are dual diagnosis. It’s like marriage and growing old. It isn’t for wimps. However, for those of us who have chosen to engage, what we gain personally and spiritually is priceless. All of us who care for people with brain disorders need to refocus every now and then and celebrate even the small stuff.
In the spirit of that, Jerri, Stan, and I are off to see Brave (Groupon) and then dinner at Ruby Tuesday’s. Here’s what I’m celebrating today:
A great theologian :-), Albus Dumbledore, once said:
Happiness can be found in the darkest of times, if one only remembers to turn on the light.
Hope you all join me in turning on the light, whatever the circumstances in which you find yourself today.
This is the first time I’ve re-posted another author’s work and I’m not sure of proper etiquette. The original post can be found here. I thought about summarizing but the post is so informative, I didn’t want to leave anything out. Of particular interest to me is the part on which came first, the addiction or the mental illness. As I’ve shared before, my mom strongly believes Jerri’s mental illness was triggered by her drug use in her teens. When I look back at our childhood, however, there were a number of signs that indicated something wasn’t quite right long before Jerri hit puberty. I’d heard of the Self Medication Hypothesis, which posits that the addict’s drug of choice is actually selected because of the drug’s effect on the “primary feeling states” of the user. In other words, the user understands, perhaps subconsciously, that something is off and upon trying various drugs, becomes addicted to the one that makes her feel less “off”. Interestingly enough, mood disorders including bipolar and ADHD are more common in cocaine abusers (Jerri’s drug of choice) than opiate abusers (20% vs 1%).
I did not include all the links in the original article so worth visiting it if you find this as fascinating as I do. Hope you find informative and please share your thoughts!
Addiction Causes: Understanding Self Medication And How I Lost My Sister To Substance Abuse
(by Victoria Costello, Posted: 02/25/2012 11:33 am, Huffington Post)
In light of the continuing controversy surrounding Whitney Houston’s death, including questions of blame and responsibility for what the coroner may determine was an overdose involving drugs and alcohol, here is a look at the science behind the central and often misunderstood concept of self-medication in mental illness, addiction and recovery. My interest in this is both professional and personal. My sister Rita died of a multiple drug cocktail at age 38 — after a downward slide that began over 20 years earlier and finally caught up with her. She was, like Whitney Houston, a victim of her own demons and a culture that favors self-medication over getting mental health treatment. As both of their premature deaths demonstrate, self-medication and aging don’t mix well.
Mystery of the Missing Spoons
When spoons began to disappear from my mother’s silverware drawer in the late 1960s, neither my mother nor I suspected my younger sister Rita’s dope use. It didn’t dawn on us that heroin had be mixed with water and cooked over a flame before it was injected. At that time, my friends and I smoked pot regularly, and we had also tried psychedelics, mushrooms and acid — tried being the operative word. Rita went further and did it much faster and more overtly. She flew through pot and discovered barbiturates, speed and cocaine.
Heroin was too pricey without help from an older dealer-boyfriend. Nonetheless, by the time she was 16, Rita had made it her drug of choice. Between boyfriends, she stole to finance her new habit. Mom’s wedding band was one of the first casualties. Soon, cash could no longer be left in a drawer or purse. This was before drug rehab as a concept had entered the American cultural lexicon, certainly that of the suburban northeast, leaving my mother baffled and ashamed at the behavior of the prettier and once the easier of her two daughters. My mother was an unknowing soldier in what had become all-out guerrilla combat.
When President Richard Nixon declared his war on drugs in 1971 — hopelessly lost in the
four decades since — it did one constructive thing by creating a new and favorable climate for
research into the causes of addiction. This research gave birth to the field of drug rehabilitation, and out of this wave of new treatments came the theory of self-medication — the idea that addiction comes about because people are attempting to alleviate the distress of preexisting mental disorders. The concept had come originally from Freud, in 1884, after he noted the antidepressant properties of cocaine.
By the 1970s, the theory of self-medication formally arrived, and immediately caused a storm
of controversy because it challenged views then held by the medical community and law
enforcement that attributed drug abuse to peer pressures, family breakdown, affluence, escapism and lax policing. For the first time, the nation’s newly minted white, middle-class drug addicts (typified by my sister) were joining their less affluent urban counterparts, who were already populating U.S. jails and hospitals. Junkies — hippies, rich and poor, black and white, addicts and alcoholics — constituted an equal-opportunity mental health crisis for public health doctors on the front lines of treatment in big-city hospital emergency rooms.
The father of the self-medication hypothesis is Edward J. Khantzian, a founding member of the Psychiatry Department at Harvard’s Cambridge Hospital. Writing in 1985, Khantzian stated his belief that addicts weren’t victims of random selection. Instead, he explained, they had a drug of choice: a specific drug affinity dictated by “psychopharmacologic action of the drug and the dominant painful feelings with which they struggle.” Like Freud, he pointed to the
energizing effect of cocaine and other stimulants in response to the depletion and fatigue of
addicts dealing with preexisting depression. In his patients who abused opiates, including heroin, Khantzian noted their calming effect on the addicts’ typically problematic impulsivity. This point particularly hit home for me as I recalled my sister Rita’s tendency to get into fist fights with her arresting officers, crash her car and land in the E.R. after passing out in public places.
