1.

Sohan

“I can get off it, but I can’t stay off it.” Sohan was 43, and he was talking about alcohol. He
liked to say that throughout his adult life he had been successful at two things—drinking and
selling insurance. Now he was having trouble with both. Sohan was the second of three sons
born to parents both of whom were attorneys.

His brothers had been excellent students. Sohan was bright, but he had been hyperactive and
the class clown. In school, he had never been able to focus his attention well enough to
excel at anything but physical education. To please his parents, after high school Sohan tried
a semester of junior college. It was worse than high school; the only thing that kept him going
was guilt. Whereas his older brother was admitted to law school (with honors at entrance),
and his younger brother mopped up the prizes at the state science fair, Sohan felt almost
joyful when his birthday was that year’s fourth pick in the national draft lottery. The
following day he enlisted in the Army.

Somewhere in his schooling Sohan had learned to type, so he was assigned to his
battalion’s administrative section. He liked to say that throughout 4 years in the military,
he never fired his weapon in anger. By comparison with some of the older men’s
alcohol use, his drinking was moderate. Although he had about the usual number of
fights, he managed to avoid serious trouble. When he left the service at age 22, he had held
onto his sergeant’s stripes through two tours of duty in Vietnam. After that, life suddenly got
serious. Working part-time after hours in the post exchange, Sohan had discovered that he
was a natural salesman. So it had seemed a logical move to take a job selling life insurance. It
also seemed sensible to marry the boss’s daughter. When 2 years later his father-in-law died
suddenly, Sohan became sole proprietor of the agency.

“The business made me, and it ruined me,” he said. “I made a lot of money having lunch with
people and selling them large policies. I told myself that I had to drink with them in order to
make a sale, but I suppose that was just rationalization.” As time went on, Sohan’s two-
martini lunches turned into four-martini lunches. By the time he was 31, he was skipping
lunch completely and nipping throughout the afternoon to “keep a glow on.” At the end of the
day, he was sometimes surprised to see how much had disappeared from the bottle he kept in
his desk drawer.
The past year had brought Sohan two unpleasant surprises. The first came when his doctor
informed him that the nagging pain just above his navel was an ulcer; for
the sake of his health, he would have to stop drinking. The second, which in a way
seemed worse because it injured his pride, occurred one afternoon over lunch. A longtime
client of the agency apologetically said that he would be taking his substantial
business elsewhere; his wife didn’t feel comfortable that he was “doing business with a
lush.” Thinking back, Sohan realized that there had been several other, less blatant instances
of customers departing the fold.

The result had been his resolve to quit, or at least to reduce the amount of his
drinking. (“Quitting is easy,” he remarked ruefully. “I did it twice in 1 month.”) At first
he promised himself he wouldn’t drink before 5 p.m.; that proved impractical, and he
later amended it to “around lunchtime.” With the level in his desk drawer bottle receding
as fast as ever, Sohan decided he would try Alcoholics Anonymous. “That was worse than
useless,” he explained. “The stories I heard from some of those people made me feel like a
teetotaler.”
A comment made by his wife eventually brought him in for evaluation. “You used to drink to
have a good time,” she told him. “Now you drink because you need it.”

By the time Sohan sought help, he was drinking the equivalent of nearly a pint of
hard liquor per day. He declined the offer of a brief hospitalization to detoxify, and
instead began an outpatient withdrawal regimen of decreasing doses of a benzodiazepine. He
was asked to return in 3 days.

On Sohan’s next visit, he looked gray and unhappy. He signed in at the registration desk
with a wobbly scrawl, and his hand shook as he reached out an arm to have his
blood pressure and pulse taken. Each of these vital signs was elevated.
For 3 days Sohan had drunk no alcohol at all. Beginning the second morning, he
had felt increasingly anxious—a sensation reminding him of his first night in Vietnam,
when he had awakened to the booming of howitzers. His anxiety grew throughout the
day. Although he was exhausted by bedtime, he hardly slept at all. When he arrived 4
hours early for his clinic appointment, he admitted that he had taken none of the medicine he
had been given. “I wanted to do it myself,” he explained. Over the next several days, Sohan’s
withdrawal symptoms abated. Within 2 weeks, he no longer needed the medication.
However, because he felt strongly tempted to drink when he was having lunch with clients,
he requested disulfiram (Antabuse) therapy. Three months later, Sohan was still taking
disulfiram and still hadn’t touched alcohol. He attended at least one Alcoholics Anonymous
meeting each day. He had rescued his insurance business from the doldrums and had even
persuaded two of his former clients to return with their business. However, he admitted that
he occasionally felt acute episodes of anger when he wanted a drink.

