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Wilson M. Sims| Longreads | September 7, 2023 | 16 minutes (4,665 words)
My watch vibrates, my cell phone chimes, and my computer monitor signals a new notification. It’s the quarantine phase of the pandemic and I fidget with a highlighter; I pop the top and recap it. Pop and recap again. There’s a brief message in the body of the email and a six-digit figure in the subject line. I can hear the microwave venting in the kitchen. I can smell frozen taquitos defrosting. The number in the subject line is a client ID and the message informs me this client would like a callback, “ASAP.” I stretch my neck from side to side, open a file that corresponds with the client ID, and promise myself a cigarette after two more calls … or maybe just one.
Officially, I’m a Senior Admissions Specialist, employed by a behavioral health company, and my professional objective is to assess the mental health needs of prospective patients and connect them with appropriate forms of care. Unofficially, I’m an addict who stopped doing drugs and started taking these calls. I’m at a desk I bought for a dollar at an estate sale, in a house with roommates I met in rehab, beside a dog who’s rescuing me as much as I am her. I like to think my work is a personal debt being paid down, a labor of love that reimburses in personal worth—and sometimes it is—but more often it seems like I’m an obstruction enforcer or the embodiment of a taunt; a recovering alcoholic who explains to callers and their families why they can’t access or afford their chance to recover.
According to the most recent Substance Abuse and Mental Health Services Administration (SAMHSA) survey, more than 43 million Americans need treatment. Ideally, whenever one of those people or one of their family members calls someone like me, their call would accomplish any necessary crisis diversion, then insurance verification, estimation of treatment costs, approval of medical and psychiatric eligibility for treatment, transportation arrangements, and admission scheduling. Ideally, there would be no need for us to save each other’s contact info on our personal phones. No need for callers to know what days and times I’m in A.A. meetings, and no need for me to know when callers are watching Survivor. Ideally, callers would get what they call for when they first call, and, ideally, callers would be ready to be helped when their calls are answered. “Ideally” is infrequent, though.
An infrequent call is one that leads to someone finding and accessing the treatment they need, and that treatment producing an outcome the patient desires. Infrequent calls become memoirs, movies, or the basis for future treatment models, but fail to speak for the majority. What’s common is one call becoming many; a series of conversations on the subject of obstructions; a pattern of apparent progress always interrupted by an abrupt “but.” The numbers show only around 7% of Americans in need of substance abuse treatment receive it. That’s over 40 million substance abuse sufferers with no inpatient or outpatient treatment from a hospital, rehabilitation facility, or mental health center. I’m not a public policy expert, but that seems like a problem.
I’m an obstruction enforcer or the embodiment of a taunt; a recovering alcoholic who explains to callers and their families why they can’t access or afford their chance to recover.
Personal absolution might be an oasis in the desert, but in the bleak landscape of addiction treatment, it can be helpful to have a reason to walk. I want to serve and save lives to justify my own, and I’m aware of how wounded this thinking is, but I was born into privilege and then spent most of my life expecting others to serve or save me. Before my story is over I need there to be more evidence of my social contributions than my crimes of action and inaction, and by my count, I won’t get there by going one call at a time. Not while 93% of the people who need what I got aren’t getting it.
So I take call after call and I disregard the sensationally infrequent successes. Instead, I inventory obstacles and categorize them based on cost: What barrier prevents the most substance use sufferers from being admitted to treatment?
Ambient acoustics play from my computer speakers. I keep the bedroom door closed while I’m working, but I can still hear my roommates. One opening and closing the microwave, then clapping a plate onto the countertop. The other, a musician, ad-libbing a song about the first roommate’s penis. Laughter, applause, and synonyms for the word “small” bounce against my bedroom door.
