I've recently read two books, Beautiful Boy and Tweak. Beautiful Boy, by David Sheff, is about the author’s struggles with his son Nic’s addiction, as well as his own denial and codependency. David wrote, “Addicts are in denial and their families are in it with them because often the truth is too inconceivable, too painful, and too terrifying” (p. 15). One aspect of this book I found especially interesting is the way the author integrates three different threads—his son’s addiction, general information on chemical dependency, and his own growing codependency. Tweak, by son Nic, provides another perspective.
While Beautiful Boy covered Nic’s entire life, Tweak covers about two years when Nic is in his early twenties, starting with a relapse that becomes a 28 day methamphetamine and heroin binge, followed by a stint in at an inpatient facility, about a year of clean time, another relapse, and another stint at an inpatient facility. While Beautiful Boy contains much confusion and helplessness, Tweak is about anger and desperation.
Throughout Beautiful Boy, David reports on his ongoing attempts to talk Nic into treatment for one more try. Like most addicts, Nic does not believe he needs treatment and does not believe it will help. Considering at least four treatment attempts are documented in David’s book, Nic’s skepticism seems understandable. It hasn’t worked before, why will it this time? This is something I face with clients frequently.
Most of my clients have been in treatment before, some several times. In fact, I’m currently working with a client who has completed inpatient twice in the past, has been in three different outpatient programs, and has been to mental health therapists off and on for nearly five years. This client is now eighteen and court mandated. Failure to follow through with all treatment recommendations would most likely lead to jail time. So he reluctantly agreed to begin treatment one more time, but he reported, “It probably won’t do any good.” Why would he think otherwise?
There is another level to Nic’s ambivalence, though, which seems quite common. Nic wrote, “Using is suck a fucking ridiculous little circle of monotony. The more I use, the more I need to kill the pain, so the more I need to keep using. Pretty soon it seems like going back, facing all my shit, well, it’s just too goddamn overwhelming. I’d rather dies than go through it” (p. 146).
At a certain point, using is no longer about getting high or the initial positive reinforcements. Instead, it becomes about escaping—at least temporarily—from the ever-mounting number of negative outcomes of using. It seems easier to just keep using. Nic wrote, “I don’t care. Isn’t that the greatest gift in the world—just not to care? I feel so grateful for it. That’s nothing I ever knew sober” (p. 60). Why give that up? For many of my clients, that’s the biggest question that needs answering in treatment.
Getting clean is hard work. It means changing everything in your life. It also means taking huge risks. Nic wrote, “Trying is terrifying because I know I will just fail” (p. 296). Nearly all my clients know that feeling. Nearly all my clients have made very similar comments. What if they say they want to get clean, but then can’t actually do it? What if they take that risk, but then fail? If they don’t try, then there's no possibility of failure. My clients know how to use. They've never failed at using. That sounds strange, perhaps, but addicts understand. And, that “circle of monotony” may be a bit of a bore, but at least it is predictable.
Many of my clients live in highly dysfunctional families, frequently filled with the chaotic fallout of substance abusing parents, family members with mental health issues, economic pressures, and similar stressors. For these youth, the predictable circle of monotony can have a certain appear. As a client once said, "I use. I get high. No surprises."
Chaos is not Nic’s history, though. Although divorced, both parents are successful and his childhood appears reasonably healthy. He went to private schools. He was successful and popular as a child, active in sports and other extracurricular activities. He doesn’t seem like a future meth addict. So what happened? I wondered that the entire time I was reading Beautiful Boy. I wondered that through much of Tweak.
Nic has a certain level of genetic predisposition, a grandfather who was an alcoholic. However, one grandparent who died before he was even born doesn’t seem enough to me, even though Nic wrote about his first using experience, with alcohol, “I drank some and then I just had to drink more until the whole glass was drained completely. I’m not sure why. Something was driving me that I couldn’t identify and still can’t comprehend” (p. 2).
Although this sounds very disease-like, I don’t believe in the disease model all that much, especially for adolescents. There must be more. There must be a missing puzzle piece. If Nic finds that missing puzzle piece, maybe he can get and stay clean. If I can help my clients find their missing pieces, maybe they can get and stay clean, too.
Maybe recovery is really about finding missing puzzle pieces.
In Beautiful Boy, this missing piece is not addressed. David is simply too helpless to look beyond the next crisis. In Tweak, though, it seemed obvious fairly quickly that Nic might have mental health issues. At first, I wondered if I was looking for this because of my work experience. After all, my clients all have co-occurring disorders, I’ve always worked with co-occurring clients, and I feel strongly that most adolescents with significant substance abuse issues probably have challenges in this area.
Much of Nic’s writing reflects a depressive state. At other times, though, he seems almost manic, even though it usually seems related to his use of meth. Nic wrote, “I… have an incredible anxiety socializing with people. I mean, if I’m at work, or I’m high, then that’s okay. But sober, going out with people my age, I am just really uncomfortable.” (p. 161). Eventually, after all his other treatment episodes, all the therapists he’s seen in his life, past diagnoses of depression and prescriptions for antidepressants that he simply abuses, and all the time spent high, Nic is given a diagnosis of bipolar disorder.
In my opinion, bipolar disorder is the new overly diagnosed condition. However, when accurately applied, I’ve seen treatment for this condition change lives dramatically. After two weeks on medications for bipolar disorder, Nic wrote, “Something has changed. And then it hits me—maybe it’s the medication… Sure, the change isn’t very dramatic. It’s no like shooting meth or something. But there is a slight difference. Keeping my head above water suddenly doesn’t seem so tiring. The blackness doesn’t swallow me up to such a horribly suffocating depth” (p. 204).
Both Beautiful Boy and Tweak can be grueling. David seems to often be lost in his helplessness and codependency, unable to live his life or even care for his other children. Indeed, David frequently wrote that he is addicted to Nic’s addiction. This is apparent throughout his book. This is also something I see frequently in the family members of clients.
Reading the relentless passages about using, crime, prostitution, and self-inflicted trauma is almost unbearable at times. After being diagnoses with bipolar disorder, Nic wrote, “How could I have spent my whole life battling so hard, not knowing what was wrong?” The better question, I think, is how could so many therapists, treatment centers, and other counselors have missed that puzzle piece?
With some of my clients, treatment is about learning skills to resist using. That's pretty simple. For other clients, though, there's much more. They know these skills. Heck, they could lead group sessions on triggers, relapse prevention, emotion regulation, and mindfulness. But, they still use. There's something missing in their recovery. They haven't found their puzzle piece. Yet.
