For example, the question of whether Darlene's aggressive, incoherent behavior results from mental illness or substance abuse (speed can induce psychotic symptoms) -- a question that, as Shavelson points out, isn't particularly relevant to helping her -- stymies her progress through the system. He describes her experience as "a cyclonic quest for rehab: referred to and then immediately kicked out of three drug treatment programs ... referred by the city's mental health counselors to the substance abuse counselors; referred back to mental health again in circles that have spun me dizzy just watching."

For another example, Glenda, joyfully sober for the first time in decades after three months in a terrific Native American-run inpatient program, steps out of it and into a treatment vacuum. The room found for her is in a "clean and sober" Salvation Army housing facility, but it's three blocks from the place where she used to hang out all day drinking with her street pals, and no one supervises her recovery beyond the Salvation Army's weekly drug tests. Two days later, she's drunk again and kicked out of her room and onto the street. A year and a half after that, she's dead.

Shavelson convincingly argues that all the money spent on treatment programs will go to waste unless each addict is assigned a case manager, someone who can guide him or her through detox (which "provides medical social services during those days it takes to get sober and withdraw"), then rehab (a program that seeks to resocialize the addict in a clean and sober environment) and finally getting the housing and employment he or she needs to become a functional member of society. Instead, he observes irately, "the seeming lack of any management that could impose order on the myriad substance abuse programs and services that have proliferated since the mantra of rehab took hold across the country" means that people get briefly cleaned up and then dumped back into the nightmare from whence they came, without anyone accounting for their need, as Mike puts it, "to learn how to live all over. Like from the beginning."

Mike, though, ran up against more than just bureaucratic hassles and inadequacies. After weeks of waiting to get in (during which time he almost died of an overdose), he became a model member of the famous San Francisco "therapeutic community" Walden House, but then relapsed shortly after moving on to transitional housing. Afraid of going back to Walden to plead for readmittance, he went on a heroin binge, then tried, without much success, to stay clean on his own. Shavelson sees this, too, as an avoidable calamity. Walden adheres to a common rehab philosophy that Shavelson calls "abstentionist." It imposes a long list of regulations on house residents, and punishes even the slightest infraction with long periods of "reflection" time on a bench in the communal hallway. A major violation like Mike's relapse means automatic ejection from the program -- unless the prodigal submits to a grueling group meeting in which he must sit in a chair in the middle of the room while the entire community pelts him with accusations and abuse.

This militaristic, "tough love" approach has disreputable roots in the scary Synanon movement that started in the late '50s and flourished in the '70s. Synanon, which practiced a form of "attack therapy" called "The Game," eventually was discredited when its cultlike antics expanded to include stockpiling weapons and placing a live rattlesnake in the mailbox of a lawyer who'd sued the group. Nevertheless, with some significant toning down of its more extreme aspects, the Marines-like, zero-tolerance model persists in therapeutic communities like Walden, which claim that the addict is like an irresponsible child whose personality must be broken down and rebuilt from the ground up in a highly structured, rigorously sober environment.

Maya Angelou reads from "The Heart of a Woman"