2. Rachel Antony

In one of Rachel Antony’s earliest memories, she was 4 years old and sitting on her
grandfather’s lap. She would rest her head against his soft old cotton sweater. He would
wrap his arms securely around her, and she would cling to his neck. Also clinging to
him was a particular smell that she always associated with her grandfather. It wasn’t until she
was a teenager that she realized what it was: beer.

By the time Rachel was 10, she had watched in horror as the old man died by
degrees of cirrhosis. Then, in her teens, she saw how her father’s drinking wrecked her
parents’ marriage. In college, when she discovered that two glasses of wine would ease her
chronic sense of tension, she promised herself that she would use alcohol and never let it use
her.
Accordingly, she had evolved a set of rules to limit her consumption. She allowed herself
only one drink before dinner, and never more than three in a day (except on weekends and
vacations, when she could have four). From her father’s unfortunate example, she had
learned: Regardless of the occasion, never drink during work and never allow “extras.” Even
on her 22nd birthday—which was also the day she married Antony, the young salesman in
her father’s office—she had only four glasses of champagne (just enough to maintain her
customary comfortable glow).

Despite her control, Rachel had had two lapses. The first had occurred 12 months earlier,
when she became pregnant for the first and only time. Although she wanted a child, she took
the precaution of having an amniocentesis. When it revealed that she was carrying a baby
with Down syndrome, she gulped several extra drinks and drove around while deciding what
to do. A Breathalyzer-measured blood alcohol level of 1.2 landed her in traffic court just 1
week after the abortion.

Her second arrest for driving while intoxicated had occurred 6 months later, when she lost her
self-control once again after her mother died of Alzheimer’s disease. The day Antony entered
treatment was therefore only the third time he had ever known his wife to be drunk. Rachel
accompanied her husband to his second clinic appointment. She had been worried about
Antony for several months, and when his agitation kept them both awake most of that night,
she had gone down to the kitchen and poured them each a drink. When he refused his, she
drank it for him. Then she lost count and had a couple more.
“Anything was besher—was better than what he was going through,” Rachel told the
clinician that morning. After correcting herself, she spoke slowly and deliberately. On the
spur of the moment, Rachel had decided that she should accompany Antony to his
appointment, to be sure he didn’t get into trouble. They had taken her car, and she had
insisted on driving. Antony hadn’t dared remind her what had happened on the other
occasions she had driven after drinking. Fortunately, traffic was light, and her only difficulty
was that she needed two extra tries when parking in an unusually long space at the curb.

As Rachel entered the clinic building, however, she stumbled and might have fallen if
someone had not grabbed her elbow and steadied her as she wobbled into the waiting room.
She fumbled with the large buttons of her coat until her husband undid them for her. She then
slumped into a chair where, with her coat thrown over her, she dozed until they were called
into the clinician’s office.

3. Laura

Laura is a very successful businesswoman in the high-stress high-powered world of corporate

finance. She has been referred to you by the company’s employment assistance program.
Laura presents herself as a no nonsense business professional. She is frank and honest about
the events that has brought her to your office. Laura tells you that although she tells herself
that she will only have one or two glasses with dinner, she usually finishes the whole bottle.

“About five years ago I started having trouble sleeping and started to take a
tranquilizer (5 mg Valium? ) I normally take one or two pills every two to four times a
week to help her sleep through the entire night.”

