My Brother's Keeper After years of prison and addiction, my brother went silent. So I visited his rehab. By Jessie Guy-Ryan

I’ve seen my younger brother Zach in person a handful of times in the past eight years. He’s spent a little over two of those years incarcerated — not counting time in county jail awaiting trial or the times he broke parole and fell off the grid. He’s been convicted of larceny, breaking and entering (vehicles, many, many times), possession of burglary tools, assaulting an officer, and resisting arrest. My brother committed each of these crimes to support his addiction to drugs and alcohol. He is 26. His entire adult life has been governed by addiction. More than his adult life, honestly. In high school, I remember his soccer teammates tracking me down between classes to alert me that he was panicking. Players were being drug tested, and Zach was sure he would test positive — at the time I assumed just for pot, but looking back, the degree of panic might have meant more. I recall hearing about the night he spent in a motel after breaking out of a 30-day in-patient rehab. Then, there was my mom’s sudden decision to bring him along to my college orientation — punishment for getting arrested again. He is 26. His entire adult life has been governed by addiction By the time he was sentenced to his first major stint in prison, he started to get serious about getting sober. He was eventually accepted into an in-patient unit for nonviolent offenders with substance abuse problems, and by the time he was released, he was sober and healthy, having channeled his energy into body-building. But maintaining sobriety was hard — finding a job was hard, walking miles to and from work was hard, and not being around alcohol or drugs was hard — eventually he fell off the wagon again. In July 2014, I was with my parents when we heard he’d been arrested again. My parents had kicked him out of the house for good the previous Christmas. We’d resigned ourselves: if he was going to get help, it wouldn’t be because of us. This past January, two deputies from the county sheriff’s office stopped by the house where we grew up in Belmont, North Carolina. My brother was scheduled to be released in March, and they needed to know if he would be able to live with my parents during parole. "Well, no," my mom said. "We’re moving." Over 200 miles east, outside the boundaries of his parole. Recent media coverage has highlighted the challenges faced by the newly paroled, who must secure the basic necessities of life as quickly as possible — shelter, food, clothes, and an income to pay for all of it — with minimal support. That’s to say nothing of the complications of PTSD, mental or physical illness, or addiction. It is a challenge few people are prepared to undertake on their own; a challenge for which my brother was likely unprepared. Shortly after he was released from prison for the first time, a trip to the grocery store triggered a panic attack. When my mother told me he had applied to a rehab program in Durham, I was relieved, although I wasn’t sure it would last. But this one wasn’t like the 30-day programs he’d been in before. This one lasts two years and includes vocational training. It also meant more silence, since Zach wouldn’t be able to contact us initially. Eventually there would be letters and phone calls, of course, but at first, nothing. The program was called TROSA — Triangle Residential Options for Substance Abusers — and none of us had ever heard of it. So five months after his release I wake up at 5 in the morning and creep out of my parents’ home on the North Carolina coast to drive four hours to Durham to find out what TROSA is.

