On a muggy night in Phnom Penh, neon bar signs blaze like the eyeball veins of a meth-head, wild with lack of sleep casting a faint glow on the cheeks of a man, mid-fifties, beer-gutted and wearing sandals. He tosses a couple of keys on a ring. They catch the streetlight as they arc, making that unmistakable tinkling sound. San Sophos catches. “The bike’s yours babe,” the man says gesturing at the shiny 110cc Honda.
For Sophos, the bargirl, it’s just another gift from a client. She’s beautiful. Brown skin, chopstick-thin with long dark hair that shines as if varnished. Sophos isn’t a prostitute, she’s a free agent, making her living selling the “girlfriend experience” to lonely men.
You wouldn’t know it today though. She’s only 32—still young enough to ply her trade—but her hair is matted and wild, she wears filthy jeans and a plaid shirt several sizes too big. Her eyes bug out and her grin is lopsided. Methamphetamine—Cambodia’s most widely used drug—is cruel. Sophos looks away, remembering her former life, “I was very beautiful and had many clients,” she says, speaking English. “They bought me jewelry, mobile phones, motorbikes…everything.”
Her charm remains, though obscured by addiction, like tattered curtains obscure the view of a verdant garden. She’s sitting in a room at Korsang, a Cambodian NGO that provides aid to drug users. One of several people being interviewed about their involuntary detention in Phnom Penh’s Orkas Knhom (“My Chance” in English) rehab. By all accounts the rehab would be more recognizable to Solzhenitsyn than Betty Ford.
In Cambodia, “undesirable citizens” are periodically removed from the capital, Phnom Penh. Usually before a festival or a visit from a foreign dignitary. Drug users, sex workers and mentally ill people are targeted. They are detained with no legal recourse for periods of around three to six months, though some reports mention years of illegal imprisonment. According to a Human Rights Watch (HRW) report 22% are under 18 and over 9% are under 16.
“Every day the guards made me exercise until I collapsed from exhaustion,” says Sophos. “But I had to get up again or they would beat me.” She was lucky. After proving that she was Korsang’s client and receiving methadone, they let her go. Others were not so lucky.
Sok San, a thin man of indeterminate age, was detained at Orkas Knhom earlier this year. “Because I live on the streets and have no money the guards forced me to work,” he says, looking at the ground, shrinking into his oversized coat. “They beat us with whatever they found lying around: a belt, branch or stick; they said I was lazy and I had to do whatever they said.”
Their claims are backed up by the HRW and several other organizations who have denounced the rehabs as being abusive, ineffective and tantamount to torture. After editing two scathing reports on the situation in recent years, Joseph Amon, Health and Human Rights director at HRW, remains adamant. “All compulsory drug detention centers in Cambodia should be immediately closed,” he says. “This is not just my opinion, this is the view of 12 UN agencies including the UN Office on Drugs and Crime, which have recognized these centers as ineffective and inhumane.”
Vutay walks fast down the thin, heat-wobbling roads. Inside his pocket he pinches the bundle of notes totaling 20,000 Riel ($5) into a small wad. Feeling the soft bundle between his fingertips causes an insatiable buzz in his chest. He has it. Enough money for a hit of “white” - heroin. Soon he would feel that beautiful rush.
Rounding a corner, he notices an ominous presence brooding down the street – a police van. In the back are men, women and children hanging their heads, handcuffed to two rough wooden benches. Vutay turns to bolt. But an iron grip seizes his arm. “We know you,” says a tough voice. “We know you’re going to buy drugs.”
“But I don’t have any drugs,” Vutay’s protests are ignored. Metal bracelets clip around his wrists, attaching him to a chain running beneath the benches on the back of the truck. There’s no shade. The merciless sun beats down on his neck. There will be no legal recourse for Vutay. He’s outside the Cambodian justice system, in a Kafkaesque space where no one hears you scream.