The idea that human psychological vulnerabilities had anything to do with addiction was a
new piece of the puzzle, and it reflected Khantzian’s psychoanalytic background as much as
his clinical work at the Cambridge Clinic. Decades later, self-medication is accepted medicine
within the mental health field. However, broader cultural understanding of its implications
for individuals with undiagnosed mental disorders who may be self-medicating has lagged far
behind; not unlike continuing popular resistance to addiction as a disease over which the addict has little or no control, and widespread refusal to accept the robustly established precept that treatment for addiction is effective.
One of the major stumbling blocks to greater understanding of the principle of self-medication appears to be the culture’s continuing confusion about which comes first: the mental illness or the addiction.
One sign of this missing understanding has to be the recent vitriolic “debate” over New Jersey’s decision to fly its flag at half-staff in honor of Whitney Houston, one of the century’s greatest musical artists; a celebrity whose cause of death will no doubt reflect her two-decade struggle with the disease of addiction but is not likely to include any recognition of an underlying mental disorder.
Chicken or Egg?
The fundamental question of which comes first when someone has what is now called a “dual
diagnosis” remained unanswered up until the 1990s. In 1992, with a first-of-its-kind national
survey of the state of the nation’s mental health called the National Comorbidity Survey (NCS),
scientific understanding of comorbid addiction and mental illness went mainstream. The NCS
evaluated 8,098 average Americans, ages 15 to 54, interviewed in face-to-face home settings by trained laypersons — making them far less able to lessen or deny symptoms and patterns.
Among the striking results of the NCS survey: 45 percent of those people with an alcohol-use
disorder and 72 percent with a drug-use disorder also had at least one other mental disorder.
Perhaps more important at a time when the self-medication theory was still under attack, the
NCS survey provided a concrete and comprehensive answer to the chicken-and-egg question
about addiction and mental illness.
So Which Is It?
The NCS showed that when an alcohol disorder accompanied another mental disorder, the alcohol abuse began after the individual was suffering from symptoms of the other mental disorder, usually a year or more after. Not including other forms of substance abuse, the most common preexisting mental disorders reported among those interviewed were anxiety, depression, and, for men, conduct disorders.
When an updated NCS survey was done with a new group of ten thousand people in 2002
(called the NCS-R, for “replicated”), its findings were strikingly similar to the first. Faring
worst by age group in the 2002 numbers were 36- to 44-year-olds, among whom 37 percent
had anxiety disorders and 24 percent had mood disorders in addition to their alcohol abuse
issues. Depressed women in their 30s and 40s have a 2.6 greater risk for heavy drinking,
compared to those without major depression. It occurred to me as I read these numbers that
age 30 to 44, when comorbid disorders are highest, are also women’s prime childbearing years.
A 2012 report by SAMHSA (U.S. Substance Abuse and Mental Health Services Administration) offers an eerie corollary in its finding that 10 percent of American kids today live with an alcoholic parent — certainly a conservative estimate.
Too Late For So Many
My sister Rita died at 38; a year after an overdose of barbiturates and alcohol put her into a
three-week coma and, upon waking, left her unable to walk or talk. It was the end of a torturous 25 years for her and for those of us forced to helplessly stand by and watch. While packing for a move not long ago, I found a letter I’d received from Rita, written during her first stint in Rockland County Jail for robbery a decade earlier, dated March 1982:
I should have known I was heading for trouble again. I was having black outs from small amounts of liquor (small amounts for me). But I went on another drinking binge and now I’m back here again. I guess I’ve hit the pits this time. I just finished speaking to a woman from the jail ministry. She’s quite sure that God brought me back here to save my life or try again. She may be right. I just feel really bad now that I won’t be home for Easter when you come. So much for all that. Meanwhile pray for me, forgive me for letting you all down, try to talk to Mom for me and take care of my beautiful nephew. Love, Rita.
I didn’t have any inkling of the unequal effect of alcohol and drugs on different people back in
the 60s when my friends and I started experimenting with whatever we could get our hands on. Back then, I suppose I went no farther than thinking that Rita and others like her were weaker than I was in some fundamental way. Science now illuminates the finer points of the unequal inheritance of predispositions to addiction even in the same family, as well as the debilitating effects on those who carry the heaviest genetic load, especially when they grow up as my sister and I did in a family and culture where, due to the continuing widespread stigma towards those with a mental disorder, self-medication is the preferred option to seeking mental health treatment.
In this broader and hopefully more enlightened context, simplifications like personal weakness
simply don’t cut it anymore. It’s time for the culture to catch up with the science and practice of treatment and recovery.
Victoria Costello is an Emmy Award winning science writer with articles in Scientific American MIND and Brain World. In addition to HuffPost, she blogs for PsychCentral.com and her own MentalHealthMomBlog. As an advocate for a prevention approach to mental health, she serves on the board of the Mental Health Association of San Francisco and leads workshops for parents and providers around the U.S. Her latest book, A Lethal Inheritance, A Mother Uncovers the Science Behind Three Generations of Mental Illness is available from Prometheus Books.