In the morning she drinks at least 3 to 4 cups of coffee daily, even on the weekends. She
noticed that her sleeping problems developed around the same time her Dad died. He was
only in his early 50’s and they were very close. His death hit her hard and she says she
wanted to give in to a big depression. However, she fought it and lost herself in her work. She
makes it a point to work out at least three times a week in the morning before going to work.
In addition to the above medications, Laura is also prescribed Xanax? as needed for panic
attacks and diet pills (amphetamine congeners) to control her weight, a problem she had since
she was a child. Over the last year she has become more reclusive. She can barely make it to
business dinners and after-work functions. Lately however, she has noticed that she has been
steadily increasing her use of wine. Before, she would only have a few glasses with dinner
but now
“....more often than not I finish off the bottle before going to bed. I just can’t seem to
stop. A lot of times I will come home and tell myself that I’ll only have one glass and no
more but by the time I go to bed, the bottle is empty and I’m deciding whether I should
open another or not. I never used to drink to excess or take anti-anxiety medication
before. Now I can’t seem to stop drinking or taking these ‘downers’ at social events. I
can’t seem to control when I take them and things are happening that I’m not too
happy about. Of course the alcohol adds to my weight problem which then causes me to
take more of my Redux. Then I have to increase my Xanax to calm my nerves and also
take my Valium to make sure I get a full nights sleep. It has become a very vicious
circle. All this has been going on for about a years but last week put the “cherry on the
pie.”
Laura tells you that last week she was to meet the firm's top client at a business luncheon. She
could not get out of bed that morning. It took all her willpower to get up and get dressed. As
it was, she was still 20 minutes late, "which is inexcusable." She was so nervous and sick she
had to excuse herself in the middle of her presentation. In the bathroom she took another
Xanax? to calm her nerves. Then at the luncheon she could not stop herself from ordering
several glasses of wine and had to be assisted to her car after the meeting was over.

"My client spoke to my boss and staff and then canceled his account with me. The next
day I met with my boss and he recommended (ordered) I make an appointment with our
EAP program (or be terminated.) I’m really scared. Work is all I have. I can’t afford to
blow it. Do you mind if I smoke?"

4. Varghese

Varghese is an 18 year old single male who was born in Bangalore, where he still lives with
his mother and his brother. His dad is a sales rep and is on the road during the week.

“When he’s home on the weekend he just drinks and watches the ball games on TV When he
gets drunk he yells at me and my mom and throws shit around the house. He drinks all the
time that he’s home but he can’t hold his booze. Like he’s a total lightweight. Mom also
drinks. Watch out when they both get ‘lit.’ Man, the fur really flies. We’ve had the cops out
several times. I just take off when they start gettin’ into it. I started drinking and smoking
when I was 13, in the eighth grade. It was a total drag, not that any of the other grades were
any better, but all the kids were talking about high school and the classes they were going to
take, and me, I was just trying to figure out were I was gonna get money for my next pack of
cigarettes. Now I smoke about a pack a day, plus a couple of joints too. I have a cup of coffee
in the morning before school and that’s it. At night I’ll drink 3 or 4 beers plus a few shots of
vodka. On the weekends is when I really get down to partying. I’ve played around with lots
of stuff. You know, trying to see what’s out there. I’ve tried pot, coke, mescaline, XTC,
mushrooms. I’ve even shot up a few times. It’s no big deal. When I’m partying, I like to mix
things up a bit. Maybe do some tequila and mushrooms, depends on what’s going on and
who’s around. If I drink too much I black out. I’ve even OD’d a few times. But, hey, it wasn’t
any big deal or nothing. I do like speed though. If any drug is my favorite, aside from
cigarettes and coffee, it’d be ‘speed.’ I saw a doctor when I was eight. My folks took me.
They said I was out of control. The doctor said I had attention deficit disorder and gave me
Ritalin? . It helped a little, I guess. I don’t know much about it. Right now, except for
partying, I don’t take any medication. Then there’s my brother, a complete math ‘geek’.
Always gotten good grades, never been in trouble; responsible, dependable, healthy and
clean. He’s a parent’s wet dream and I’m his evil twin brother.”

5. John peter
“You got a candy bar on you?” John peter shambled into the interviewer’s office and
slumped onto the sofa. He flicked a lock of hair back across one shoulder of his torn denim
jacket. “I know it’s only an hour since breakfast, but I’m really hungry.”

At age 27, John lived on general relief and was often homeless. In the hills of northern
India where he grew up, the principal cash crop was marijuana. For the first several
years since leaving high school, he had worked at its cultivation and marketing; more
recently, he had been more or less exclusively a consumer. Now he had been referred to the
mental health clinic by a judge who had grown weary of his repeated courtroom
appearances for possession of small amounts of marijuana. John volunteered that he
had enjoyed a joint in the alley outside, just before coming in for his appointment.

John wasn’t especially unhappy about being evaluated; he just didn’t see much need for it. He
required very little to live on. Whatever his relief check didn’t cover, he earned by begging.
He had his own corner in the business section of town, where for 6 hours a day he lounged
behind a sign requesting contributions. Every couple of hours he would walk back to the alley
and sneak a toke. “I don’t smoke on duty,” he said. “It’s bad for business.”