As the setting sun drenches the sky in pink and orange, Vutay and a few dozen other “undesirables” wait in a carpark behind a government building. In the twilight they cut thin shadows. Fleeting figures – ephemeral as mayflies. An official comes with a clipboard. A few of the women and children are released into the custody of family members or NGOs like Korsang. Everyone else is taken to Orkas Knhom or similar centers. “They don’t want tourists to see vagrants or drug users,” Vutay explains. “It makes the city look bad so that’s why they pick us up.”
It’s 10am on Vutay’s first day. His muscles aching from military-style exercise drills, he and the other inmates form a dejected huddle in the courtyard. A team leader approaches. Team leaders are inmates who have been chosen by the guards to keep order and discipline. They operate with impunity and have been accused of the most appalling abuse, from capricious beatings to forcing inmates to perform sex acts. “It doesn’t matter what they do,” he says. “The guards will never hear a complaint.”
The team leader silently cuts the group in two. He shoves Vutay and the other street people to one side. The other group are better dressed and their skin less blackened by the sun. They are the wayward youth detained at the request of their families at the cost of up to $150 per month (the average monthly wage in Cambodia is roughly $200). The paying inmates are allowed to rest. Vutay and the rest are forced to work in the sweltering fields.
Families send drug-addicted members to Orkas Knhom in the hope that it will cure their addiction. But with local press reporting relapse rates between 85 and 95%, they are in for disappointment. “Many parents are uninformed about the risks and dangers from drug use and dependency and how it can be addressed,” says Amon. “They do not have accurate information or real alternatives.”
“Orkas Knhom is a temporary center where drug users can detox, have some education and train in new skills,” says Meas Vyrith, head of Cambodia’s National Authority for Combatting Drugs. “We don’t keep it like a prison, we want to help people.” The minister dismisses allegations of abuse. “We don’t allow people at the center to beat each other,” he says. “Critics get their information from drug users but they are not reliable sources of information.”
The amount of abuse inmates suffer at Orkas Knhom depends on their ability to pay, according to former inmates. Richer inmates can afford to “live like kings” and treat poorer inmates like servants. But Vyrith denies that this is coercive. “When people live in the center they agree to exchange money for massage or cleaning services with each other,” he says.
Massage services can become sexual abuse. “I saw it once in the dormitory,” says Sok San. “A team leader thought someone was gay so he forced him to give oral sex.” Human Rights Watch has reported numerous other instances of sexual abuse at Orkas Knhom and other rehab centres.
Driving through Phnom Penh’s dusty hinterlands there are no signs for Orkas Knhom. The address given in the Cambodian Yellow Pages doesn’t appear to exist. A boy living in a local village knows the way. He has leads, wielding a decaying motorbike over bumpy dirt roads.
“No picture, no picture,” rage two guards outside Orkas Knhom’s 10-foot iron gate. The surrounding wall is high and garnished with barbed wire. Access will be impossible. Sure, there is the possibility of arranging an official visit but that would be a pantomime. “When journalists come they tell you not to say anything,” says Sok San. “If you say anything they beat you.”
Walking away, I swing around and snap a shot. There is a cry of outrage from the men. Before I can slide the keys into the ignition of my motorcycle, one of them has my fist and is trying to prise my keys away. His colleague is making alarming sounds into a walkie talkie.
“I’m a journalist, journalist,” I insist in Khmer, holding onto my keys. It must register because the man halves his efforts at holding me, allowing me to escape in a cloud of dust. All that can be concluded from this unpleasant episode is that the NACD go to a lot of effort to hide their philanthropic efforts to “detox, educate and train” drug users.
However, there are positive changes that the Cambodian government are happy to share with the press. Methadone maintenance has been available in Phnom Penh since 2010. While chronically underfunded, the program has allowed Sophos and others like her to stabilize enough to find casual labor.
As for methamphetamine abuse, a nascent community-based treatment program (CBTx) was launched in Phnom Penh last year after a successful pilot program in Banteay Meanchey in the north of the country. These changes could signal the start of a sea change away from forced rehabs. Indeed, at the time of writing, Vyrith and a team from the NACD are on a fact-finding mission in neighboring Thailand where CBTx has been used by the criminal justice system for nearly 20 years.