Much of what we associate with substance abuse treatment in the United States began in the early 1930s. That’s when, for the first time, alcoholism was treated as a public health issue rather than a moral failing. Alcoholics Anonymous, established in 1935, advocated approaching alcoholism as a treatable disease and by the 1950s, the "Minnesota Model" had emerged, incorporating principles of holistic treatment into residential facilities that introduced the now-ubiquitous 28-day treatment model. Eventually, both approaches were adapted to address narcotics addiction. Today, more than 14,000 drug treatment facilities operate in the United States. Addiction is considered a complex disease Addiction is considered a complex disease that lacks a "one size fits all" approach. Treatment typically begins with detoxification and continues in an in-patient or out-patient setting with some combination of pharmacotherapy — the prescription of drugs like methadone to stave off the effects of opiate addiction — and behavioral therapy. Generally, relapse rates hover between 40 and 60 percent, similar to those for chronic diseases like diabetes and asthma. Fewer than half of all treatment facilities provide services such as comprehensive mental health assessments, housing or transportation assistance, and domestic violence services. At first glance these services might seem tangential to addiction treatment, but they may be the key to maintaining long-term sobriety for people who have a mental illness in addition to addiction or — more to the point, in the case of my brother — who have been incarcerated. Durham seems to have avoided the soulless strip-mall aesthetic that dominates other small cities; in the quiet residential area where TROSA is located, massive trees create a green canopy over quaint houses. As I drive through, I mentally make note of street names so I can check real estate listings for domestic fantasy purposes later. TROSA’s campus stretches over 13 acres and occupies a vacant elementary school and a former dairy. I pull up to the security booth and greet a polite, well-dressed young man, who asks my name, announces my arrival, and provides detailed directions to the administrative office. I know without asking that he is a resident of the program — the nature of TROSA means that nearly everyone I will speak to today is a resident of the program. Zach is in the period of limited contact, and though I don’t know where on campus he lives, or what his work schedule is like, I know I won’t see him today. But I can picture him working in this security booth, putting his natural charm and friendliness to good use. In early TCs, group sessions were marked by vicious confrontation and ridicule TROSA is a therapeutic community — that’s National Institute on Drug Abuse lingo for drug-free residential settings that emphasize the role of the community to help addicts change. The first therapeutic community, Synanon, was established in California in 1958. Synanon is now more commonly remembered for its evolution into a cult, but the principles established during its time as a rehabilitation community inspired hundreds of other TCs. In those early TCs, confrontational and aggressive group treatment methods were commonly used; at Synanon and its direct descendants, residents played "the game" — group sessions marked by vicious, often profane confrontation and ridicule designed to expose and weaken barriers to personal honesty — sometimes for hours or days at a time. Modern TCs have evolved away from these methods. Today’s programs combine clinical groups, vocational and educational activities, and community meetings under a rigid structure designed to establish positive behavior and attitudes. They’re different from traditional rehabs in a lot of ways, not least of which is the length of their programs: 18 to 24 months, instead of the traditional 30 to 90 days. And while traditional rehab facilities commonly cost between $15,000 to $38,000 a month, many TCs — including TROSA — provide services at no charge to the patient.

In the administrative office, a petite young woman is stationed behind one of those giant, round monolithic desks granted to every receptionist. Beth is a freckled blonde who I correctly assume is from a nice, upper-middle-class family. She has been a TROSA resident for seven months, a sexual abuse survivor who turned to alcohol and prescription painkillers in college. Her mother referred her to the program. TROSA’s CEO, Kevin McDonald, is imposing beyond his height but maintains a folksy and reassuring demeanor. He’s a military brat, he tells me. His difficult home life bloomed into an early dependence on alcohol, and then, later, heroin. McDonald was facing a 20-year prison sentence for armed robbery when a state supreme court let him begin a lengthy stay at Delancey Street, a San Francisco therapeutic community. "So I go there, and it’s a two-year program," he says. "I started going forward, learning how to communicate a little better, eventually realizing I didn’t have to use my fists and I hated violence. Learning to care about people, letting people care about me, learning job skills, et cetera. So I stayed 12 years." "Learning to care about people, letting people care about me" McDonald eventually began working for Delancey Street, and after helping to establish a facility in Greensboro, North Carolina, McDonald returned to California. He was working in a program for homeless parolees in South Central LA — "It was just about bed counts and getting paid by the government for each bed we kept full" — when a group from Durham came calling. They’d seen Delancey Street and wanted something similar for Durham. The group only had $18,000 to start the program. In 1994, Durham county leased TROSA the Old North Durham Elementary School for $1 a year. Since then, additional housing has been added, in the form of multi-story modular homes on brick foundations laid by residents. An old dairy was converted to maintain a fleet of donated and second-hand vehicles, and now also houses a cafeteria, computer lab, and barber shop. They’re in the midst of fundraising for their next expansion, a medical clinic intended to increase their capacity to care for residents on-site. That’s important since residents can’t leave the campus unsupervised, so every doctor’s appointment requires coordinating transportation and a staff or senior resident escort.

As I begin my tour of the campus, it’s quickly apparent that TROSA’s staff and residents alike are expected to follow and enthusiastically display the community’s values and principles. This includes strict behavior expectations: everyone greets each other when they pass in the hallway, everyone uses sir and ma’am, and everyone stands when someone enters a room. In my brother's letters, he complains of long hours and exhausting work Work is a key component of every therapeutic community, and TROSA’s work assignments extend into the larger Durham community: the organization operates a thrift store and frame shop, moving company, lawn care company, furniture repair business, and Christmas tree lot, all staffed by the program’s 500 residents. According to 2014 tax filings, these operations bring in over $8 million — just over 60 percent of TROSA’s revenues. The work assignments are also a key component of TROSA’s treatment model. Each resident is assigned to a six-person team, with more senior residents supervising. This is intended to help patients learn interpersonal skills, as well as give them work experience. Work assignments may also include vocational training or other education — TROSA helps residents earn their GEDs and some residents enroll in the nearby community college. My brother works for TROSA’s moving company, where he’s earning his commercial driver’s license. In his letters, he complains of long hours and exhausting work, but I hope he is also learning to find value in the trust that’s being placed in him. For years, I’ve quietly avoided leaving my wallet unattended around him; my parents began keeping their valuables under lock and key after he pawned hundreds of dollars’ worth of musical equipment. The fact that strangers are now trusting him to enter their homes and pack and move all of their belongings astonishes me, and I’m hopeful that he won’t betray that trust. Part of me is afraid that it’s misplaced.

