The Methadone Clinic: The Deplorable group- a memoir

Rivkah Lapidus, Ph.D. 

 

 

I wrote this piece in response to an organizational newsletter in which racism in a mens groupgroup in a methadone clinic  was discussed) . (NSGPeople, 2020.. It stirred reminiscence of my years as a counselor at a methadone clinic in the 1990s. This is a work of reminiscence and a story. Identifying markers have been altered. 

Years ago, in the 1990s, I worked in a methadone clinic. I was a counselor or therapist, trained as a psychodynamic clinician. I was new to the “substance abuse” field, and started at the lower echelons of the field (methadone still carrying stigma for clinicians too), having moved from the DMH system to a new “population” then known as “addictions.” I knew nothing about substance use treatment or its assumptions

 

 

When I started my employment at the ________ Treatment Clinic, located in the Greater Boston area, I didn’t know that it would change my way of thinking, strengthen my passion for a social psychology orientation, and startime on the path to embracing a Harm Reduction orientation to my clinical work for the next 30 years.. 

 

 The Beginning

As a clinical assignment  I was given the “Tuesday evening group”, a pre-assembled group of men who did not fit into any other clinic group at the time: not relapse prevention, not transition (away from methadone) group, not Meditation group. Group was a requirement for every client, with two “misses” allowed for each 3 month cycle. This group had about 6 men who, with a reverse or perverse sort of pride, deemed themselves as the bottom of the barrel. They were the Lifers who had been in treatment since the early days of methadone therapy, and expected to continue to the end., They had menial jobs, in junkyards or in grounds maintenance, so required an evening group. That was the criterion for placing them together.  They probably should not have been assigned this way, or been in group at all;  but it was a requirement. Regulatory agencies mandated that all clients (or patients, to adhere to the medical model) were to attend one individual appointment and one group session for week.

 This particular group was a challenge. No other therapist would work with them, and they were assigned to me as a Newbie with a resigned “well, see what you can do with them.” 

 

 

“Deplorables”

 

Why was this group such a challenge? The elephant loomed huge in the room. Graphic expression of racism was the pride of the group. At times it was absolutely disgusting, honed to a surreal intensity. I listened to unspeakable words about black and brown people, about Moslems and Jews (I am Jewish.). I felt that for whatever reasons the group wanted to provoke me and make me nauseated. (One guy from Charlestown specialized in gory murder descriptions involving chainsaws. He was later cast as an extra in a Boston crime movies.) But what to do? 

 

The worst offender seemed to relish the power of his provocation. He smelled horribly.  It is impossible to describe a noxious smell of unwashed clothes and body, but to this day if I come very close to a person experiencing longterm homelessness, I get a whiff of that smell and I think “that’s Joe.”. 

 

Friends and colleagues suggested that I “educate” the group, or at least forbid the use of offensive language. Of course, that would have been the right thing to do.  But I did not do that.  Something about “the right thing to do” felt wrong .

 

 I think of Tom Fogarty’s construct of “the hook.”[ 1] I knew if I took the bait I was finished.  Then there was the concept of :Educating them.” I think it was also Fogarty who said that the notion of having to “educate” even well-intentioned people is in itself an act of “othering.” The group lauded me for not being a “phony liberal.”   I asked them why they wanted to make me sick to my stomach if they liked me so much. I did not get an answer, except that I proved I was not a knee-jerk liberal who would find them abhorrent.

 

I remember thinking (yes, rationalizing), well, these men were not ideal candidates for group therapy anyway. They were bikers and tough guys who despised anyone more successful than they. (I remember some mockery of the figure skater, Nancy Kerrigan” crying “why me.”  Why assign them to group at all?  I decided, perhaps out of intimidation, perhaps for my sanity, that my job was not to change them, but to show up.  I tried to bear what they had to say, and listen with a third ear. 

 

Let’s just say I did not handle the group in a sophisticated way.  It was shocking, but there I was, among “the deplorables” and I wasn’t rejecting them. Was I condoning them? Looking back, I regret not my decision not to condemn them, but my shyness about inquiring further into why they felt so hopeless, angry, and defeated.  

 

Was I intimidated? I figured—or rationalized--this is the group I was handed, and I never protested that assignment.   I wondered if I was “enabling” them, and I wondered what I was afraid of.  Their dislike? Was I endorsing their repulsiveness by not “educating” them or making their language punishable by a clinical consultation with the administrators?