But there is a long way to go before Sophos, Vutay and Sok San can walk the streets unafraid of sudden, arbitrary incarceration in horror shows like Orkas Knhom. “In order for CBTx to be effective the government should involve NGOs who work with drug users in the program,” says Tiang Phoeuk, executive director of Korsang. “CBTx needs to include housing, vocational training, loans, job placement and reintegration plan for the drug users.” The program is not ready to offer that yet. It doesn’t look like the spiked walls of Cambodia’s forced rehabs will be coming down anytime soon.
Nathan A. Thompson is a journalist and poet. He has written for the Telegraph, the Guardian, Vice and Slate. His debut poetry collection, I Take Nothing Strong, Only Lightning is out soon on Wow Books. Follow @NathanWrites. He last wrote about the Cambodia needle exchange.
With the exception of Mad Men, Shameless, and Nurse Jackie, I rarely ever learn anything new from television about the addictive mindset or the nuance of being an addict in recovery. I can now add the new USA drama series, Mr. Robot, to the list of shows that showcase addiction and mental illness in a unique way. The show deftly deals with addiction and mental illness, two issues that can often walk hand-in-hand, and the showrunner and writers do it well.
A little back story: I have been the copy editor on The Fix staff for nearly a year. While I have never had to deal with substance abuse myself, I have seen its effect on too many people in my life. On a daily basis, I read copious amounts of addiction and recovery information and this information has now become a part of my life. I find myself slipping addiction statistics into friendly conversations or wanting to illuminate friends on the growing heroin epidemic that is quickly infiltrating our society. I am no longer shocked that "regular" people are unaware of prescription painkiller abuse, or the reality of living with alcoholism, or the fact that naloxone is a game-changing medicine that can save lives. It's not like they're covering this information on the local news. The effects of the War on Drugs is only recently starting to trend in the news cycle with Obama granting clemency to a record amount of non-violent offenders but the coverage is microscopic compared to that of a celebrity's impending divorce or a popular wrestler's alleged racist tirade.
Addiction is not glamorous and is rarely discussed without stereotypes in the mainstream so I don't look at people any differently for lacking addiction awareness. But my veil has been lifted and I can see my daily work is quite ubiquitous. Addiction is everywhere, including the entertainment I love. It can be found in the books I read and throughout the plots of the TV shows I watch. The addict trope is often portrayed in a derivative manner with the same set of familiar outcomes—the characters walk away nice and clean or eventually something terribly permanent happens. Mr. Robot has arrived to challenge the tired tropes with a different take on addiction and mental illness.
Sometimes I dream of saving the world. Saving everyone from the invisible hand. One that brands us with an employee badge. The one that forces us to work for them. The one that controls us everyday without us knowing it...
The psychological thriller centers around a young computer programmer named Elliot (Rami Malek) who works in cyber security. The audience is introduced to Elliot while he is riding the subway and in the middle of a possible schizophrenic paranoiac episode. Elliot informs us via voiceover that he has developed a relationship with the voice inside his head, whom he affectionally calls "friend." He internally wonders if he should name the voice but decides against it. He then begins to tell his "friend" of a top secret conspiracy about a powerful group of people that are secretly running the world.
"What I'm about to tell you is top secret. A conspiracy bigger than all of us. There's a powerful group of people out there that are secretly running the world. I'm talking about the guys no one knows about. The guys that are invisible. The top 1% of the top 1%. The guys that play God without permission...and now I think they're following me."
As Elliot sits uneasily in a moving subway car wearing his signature black hoodie, he sneaks a glance at two men in suits whom he believes are tailing him, though they never actually make contact. Elliot is an unreliable narrator and this device serves two purposes: To make us distrust what we see on screen and to allow us inside the head of an introverted, socially anxious paranoid schizophrenic.