Our neighborhood is cookie-cutter suburbia. White trim, matching mailboxes, and a whole lotta suspicion about the house on the corner where all those men live. We keep the yard tidy and we wave whenever we’re walking to the mailbox, but our shitty cars spill from the driveway to the curb and moms cough performatively if they walk by while we’re smoking cigarettes on the porch. I don’t like it, but I understand it. We’ve got a lot of tattoos, we all work out like we’re missing some crucial endorphins (probably are), and our sponsees come over sometimes—and are usually in worse shape than we are. It probably looks like our sober house is actually a crack house. The neighborhood’s nervous about all of us adult men, but what we’re afraid of is their opinions.
Shame haunts all addicts. Should our struggles with substances become known, we might be hurt by professional, personal, or social consequences. It’s why the identities of my callers and what we say to each other on the phone is protected by patient privacy laws. And thank goodness! Nobody would talk to me if there was a chance I’d tell their boss about their addiction or use their story as a public address apparatus. Individual anonymity is essential for safety and dignity, but protecting personal privacy can come at the cost of potentially helpful public awareness. If all my work calls were broadcast I suspect there’d be little mystery as to why 93% of people who need treatment aren’t getting it.
So what follows is a conversation that never happened but is also always happening, a composite-made fiction of a father, mother, and daughter, who I’ll call “Emma.” A reflection of the thousands of calls I’ve answered in my career. A story that can belong to everyone because it doesn’t belong to anyone.
Let’s say Emma’s a woman; she’s a daughter and an adult, and she’s not doing well. Maybe it was nature or maybe it was nurture or maybe it was both, but for years she’s had issues with feelings and substances. Her family is worried, and a few days ago Emma’s father started calling phone numbers. Maybe he found the numbers online or maybe an old hunting friend who “has a brother with problems” texted him a contact card. Maybe the father of this sick daughter called one phone number or maybe he called half a dozen—but however it happened, let’s say it’s me that answered.
He wanted to make sure he and his wife could afford the cost of sending their daughter to rehab. He told me his daughter couldn’t handle another setback. I told him I’d do my best and verified that his health insurance covers Emma and that the policy is in network with the facility she wants to go to. He said they’d find a way to pay the deductible, that he’d talk things over with Emma, tell her the good news, and call me right back.
Normally the next thing that happens is—nothing. For days I make follow-up calls and send texts, but for days I don’t hear anything back. Someone like Emma still has a chance, though. The first conversation with her father cleared a major stumbling block.
A reflection of the thousands of calls I’ve answered in my career. A story that can belong to everyone because it doesn’t belong to anyone.
The average price for residential treatment is $57,000, and though the idea is that insurance mitigates these costs, around half of the nation’s insurance is tethered to employment (working is difficult when living seems impossible). So, for uninsured callers, the equation for mental health treatment can read like this:
no health = no job = no insurance = no treatment =
no health = no job = no insurance =
no treatment =
no health
Emma is lucky, though. She’s spared this equation not by her parents’ love, nor by some past foresight or wise decision-making, nor by trying really, really hard. Emma is lucky because she happens to be young enough to be covered by her father’s insurance. She’s lucky she has a father. She’s lucky she wasn’t born earlier or addicted later, lucky legislation determined she should be so lucky, and lucky the American word for “systemic benefit” is “luck.”
But even though Emma is lucky to be covered, lack of insurance isn’t the biggest barrier between need and treatment.
Emma may be covered by her father’s policy, but “covered” belies the financial exposure she or her family might face. Almost all insurance policies include a deductible, and the insurance policy will not contribute toward residential health services until the deductible has been paid by the individual or family—a modest average of $1,700 for individual coverage and much more for family policies. Each plan also harbors potential carve-outs and co-insurance, obscure fees, and inexplicable coverage gaps.
When a family or individual calls someone like me and asks, “How much will it cost?” there’s no answer that’s both precise and honest. If I call the policyholder’s insurance company, they won’t have an honest and precise answer, either. Only questions: Will the treatment seeker be diagnosed with an illness that requires expensive or inexpensive medication? Will treatment therapists find it clinically appropriate to recommend an outpatient program as a follow-up to residential treatment? And how frequently does the policyholder plan on catching a cold or spraining their ankle while on the property?
