When I walked into a certain tin warehouse in North Miami Beach in 2006, I wasn’t quite sure what I’d gotten myself into. I was new to Florida, and needed a job; this one paid well. So I figured it was a start.
It was a drug treatment program, they told me—more specifically, a therapeutic community (TC). The patients came in for treatment from around the country (so long as their insurance would pay), looking for a pathway to recovery.
Arriving from the bubble of New York University, naïve me had never heard of a “TC” before. But I was familiar with abstinence-based treatment, having interned in a program using this model during grad school, and could see the merits in AA, NA, and the rest.
In Florida I was hired to run groups as part of the day program. It seemed easy enough. I worked from 8 a.m.-3 p.m., got to wear shorts and flip flops at work, and was able to avoid most of the horrible Florida traffic on my commute.
It became so normalized for me that I only gradually realized that no one should put a sign around a patient’s neck saying, "I am trash."
It soon became apparent that something wasn’t quite right. Perhaps finding out that the patients lived in the houses of the case managers who ran this place should have rung some alarm bells. And the case managers generally seemed to be treated like gods.
Now mind you, these case managers had no formal training or education, rather familiarity with the systems and processes used through their own experiences. There is some value in this for sure. But after what I later witnessed, it seemed far from a best-case scenario. At this particular TC, shame, degradation, and humiliation were built into a “treatment” model in a way I could barely believe.
One particular time of the month that we needed to be aware of with our clients was check day, when clients received their public assistance or disability checks. One time, after receiving her check, a patient of mine decided not to pay her rent. She went instead to a certain local motel where many of the patients would go to get high on check day.
When the case managers found her there, they made her pack her bags. They told her that they were going to send her back to New Jersey where she came from. But before that, they made her drag around her luggage for two days, throughout the program site, forcing her to wonder when they would send her home and ensuring all the other patients were made aware that she was going to get kicked out. Finally she broke down, begged the case managers to keep her in the program, and was permitted to stay.
Another patient put his cigarette out on the ground, instead of the ashtray. So the case managers made him walk around the site with a broom, sweeping up, so he would “learn not to make a mess out of the program, even if you made a mess out of your life.” He was devastated, and left the program soon after. No one heard from him again.
I could fill volumes with all that I saw. There were other situations where patients walked around with signs around their necks, saying, “I’m a loser,” “I’m nothing,” or “I’m not worth caring about.” The “transgressions” that earned these sanctions included getting in an argument with a more favored client, yelling at a case manager, and getting high.
There was little compassion in this place, and little-to-no therapy. Individual therapy was not permitted, although I’m still unclear why. And there were no formal policies or procedures; grievances couldn’t be filed, and if you were bold enough to lodge a complaint you would soon find yourself on the Greyhound back to where you came from.
The case managers would control your money, your shelter, and your medication. When you left, your medication wouldn’t go with you. Instead, it would be passed along or re-distributed to the next person, prescription or not—that was up to the pharmacy technician’s discretion. There was one time when I had gotten a terrible virus and was out of work for days, when the pharmacy tech offered me a Z-pak on my return, saying he could always hook me up, no matter what. He had everything.
I stayed because it was easy and paid well. And despite the crap happening in this place, I was doing good work with a great group of patients. The environment I created in my group room was ethical, supportive, and therapeutic. Outside my group room was beyond my control.
Even though I wholly disagree with the TC’s practices, there was good work being done by the clinicians. For some clients, this treatment was making a difference and fostering positive change. I did not want to jeopardize that, which is one of the reasons I didn’t report the TC at the time.
I used to justify my involvement in the TC by telling myself that some patients could benefit from this type of “tough-love” treatment. It became so normalized for me that I only gradually realized that no one should put a sign around a patient’s neck saying, “I am trash.” Many people with addiction say that to themselves—sometimes much worse—every time they look in the mirror. The research also backs up the idea that confrontational approaches can be harmful—something that Substance.com columnist Maia Szalavitz, among others, has written about extensively.
Why should we be trying to break people down, tear them apart? Isn’t the whole purpose of this work to help people see and be their best selves?
I knew things at the TC were going from bad to worse by the time I moved back to New York. There were persistent rumors of Medicaid fraud. In any case, I knew there must be a better way to help my patients and do more therapeutic work, and that just wouldn’t be feasible in the little tin warehouse. Last I heard, the clinic is still working, and has moved to a larger space. The management changed, but the owners and case managers have remained the same.
We should note that the vast majority of abstinence-based programs don’t use the kind of abusive practices that I witnessed in Florida. Most abstinence-based practitioners are genuinely compassionate and believe in this model and the successes that can be achieved by patients. But too many do still make these kinds of mistakes, and I was searching for an approach that made more sense to me.
It was only recently that I became familiar with harm reduction; I started utilizing this model in my work in 2010. Through harm reduction work, both in programs and in private psychotherapy, I have seen patients succeed, and succeed with more consistency and longer periods of success than during the work I did in Florida. I see growth and confidence develop within my patients. They set a goal, they take control of their lives, often for the first time in a while, and it’s a beautiful thing to see as a therapist.
I will never forget asking one patient what he wanted to work on. This patient looked at me stunned, like I had 20 heads. I asked him why, and he replied, with absolute amazement: “No one has asked me that question in so long!”
Why should we be trying to break people down, tear them apart? Isn’t the whole purpose of this work to help people see and be their best selves? To help them feel as close to whole as possible?
Despite my views today, I have no regrets (on my own behalf, that is) for my involvement at the Florida TC. If I hadn’t seen how exploitive and damaging treatment can be when done poorly, I might not have gained a new perspective. Now I have a frame of reference when patients come to me discussing traumatic treatment experiences. I get it. I can offer them a space to do and say whatever, without judgment or punishment. And this fosters positive change.