Paranoid schizophrenia is one of the most common types of schizophrenia in the world, but it is not the only type of schizophrenia, there are a handful of subtypes including: catatonic, disorganized, residual, and undifferentiated. There is no uniformity within the illness; Half of all people with the illness have not received any treatment; and between one-third and one-half of all homeless adults have schizophrenia. The suicide rates of schizophrenics is very high with 10% of adult male sufferers dying by suicide. According to NIMH, people with schizophrenia "are much more likely to have a substance or alcohol abuse problem than the general population."
People who suffer from this illness are usually relatively stable, though they experience auditory hallucinations, delusions of persecution, or of having a "special mission," among other symptoms. Though he regularly sees a psychiatrist, Elliot has not been clinically diagnosed, as he makes rigorous attempts to hide his symptoms from the people around him. As the show progresses, we start to see examples of a larger conspiracy brewing in Elliot's workplace, which eventually leads him to take on a "special mission" with an anarchist hacker collective called Fsociety, which is lead by the enigmatical Mr. Robot (Christian Slater). Every decision and person that arrives into the story seems to fit a perfect piece of the conspiratorial puzzle. As a viewer, there is an ominous feeling of distrust because you get the feeling that this entire call to arms exists only in Elliot's head.
While the show has definite Fight Club undertones (which is one of the reasons I love it), it does manage to depict a more realistic version of a paranoid schizophrenic than the 1999 cult classic. In Fight Club, the character with schizophrenia is depicted as an aggressor, when in real life, schizophrenia can have an almost dulling effect on the individual. The documentary, Living with Schizophrenia: A Call for Hope and Recovery features firsthand schizophrenic accounts that illustrate the debilitating nature of schizophrenia and the stigma attached to the illness. These accounts sound similar to Elliot's journey, which also includes substance use disorder.
"If it weren't for QWERTY, I'd be completely empty."
Elliot is a drug addict. He uses morphine to stave off his loneliness. Like many drug users, he has a code. "The key to doing morphine without turning into a junkie is to limit yourself to 30mgs a day. Anything more just builds up your tolerance. I check every pill I get for purity. I have 8mgs Suboxone for maintenance in case I go through withdrawals."
This is the first TV show I've ever watched that has mentioned Suboxone, the medication used to treat narcotic opiate addiction. The drug is quite controversial though it has helped many users manage their opiate addiction when taken properly. I was absolutely thrilled to see it showcased and explained on a major cable network show because the more people that know about Suboxone, the better. The drug has the potential to save lives and sometimes it takes bringing things to the mainstream to promote awareness and make necessary change.
Elliot explains that Suboxone is difficult to get a prescription for so he is left no choice but to get it illegally. This is an all-too-familiar tale for users of Suboxone. Elliot gets his Suboxone from his neighborhood dealer Shayla (Frankie Shaw) but when her supply goes dry, he is forced to break his own code and retreat into the arms of morphine to get through his day. Elliot's morphine addiction reaches peak levels just as he is forced with the decision to either digitally snitch on Shayla's abusive supplier or shut his mouth and maintain his morphine addiction. He chooses the former and proceeds to go into heavy withdrawal.
We watch Elliot attempt to follow through with a major hacking scheme despite being in the early stages of withdrawal and he fails miserably. The hacker collective and Mr. Robot check into a motel and babysit him while he goes through a brutal few days of morphine withdrawal's greatest hits—sweats, nausea, tremors, and nightmarish visual hallucinations. Elliot makes it out the other side, but just barely. The few days post-withdrawal prove to be more difficult than he expects.
Mr. Robot is a tense, entertaining, thriller that manages to address mental health and addiction in a nuanced way. There isn't another dramatic show on air that handles the chaotic balance of mental illness and drug addiction with such attention to detail. What I love the most about it is the unpredictability. I don't know if Elliot will remain sober; I don't know if/when his schizophrenic episodes will progress and I don't know if Mr. Robot and Fsociety are real or just figments of Elliot's imagination. I applaud showrunner Sam Esmail and his team of writers for being fearless enough to break the stereotypes involved with addiction and mental illness, and for creating such a layered character in what could have been a flat one-dimensional portrayal in lesser hands.