Luckily for Emma, her father can cover the extra costs. But out-of-pocket expenses aren’t the biggest problem, either.
She’s lucky she wasn’t born earlier or addicted later, lucky legislation determined she should be so lucky, and lucky the American word for “systemic benefit” is “luck.”
There’s also “insufficient criteria.” A client may have insurance, financial resources, and wish to go to a residential program that happens to be in-network with their policy, but still be denied coverage because an insurance company does not deem it required. Treatment seekers might report being severely anxious, lonely, or depressed, but feelings carry little weight. Feelings not accompanied by material or physical consequences (arrests, job loss, etc.) are not, according to many insurance policies, justification for residential treatment. Insurers want proof rather than professing—and the same is true for residential substance abuse treatment.
If a policyholder drinks a bottle of vodka every day and as a result of their drinking is arrested, then that policyholder will likely remain sober for as many days as they are incarcerated. The irony is that after 14 days of being in jail, they’ve likely been sober too long for their insurance company to deem residential treatment necessary. Similarly, if someone who mainlines heroin somehow detoxes on their own and seeks to enter residential treatment 20 days after they last shot up, they too will likely be denied coverage because they haven’t used heroin recently enough. Addicts and alcoholics cannot prove their need for treatment by requesting it. They’ve gotta bleed and pee for it. And even that might not be enough.
Substance abuse is Russian Roulette and coverage criteria lengthens the game. Each illicit drug substance (cocaine, meth, heroin) is more and more likely to be laced with fentanyl, and fentanyl kills. Each drink is one too many for the already beleaguered liver, that much more fuel for the automobile driver. And each use of meth or crack is a dice roll with the irreplaceable faculties of the brain. But despite the stakes, you must use the right amount of the right type of drug frequently enough for treatment to be covered. The person with a mental health disorder must prove that they have a history of wanting to die and that their desire to die manifests in the correct thoughts and behaviors, but, of course, they must not yet be dead. We must have evidence of financial losses, arrests, and medical deterioration, but we must also pay the deductible, have court approval, and pass an admission assessment. Substance abuse disorders and mental illnesses are identified by the very symptoms that preclude their sufferers from escaping them.
Addicts and alcoholics cannot prove their need for treatment by requesting it. They’ve gotta bleed and pee for it. And even that might not be enough.
While these issues prevent some callers from being admitted to the programs that are covered by their insurance, we’re frying bigger fish, so Emma gets lucky again. She’ll be considered clinically appropriate for treatment, so long as she’ll talk to me on the phone. If she’ll speak with me, then she’ll get to live in a bungalow with other women who have similar diagnoses. In addition to meeting with a psychiatrist and regularly receiving Cognitive Behavioral Therapy and Dialectical Behavior Therapy, she’ll get programmed activities that offer supplemental social and expressive therapies. One such modality is equine therapy, and while it sucks to go to rehab, it sucks a whole lot less if there are horses. Horses are awesome.
But even though Emma is lucky enough to be the right amount of drunk recently enough, there are more substantial impediments than strict coverage criteria.
Statistically speaking, me and the other guys living in the house are miracles. The guy eating taquitos went from being the golf pro at a prestigious country club in Miami to stealing copper from abandoned homes in Kentucky. The musician grew up without parents, in a trailer that had holes in the floor. (He says it’s better to have no floor at all.) The third roommate plummeted from a D-1 track scholarship to a long tour of rehab row; four rehab stints the year he got sober. And now all of us have valid driver’s licenses and employers who report their earnings. I’ve kept a dog and two plants alive for two years, the musician is making money with music, the track star is engaged to be married, and the former golf pro is scaling the ladder in the local comedy scene.