 

 We had a group consultant at the time who described the awful odor as “the elephant in the room Why did I not do anything about it? Later I described the group to another consultant in group supervision as a “culture”- She remarked that as a “culture it was a dysfunctional one.”  I wondered if I was foolish to think of them as a culture.  

So the question looms here: why did I value the respect of a group of dysfunctional racist men? I don’t know- why do people like Tony Soprano? Why did Dr. Melfi work with Anthony for so many years? Why was she not consumed by countertransference hate?

 

This is the real question.

 

Perhaps deplorables who hate themselves because they have ended up in a disempowered place appeal to me. Perhaps there is a part of me like Dr. Melfi, who worked with Tony’s panic attacks despite “What you [Tony] do for a living [kill people] ” Maybe Dr Melfi hoped that the emotions and family values of the Sopranos would triumph over sociopathy. Maybe she thought insight would change him. Maybe she was doing her job as she thought she should..

 

And maybe ugliness is appealing. Ugliness exists within all of us, along with our righteousness and kindness.   (If it were simply a matter of the sexiness of toxic masculinity, I would be enjoying the presidential debates and admiring Donald Trump. These induce a different kind of nausea, and outrage. So it is not so simple.) 

 
One thing I took away from my work there was awareness of powerful internalized stigma of people in methadone maintenance treatment.  Although Methadone Maintenance is a proven long term replacement therapy (MAT), People still question it as “giving drugs to drug addicts.” 

The structure of methadone maintenance is based on long term dependence: it demands attachment to an institution. One may not be privately medicated in a doctor’s office.  Every day of the year men and women, sometimes with a child in tow, lined up starting at 6AM under the watchful eyes of security guards and urine monitors (when that  practice was still accepted) and then went to mandatory counseling in an unmarked brick building.  Someone had to watch them closely as they peed. They were not allowed to loiter because the neighbors would attack the clinic administration for bringing these people to their backyard.

 

Sometimes a patient had been incarcerated, and escorted to the dosing clinic in shackles. Others were not allowed to get their methadone because the prison system denied them the right to get medication. They were left to withdraw on their own.

 

I grew to care about these men, and the women I got to know during those years.. I worried that some would die.  One group member talked in a stirring way about using heroin and attaining that blissful state of “being as close to death as possible without crossing over.” A state of security, of no more worries.  I could silence them with my disapproval, but they had already been silenced in life.  They would not be seated in that group room had their lives gone differently. These “lifers” hated themselves, so they hated everyone else. Underneath all this hatred was a powerful need to attach.  "My dose isn't holding me"  Holding. At some primal level they wanted to be held.
 

Not every methadone patient is like this, and if you come away from this piece thinking “that’s what junkies are like” it is the wrong message. They worked to earn privileges like take-home medication and fewer required counseling sessions.  My group scorned them as the “good ones” who flaunted their locked take-home boxes. 

Some of my clients died of AIDS or complications, some overdosed, Others got stronger and better through their own determination; the younger ones avoided the fate of the lifers- eventually detoxing from methadone and moving to the suburbs, to join the PTA and have barbecues and neighbors as friends. They are professionals and PTA members live in your neighborhood—but you will never know their secret. 

Metaphor of the cat:

 

 I saw some of these these men many years later, when I was doing some outreach work for the same agency. It was amazing—a few actually had gotten better. The smelly guy didn’t smell, was well-groomed and no longer supplementing his methadone with heroin.  He even had a locked box- he had earned take-homes. 

Sometimes it takes time for a loser to feel like a member of society.  

At his worst, this dirtiest and most provocative group member asked me if I wanted a kitten. The kitten lived with his littermates in a junkyard with dangerous machinery. I noted the smelly racist’s love of animals- he always had bags of dog and cat food in his van—he said “Hitler liked animals too.” He did not want to be seen as good in any way. 

 Of course the cat was black, and of course he had been named Spooky.  He was introduced to me in group one night. We coaxed him from his hiding place under a torn black couch and got him into a box. I brought him home without even telling my family.  At first Spooky was terrified of domesticity, but he eventually claimed his place as in our household, a gentle and independent and tame “guy.”  (You could only scratch behind his ears though- claws came out if you rubbed his belly) .We had the cat for 17 years, many years after I left the job.  Spooky lived a full and happy life.  

 

 

[1] Tom Fogarty: The pursuer and the distancer