Desiree Bowie is a copy editor for The Fix and a freelance writer.
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Although there is some controversy about the effectiveness of interventions, there are undoubtedly situations where, lacking intervention, an individual’s downward spiral would likely continue. In these situations, a skilled interventionist can prove the catalyst that begins the journey to lasting recovery for the patient while also uniting family and friends behind a chosen treatment plan. Rickard Elmore, an experienced addiction and mental health interventionist, recalls a case in which multiple challenging variables were overcome in order to help a man begin treatment and attain early recovery...Richard Juman.
Intervention is a craft. It calls for a well-trained clinician with real-life experience to identify the various components of a situation and then direct it into complete solution. Inviting an unqualified interventionist into a volatile situation could potentially exacerbate the problem. But an interventionist who incorporates strategy, patience, and compassion can help someone to begin the journey of recovery and alter the whole direction of their lives. As an experienced interventionist, I’ve found that a lot of the work I do is more about treatment strategy than anything else. Not everyone is going to make a lifetime commitment to abstinence in the beginning. Even so, we have successfully entered people into long-term recovery by allowing them the opportunity to get some help before making such a daunting decision.
Most of the time it just makes sense to start off with abstinence. If a person has been consumed with toxins and their behavioral patterns or emotional condition have caused them to continue to make decisions that create great conflict and turmoil in their lives, they will often admit that they need to take some time to get better. Eventually, they gain insight, as do their treatment providers, about what might be the best lifetime solution for them. Although intervention techniques can be taught, not everyone has the experience and diversity to be able to handle the complex situations that often occur without warning.
“Dan” was a retired 53-year old professional man who had been consuming 20 to 30 ounces of vodka a day for the last five years. His significant other had finally convinced him to seek treatment. During his intake assessment at the treatment center, he said he thought of killing himself every day and that he slept with a gun beneath his pillow. The treatment facility followed protocol and dialed 911. The client was arrested as a possible danger to himself and others, and transferred to a hospital for a 72-hour evaluation.
That is when I received the call.
At this point, he had begun to exhibit signs of delirium. The hospital staff diagnosed him and proceeded to give him medication (not for detox of alcohol). You see, detox from alcohol can cause a person to be in a great state of confusion about time and place and have a decrease in short memory recall as well as disorganized thinking. These same symptoms exist in many other mental health disorders. Even for trained professionals (in this case, the staff members of a hospital), it can be difficult to discern what is really going on.
An experienced interventionist will be able to ascertain a potential client’s level of substance misuse and to determine the extent to which a psychiatric disorder is impacting the presenting problems. It is critical to recognize a traumatic behavioral episode in the client’s history and understand the underlying issues being presented. Those issues need to be assessed before further diagnosis can commence.
Now, what happened next may seem shocking but it is not an isolated incident in the world of addiction treatment and behavioral healthcare. While the client was sleeping, the nurse decided to wash his body. When she got too close to his private areas, he reached out and attacked her. He was then restrained to the bed and charged with assault. Fourteen hours later, he was discharged to police custody. Not a good place for him to be in his condition; or at all for that matter!
I’ve found that it takes a great capacity for patience to help people find their road to recovery. All too often, medical professionals and treatment providers alike try to determine the cause and the nature of a person’s problem without the knowledge or expertise that’s necessary, and long before a diagnosis can be considered conclusive. This has unfortunately led to many faulty diagnoses.
If a person who has a true mental health condition is consuming a substance to “self-medicate,” does that mean that they have the “disease of addiction”? An accurate diagnosis can not be determined until further analysis has been completed. True diagnosis can only be determined over time. To facilitate emotional, psychological, biological and behavioral stability in a patient, one must allow the journey to unfold.