Being a miracle doesn’t always feel like being a miracle, though. Taquito guy never refills the water compartment of the Keurig, I swear the musician thinks there’s some automatic mechanism attached to the dishwasher that returns silverware and plates to the cupboards, and transitioning from penis songs to client calls is like being in an emotional trainwreck. But mundane annoyances and balancing work and relationships is the miracle. We get to feel every single pain in the ass life has to offer; sometimes we’re even grateful for them. I rub a hand up and down my face, increase the volume of the “ambient acoustics” playlist to a level beyond ambient, and punch numbers into the work phone.
Let’s give Emma her chance to heal with horses and say Emma’s dad eventually answers my call. Emma’s mother joins the line, and in 20 minutes they try to explain every second of their daughter’s life: She was a lovely little girl; the apple of their eye. She cooed and giggled and had a nose like her grandma. It was no surprise that she grew into a straight-A student. Not a shock when she became a peer-tutor or junior lifeguard. But the lifeguard director was a problem. Or maybe it was a teacher? They aren’t sure. All they know is what Emma has told them: There were some texts. Some drinks and pills and questions of consent. The definite consequences of rape.
It’s a common story among callers, but each person is speaking of their own distinct tragedy. The information is relayed in sobs and sighs, and then the speakers gather themselves and continue in stops, starts, and contradictions. Like Emma’s parents. That friend of hers, Cheryl, is a problem, says the father. No, Cheryl isn’t a problem, corrects the mother, she’s Emma’s sponsee. The pharmacy keeps messin’ up her medicine, says the mother. The boss at her work got rid of her just for speaking her mind, says the father. The rehab in Florida she went to wasn’t helpful at all, they both agree, all it did was treat her like an animal. Now she’s saying she’d like to turn her brain off, says her father. Not suicidal, says her mother, but our trashcans are full of bottles and she’s said she wishes “it would all just stop.” She’s worth helping, they both say.
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And when they ask how I got healthy, I know what they want to hear: I was sick and addicted until my parents made me go to rehab, then I went to treatment and joined A.A. and now I’m sober and happy. It’s the story of a promise. A suggestion made by the hashtag #RecoveryIsPossible. The premise is I was once in Emma’s position and now I’m not. The promise is that this means the same can be true of Emma, too. My story happened. I was jobless, estranged from family, financially bankrupt, chemically addicted, and suicidal. Now, I’m none of those things. Now, my life makes the lives around mine better. But this job has taught me I’m no promise. I’m an exception, aided to stability by systems that point to my story as validation for their rule. To be well enough to tell a recovery story like mine is to be one of the very few who are made well by this system of care.
So I tell the parents I was lucky. That I caught some good breaks and some bad ones, that I’m grateful to be well enough to try and help people who are sick like I was. But when I ask if they’re willing to wake Emma from her nap so I can speak to her, they say they’re not. Sleep’s been a big issue, says the father. And we’re trying to treat her like she’s an adult, says the mother. We watch her pills and sneak sniffs of her breath and we appreciate you checking in with us, they say, but she’s finally asleep and we’ll have her give you a call first thing when she wakes up.
I have two new text messages and one new email. The first text is from a sponsee I’ve been working with for a year and a half, the second text is from an ex-girlfriend who I’m still sleeping with, and the email is from a coworker to one of our partner facilities, with me copied.
The sponsee says, “What’re you wearing?” the woman says, “I’m with Meg and we’re tequila-ing,” and the email says, “Anything available for female MH SAME DAY?”
The sponsee’s joke means, “Can you call me?” The ex’s text means, “In about an hour you’re gonna want to be in my apartment.” And the email means, “Is there an immediate admission spot available for a female Mental Health client?”
My story happened. I was jobless, estranged from family, financially bankrupt, chemically addicted, and suicidal. Now, I’m none of those things.
My dog’s head rests so close to my foot I can feel her breath through the mesh of my shoe. I keep my feet planted and arch my spine until the back of my head rests between my shoulders, mouth hanging open, the room upside down and the pressure in my vertebrae popping.