TROSA residents earn privileges as they work through the program, and the most obvious is improved housing. At first, residents reside in rooms not unlike college dorms — cramped and spartan, with whiteboards and posted rules. During the tour, I see one resident has carefully laid books between the utilitarian mattress and metal bed frame to create some additional support. I briefly wonder if it’s my brother’s bed; as a kid, the only thing he read enthusiastically was Harry Potter, but he became a voracious reader in prison. Every letter he wrote me included a list of what he had read since our last correspondence, and maybe the best gift I’ve ever given him was a request form for The Prison Book Program, a charity that mails free books to prisoners. But the haphazard collection of spy thrillers and self-help books doesn’t match Zach’s preference for Updike, Vonnegut, or George R.R. Martin. "I didn’t want to be here." After completing their first year in the program, residents move into the modular, prefabricated homes. These homes are subdivided into four-person apartments with separate bedrooms, a living room with a television, a private bathroom, and a small kitchen — although residents are still expected to eat breakfast and dinner in the communal dining hall. Wherever they are housed, residents are expected to adhere to strict housekeeping standards. These sorts of rules chafe my brother, and it’s not just him, either — TROSA staff readily admit new residents struggle with the rigid, rule-driven structure. The last time my brother had his own bedroom, the bed didn’t even have sheets, so imagining him making his bed every morning seems beyond belief. During my tour I meet a young man named Arman. Arman is crisply dressed in a well-coordinated button-down, slacks, and tie — for a brief moment I think he may be one of the counselor trainees from nearby Duke University. He’s been at the program for a little over 17 months, after being suspended from college for stealing to support his heroin addiction. Things got worse from there until his family urged him to seek help at TROSA. At first, he admits, the program was very hard for him. "I didn’t want to be here," Arman says. But after a while he realized, "I was 23, and it was time for me to take control of my life and start helping myself." Three years younger than my brother — but I wonder if Zach has had this breakthrough. He certainly does not want to live the life of an addict, whether in prison or on the street, but is he ready to make the effort to help himself? He’s repeatedly described his struggles to me in a way that implied he was waiting for something or someone to save him. It’s as if he felt that as long as he didn’t want to be the way he was, things would change without him expending effort. Perhaps, as with Arman, he’s realizing at TROSA that he can help himself change.

Paul Nagy, a licensed counselor and addiction specialist, is part of the original group that recruited Kevin McDonald 21 years ago. He’s also an assistant professor in psychiatry at Duke, where he arranged for a partnership between the school and TROSA. TROSA doesn't ask residents to white-knuckle through cravings Nagy is part of the reason TROSA is distinct from other programs: instead of asking residents to white-knuckle through cravings, his team uses the drug naltrexone, which reduces cravings for alcohol and interrupts heroin highs. Medication-assisted therapy is controversial in treatment program circles and not widely used in US rehab facilities. This reluctance is partially due to influential treatment philosophies of AA and NA, which take a broad stance against the use of any substances, including medication, and the attitude that such medication is a "crutch," says Shelley Streenrod, an associate professor at Salem State University in Massachusetts. (Streenrod is not affiliated with TROSA.) Additionally, naltrexone (and other pharmacological treatments) must be prescribed by a physician; not all treatment facilities have staff qualified to prescribe medication. And even if an addict speaks to a physician about treatment, the doctor may not discuss drugs like naltrexone, says Judy Fenster, associate professor in Adelphi University’s School for Social Work. There are legal barriers, as well — many FDA-approved medications for substance use disorders are highly regulated. "Physicians, especially general practitioners, may be unfamiliar with these medications or may not be comfortable prescribing them," Fenster says. Some doctors are reluctant to prescribe medications to addicts, and some people with addictions are wary of taking these medications, she says. And that’s despite research that shows that naltrexone and drugs like it can be helpful in treating substance abuse. TROSA symbolizes a "gradual shifting" from the more confrontational TC model of Synanon and earlier communities, to methods such as motivational interviewing, according to Paul. Motivational interviewing is a counseling approach that avoids direct confrontation, instead relying on empathetic collaboration to help addicts resolve their ambivalence toward addressing their substance use. Despite these new approaches, Paul is careful not to undermine the core foundations of the therapeutic community. Training and work assignments are still paramount, and group sessions and counseling attendance are secondary to completing work assignments. Combined with the small staff, this creates something of a "catch as catch can" environment.