Unfortunately for Dan, he was looking for help but instead of being admitted into a treatment facility, he found himself in police custody. His road was turning out to be rougher than anyone expected.
After hiring a bail bondsman and getting an attorney on retainer, I found out that my client had been transferred downtown under a false name that he had given to the authorities in his continued delirium after his questionable release from the hospital into police custody. We were told that, once cleared, he would be transferred back to the main jail and released. Instead, they discharged him on his own with someone else’s clothes on!
After a full-on manhunt with family, investigators, and a contracted security team, we found Dan. By this point, I was in communication with a number of different friends and family members. Each one had a different account of what was going on and what needed to be done, but they all hoped that I would be able to help their father, brother, son, ex-husband, father-in-law, son-in-law, or boyfriend. I explained to his family that I could orchestrate things such that Dan would agree to go to treatment as long as we all agreed to be on the same team. They agreed, reluctantly. You see they, too, felt betrayed by the system.
Clearly, an interventionist must hold space not only for the individual in treatment, but also for the family and friends of that individual. An experienced interventionist will be able to educate and support the families and loved ones of those who are suffering. That education will, in turn, allow them to support their loved one without sacrificing their own peace of mind.
Once we were all on the same page and the family understood that I was there for them as well as for their loved one, we began the intervention. The tension in the room was palpable. My client was in the middle of negotiating another drink before going to treatment when I asked his daughter to get the soda I had in the refrigerator. I told my client that for the last 36 hours I’d been riding around with this in my car, and I held up his favorite non-alcoholic drink: a can of Orange Crush.
With a sparkle in his eye, he thanked me and took the soda. After another 10 minutes of negotiation I said, “Hold on.”
All eyes were on me. But my eyes were on him and there was a big smile on my face. I said, “It seems to me that you have a heart that flows with love and compassion. It’s gotta be hard to hear everyone offering their love and support for you. Not only that—I’m over here watching you drink that soda, and I’m drooling after two days of not cracking the top off that drink myself. Aren’t you even gonna offer me some?!”
The tension in the room deflated. He smiled as he handed me the Orange Crush. “Of course my friend, sorry about that.”
I took a drink, smiled, and handed it back. “No worries, thank you for allowing me to be here.”
With that, I could feel his daughter come around, the one that had the least confidence in me, who reluctantly allowed me to proceed with the intervention and whom I purposefully sat next to me. In that moment, the entire room united in support of Dan’s recovery. Of course, there is more to the story, but my hope is that what I’ve described highlights one of the key elements involved in intervention work. It’s about having the ability to work with what is in front of you without allowing unexpected roadblocks or tension to break your resolve. And it’s about compassion.
We have found that the only true healing for a person’s wounded sense of self comes from love and understanding. If you can start a person on the road of recovery, it can alter the whole direction of their life. It’s a magical opportunity to open the doors of recovery and fulfillment to someone who has been suffering from a seemingly hopeless condition.
The craft of intervention is needed to truly move people from their troubled condition into a place of recovery with kindness and compassion, the same compassion anyone would give to someone who they could see was suffering from a life-threatening condition. The right interventionist will approach your loved one with an abundance of compassion as opposed to bullying them: this is an intrinsic value to having a successful treatment episode.
Dan went to treatment the next morning. The treatment team found out why he attacked the nurse, something that had been causing him harm since childhood. Today, nearly one year later, he is sober.
As an interventionist, I have to say it’s quite a blessing to facilitate sustainable recovery for so many people in need. Times have changed, but life in recovery without shame or regret is the clear winner. As a lifetime participant in recovery myself, I have found that there is no need to rest on yesterday’s accomplishments. There are constantly new developments in treatment and recovery that a well-versed interventionist will be informed about. In case you haven’t noticed, tomorrow is the place where hope lives.
Rickard Elmore has been in the field addiction and mental health for over 20 years, and is one of the few interventionists who specializes in mental health interventions. He is the founder of Rickard Elmore Intervention.