On the far wall gray curtains seem to rise like columns and a painted boy and horse nonchalantly fall headfirst towards the sky of their canvas. The painting’s frame is gold and ornate, inherited from a grandmother whose house made a more appropriate home for such grandeur. Here, though, the painting looks so conspicuous my roommates at first thought it was a joke, then asked who I stole it from. One of their girlfriends made a face and said, “That’s…a choice.” But I don’t care how wrong it looks. I’m trying to let go of the need to do everything right.
The frame is a square island of extravagance in a sea of efficiency. Beneath the bathroom sink sits backup shaving cream, deodorant, toothpaste, and shampoo. I pay rent seven to 10 days before it’s due and keep all my important papers in folders with tabs labeled, car, court, taxes, bankruptcy, or bills. In an Excel document, I make a schedule for each coming week, and in a Google Doc I inventory my daily conduct, all minutes planned and then accounted for, exactly. Addiction may have abducted me, but recovering from addiction made a machine of me. A machine whose oil and grease—things like meditation or the gym—are assignments I never skip. I spend every moment stocking and scheming against the small slip that might lead to wasting the life I’ve been gifted, but the painting and its gaudy frame are blessedly useless: a rebellion of frivolity. A reminder that I won’t survive the payment of my moral or financial debts unless I learn how to let my humming in the shower, or my drumming of the steering wheel, turn into something more. But moderation hasn’t seemed to be my strong suit and I’m afraid of the risks that can come with “fun,” “play,” “freedom,” and whatever other pleasant feelings the movies mean to communicate with shower singing. These are opportunities for errors, and for me, the cost of a mistake is, at best, re-becoming The Caller.
I text the sponsee, “Emergency?”
I text the woman, “Working [melting face emoji].”
I ignore the email.
It doesn’t matter if the last available admission spot is currently being reserved or if there’s a waitlist that’ll last a month. It doesn’t matter where there are or are not treatment beds available, because tonight is one of those shifts in which I’ve answered 40 phone calls but not one of them was from someone who could admit.
What I didn’t tell Emma’s parents is their daughter is probably lying when she tells them about being someone’s sponsor or going to an A.A. meeting. I didn’t tell them their daughter is absolutely abusing her meds and probably drunk on a daily basis. I didn’t tell them the rehab in Florida may not have been as bad as their daughter reported it to be, or that the friend who they think is a sponsee is probably a fellow in active addiction. I didn’t tell them their daughter’s path to sobriety, as a woman, would be marred by obstacles I’d never faced, or explain how I benefited from contemporary treatment modalities being a reflection of my white/western household culture. I also didn’t tell them I tried harder and more consistently than most people are willing to, or that recovering has, at times, brought more loneliness, pressure, and grief into my life than my illness ever did.
I didn’t tell Emma’s parents how few treatment alumni maintain sobriety, I didn’t tell them not to spend money they don’t have on an unlikely gamble, or that their daughter is coherent and awake, merely performing sleep from her bed. I didn’t tell them that she might be avoiding treatment because of recovery, and I definitely didn’t tell them that she could have a point. That recovering costs, too.
I also didn’t tell them I tried harder and more consistently than most people are willing to, or that recovering has, at times, brought more loneliness, pressure, and grief into my life than my illness ever did.
The cost of recovering is the pressure of the financial investments, multiplied by a lifetime of damages done and suffered. The cost of recovering is sleep, Super Bowl commercials, and the innocence of certain scents. The cost of recovering is safety after surgery. It’s losing the hour scheduled for “happy,” the self-prescribed solution to years of sad, and the pleasure of eating after an edible.
The cost is an exchange of wedding toasts for funeral juice, your name for your anonymity, your denial for your disorder. The cost is loving/missing/mourning those who didn’t recover, and the cost is wondering what you are and what will you do about it. The cost is culpability, responsibility, and a new duty. The cost is a gift that must be given.