All of TROSA’s specific treatment methodologies have shown efficacy in research reviewed by national authorities. A handful of studies have found that therapeutic communities lessen the likelihood of relapse and reincarceration compared to control groups, at least in the short term. But studies only take you so far; when it comes to any individual addict, it’s more important to consider what environment might suit their needs, Fenster says. TROSA’s internal numbers are flattering: they claim 95 percent of graduates are employed a year after completing the program, and 90 percent are sober. Everyone I’ve spoken to has reiterated that the program is "not for everyone" but the program has clearly met a need in North Carolina: 80 out of the state’s 100 counties are represented (along with out-of-state residents). There’s a 50 percent increase in residents since 2012, and TROSA’s office fields 450 new inquiries a week. "It’s a public policy debacle." Offering services at no cost requires substantial funding and resources, which both Paul Nagy and Kevin McDonald emphasize are extremely difficult to secure — in 2014, only 12 percent of TROSA’s revenue came from government grants or other cash contributions. "[As a country] we spend more money on clean-up — anti-trafficking, incarceration, et cetera — than we do on treatment," Paul explains, "It’s a public policy debacle." Although medical professionals understand that addiction is a disease, addiction is still extremely stigmatized by the general public, Adelphi’s Fenster says. "We tend to think of people experiencing alcohol or other drug addiction as morally or psychologically flawed." This stigma leads to underfunding and other iniquities. Dr. Steenrod adds that these funding issues go beyond government spending, as insurance companies resist covering long-term rehabilitation programs like therapeutic communities despite their efficacy. I never see my brother on my tour of TROSA. Before I head back to my parents’ home, I stop by a fast food restaurant to grab some food so I’ll have enough energy to make the drive. The restaurant is bustling with employees of the nearby medical facilities, families desperate to preoccupy their children with a ball pit, retirees, and a couple patrol cars’ worth of sheriff’s deputies. People whose lives may not be as governed by addiction as TROSA’s residents, but who may have shopped at the thrift store, or hired the moving company, or decorated a Christmas tree from TROSA’s lot in their home. In a small way, they have given Zach an opportunity to heal, just as much as the staff and residents of TROSA. There are tiny threads of connection that stretch from them, to my brother, all the way to me.

"There are my two angels." My mom has caught me staring at the 5-foot-tall oil painting of my brother and me at two and four, respectively, that she commissioned online from China — a size just small enough not to qualify as outlandishly garish. "I’m glad you went to TROSA," she says. I have slowly, painfully hardened my heart against false hope She wants to know her son is in a place that can help him, or at least wants to help him, if he is ready to be helped. After his formal acceptance into TROSA but before his release from prison, he told my parents that other inmates criticized the program when they heard he was going, told him it wasn’t worth it. My parents counseled him not to take stock in the opinions of people still caught in the cycle of addiction and incarceration, but the anxiety was contagious. Of the group he came in with, only three are still in the program. Everyone asks me if I think this time, in this place, my brother will finally overcome his addiction, or learn to manage it, or learn to live his life fully. I don’t know, and I don’t want to guess. For over 10 years, I have slowly, painfully hardened my heart against false hope, diligently managed my expectations, tried to learn what to do or say that would do more help than harm. I’ve found that the best way to prevent another heartbreak is not to allow yourself to hope for anything.

That feeling solidified in December 2013. That was when my parents asked Zach to leave the house for good. Here’s what I didn’t say, earlier: by then, my brother’s drinking had become constant and unavoidable, and when he made an obvious attempt to sneak whiskey up to his room, we confronted him. I made a grab for the bottle; he twisted my arm away hard enough to leave a bruise. Then, he left. He sent a letter to me later, apologizing even though I wasn’t angry. We haven’t communicated directly since. I make him feel ashamed of himself, I think, and I don’t know how to tell him he has nothing to be ashamed of. So I spend my time tiptoeing after his ghost; interrogating my parents for every detail of their conversations with him, trekking to Durham to find out if he’s in a good place. And physically, yes, I think he is in a good place. As for his mental state — well, the thoughts of a ghost are unknowable. But I hope that he is.

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