All in all, life seemed a lot better now than when he was a kid. Both of John’s parents had
died in an automobile accident when he was 6. For 2 years after that, he had been passed
around among grandparents, aunts and uncles, and a cousin. No one really wanted him, and
he had terminated a 6-year tour of various foster homes by running away when he was 14.

The alternative lifestyle of the northern marijuana industry had suited John just fine, until he
discovered that no industry at all suited him even better. It had been years since he had
worked at anything, and he supposed he never would again. His mood was always good. He
had never had to see a doctor. He had tried all the other drugs (“except smack”), but he didn’t
really care for any of them. John stood and stretched. He rubbed his already brick-red eyes.
“Well, thanks for listening.” The interviewer asked where he was going and pointed out that
his appointment wasn’t over. “You’ve only been here about 20 minutes.” “Really?” John
slouched back into his chair. “It seemed more like an hour. I’ve always had a lousy sense of
time.”
John was taken into custody after his evaluation. A bored judge quickly agreed that he should
remain incarcerated, then departed for the long Labor Day weekend. John’s first few hours in
jail weren’t too bad. That day and the next, he talked to a friendly guard and played carroms
with his cellmate. But he slept fitfully, and by Sunday he was boisterous and agitated, hitting
the bars of his cell with a spoon—which was the only good he got from his dinner tray. “I’m
just not hungry, OK?” he snapped, as the guard removed the untouched food.

John lay awake practically the whole night. He felt sweaty and had chills (but no fever),
headache, and a cramping pain in his stomach that doubled him over on his bunk. “It was like
the worst flu you ever imagined,” he whined to the nurse practitioner making rounds, even
though it was a weekend. The doctor found nothing physically wrong and told the guard,
“Just a pothead coming unglued. A couple of weeks will put him right.”

Piyush Yadav

Piyush was admitted to the detox unit 24 hours after he last shot up. The junk had
been good-quality— he knew, because afterwards he had slept for nearly 8 hours. But
then he awakened to the all-too-familiar aching muscles and runny nose that told him
it was time to go out and earn his next fix.

He had had no regular job for at least a year, but he knew some ways of getting money that
didn’t involve waiting for a paycheck. At a young age, Piyush had become familiar with the
symptoms of withdrawal. His father’s drinking was well known in their working-class
neighbourhood. By the time he was 10, Piyush had watched his father suffer through at least
two episodes. Alcohol had never done much for Piyush. He didn’t care for the taste, and he
certainly didn’t need the hangover. His mother, a public health nurse, had her own problems
with Demerol.

Off and on since he was 12, Piyush had smoked marijuana. But it wasn’t until a
neighbourhood block party the night he turned 16 that he first snorted heroin. “All of a
sudden,” he told his most recent clinician, “I knew I’d found the way.”
Within a few minutes, Piyush had felt happier than ever before in his life. It was as if a warm
bath had leached out all the anger, depression, and anxiety he had ever contained. For a few
hours, he even forgot how much he hated his old man. All he had left was an overwhelming
sense of tranquility that gradually gave way to drowsy apathy.
The following day, using a sterile syringe he stole from his mother, Piyush injected heroin for
the first time. Almost immediately, he vomited; this was followed at once by a sense of
pleasure that seemed to race outward to the tips of his fingers and toes. Rubbing his itching
nose, he fell asleep. When he aroused himself, several hours had passed. He injected again,
using a smaller quantity of the drug (all he had left). When he awakened this time, he briefly
considered stopping. His next thought was the realization that, more than anything else he
could remember, he wanted to use heroin again.

Sixteen hours after his last fix, Piyush still hadn’t scored. His usual suppliers had refused to
extend him credit. He had tried to borrow money from his mother, but she had refused, and
the earrings he’d stolen from her dresser top had proven worthless. Although the abdominal
cramps were worsening and he felt nauseated, he managed to make it to the apartment of a
former girlfriend for whom he had briefly pimped. But she had just shot up the last of her
own stash and was asleep. He appropriated her used syringe for his own use later, in case he
scored.

Ducking into a restroom in the bus station, piyush narrowly averted the disastrous
consequences from a bout of explosive diarrhoea. As he was about to emerge from the
stall, he suddenly retched into the grimy toilet bowl. He sat down on the cool tile floor and
tried to rub away the goose flesh on his arm. He dabbed at his runny nose with a
bit of toilet paper. He was too weak, he realized, to hustle. He would have to enter detox for a
few days and get his strength back. Then he could go out and get what he really needed to
make him well.