And given.
And given.
But the costs of recovery aren’t the biggest barrier to treatment.
Emma and her parents are all aware of her financial ruin, her professional inability, social severance, substance abuse, and suicidal ideations, but Emma and her parents are all performing various forms of not-knowing.
Emma already went to a rehab in Florida. And some months after that attempt proved unsuccessful, her parents did call me for help. But if Emma is unemployed and cut off from all former relationships, spending days in a bed in her parents’ home, then what is it that prevented this family from seeking treatment sooner, from opening the door and giving her the phone?
Not-knowing.
Not-knowing is like puddle-water filling footprints the moment there are no feet present; it’s an inclination impervious to previous moments or days that were free from denial; it’s the most significant barrier between prospective patients and behavioral healthcare. Yep. More than a lack of insurance coverage, more than the costs or requirements of either insurance or recovery. The biggest problem is choosing not to see certain problems.
Ninety-six percent of Americans deemed to be “in need of treatment” are not receiving it because they “feel it is not needed.” And these 39 million people are not folks who got a little sloppy at the office Christmas party once. They aren’t your friend who smokes some weed. These 39 million people have—within the last year, as a direct result of substance abuse—suffered major health problems, physical disability, or major consequences at work, school, or home. For these 39 million, substance use has become abuse, and for most of them, this transition has occurred before the willfully blind eyes of familial observers who prefer comfort to confrontation.
Yes, they may have admitted, at some point, to someone, the presence of addiction. Yes, some may have attempted some form of treatment in the past. But not-knowing is an almost automatic practice that can’t be relegated to the past by a one-time acknowledgment; it’s as active and relentless as addiction itself, and only treatable with regular attention.
For these 39 million, substance use has become abuse, and for most of them, this transition has occurred before the willfully blind eyes of familial observers who prefer comfort to confrontation.
In 12-step recovery, we introduce ourselves by sharing our name and the name of our addiction. In a single meeting, I might say “I am Wilson and I am an alcoholic” five times within 30 minutes. The amount of repetition may seem absurd but experience has taught us that we have a disease that tells us we don’t have a disease; that the cure is knowing we haven’t been cured. So no matter how many days or years may have passed since our last drink or drug, and no matter how strongly we feel that we are fine, we stave off participation in addiction by admitting awareness of it into our presence.
Not-knowing protects all of us, addicts or not, from minute-by-minute second-guessing of our own answers to existential questions; it allows us to see a sunset without considering the smog, to worship without wondering if we’re wrong. Applications of ignorance can be essential for a little bliss, but our not-knowing isn’t intermittent. It’s highly consistent.
Are you able to answer questions like “What might I be wrong about?” or “Could they be right about…?” How frequently are you willing to do so? This is the sort of acknowledging an addict and their family has to undertake daily. This is the treatment for a sickness that says it isn’t.
Every barrier to healthcare matters. It’s easier to see a need when the solution is $6 than it is to see a problem that costs $60,000 to fix. National not-knowing doesn’t make addiction or mental illness. Genetic predispositions and traumas do. But nothing inhibits recovery from mental illness like not-knowing does. And when denial is socially pervasive and relentlessly practiced, it should be no surprise that people like Emma or her family find it hard to admit and admit and admit.
I pick up, uncap, then recap a highlighter. Red lights blink across my work phone. I have two new text messages, one from the sponsee and one from the ex. I have another email, a response from the treatment facility for me and my coworker. I need 100 simultaneous cigarettes.
Wilson M. Sims is a Behavioral Health Worker based in Nashville and South Florida. His work is forthcoming in Witness Magazine and he was recently published in The Florida Review. He is the winner of The Lascaux Prize in Creative Nonfiction (2021) and his memoir is under construction.
Editor: Carolyn Wells
Fact-checker: Julie Schwietert Collazo
Copyeditor: Peter Rubin
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