“Trust In Your Environment,” declared the fading sheet of 8 1/2 x 11 that greeted me at the front door of Rumah Cemara’s Drug Rehabilitation Center. It felt like a heavy first request, as I arrived with no experience or expectation of how a drug rehabilitation center would appear or function. Still lacking the fluency to understand the rapid speech around me, it was only with my vision that I noticed an abundance of rules manifest themselves. My eyes explored the two-floor home: busy walls covered in motivational catch phrases, a tidy kitchen with residents’ name artistically scripted on the bottom of identical cups, a looming white-board with weekly roles and responsibilities spelled out beneath the daily “Just For Today” philosophy.

Seemed trustworthy enough.

As I got to know each of the 9 residents and 7 staff – all men save one female staffer and almost all staff reformed addicts themselves – I began to realize the weight that such a statement possessed in the life of someone tackling an addiction.

Life amidst addiction, they each revealed throughout the week, was life without an ounce of trust: dodging the authorities, lying to friends and family, and daily denial of one’s own dependence. With no one and nothing to trust, most of the residents’ addictions snowballed into a solitary and desperate refuge, though temporary and consequential. And those consequences grew even more serious for those who are married and have children, and those who are living with HIV and/or Hepatitis C.

Learning how to trust again is indeed a heavy order, and probably not an indicator of success on any evaluation of rehabilitation programs. Like so many other instances in public health, I see evidence here that intangible aspects of human relationships are oftentimes the key to long-term success of therapies – trust, friendship, dedication, honesty. However because they are unable to be quantified, monitored, and cost-analyzed in a traditional sense, they are therefore taken less seriously as ingredients of an effective health intervention. As a resident staff-in-training for the week I experienced the program as residents do. And through a barrage of questions – likely grammatically incorrect – I tried to glimpse at the program efficacy, from both quantitative and qualitative angles.

While there existed a perhaps unintentional camaraderie between residents and staff, the program design was undeniably deliberate in its every action. Every moment – from waking to showering to eating to sleeping – was a scheduled activity whose title was monotonously announced at the same time each day. “Wash Up” and “Curfew” were clear enough, but I was in for a surprise with a group therapy session called “Group Encounter.” In this once-a-week opportunity, residents can raise their voice and emotions through direct, non-physical confrontation with another resident, to express hurt feelings about anything that happened in the week prior. Thankfully I was warned there would be yelling, but I still had to brace my facial expressions from revealing any shock after each mind-blowing scream-fest between residents.

“But he’s not mad about that,” explained a staff member, when I asked to clarify the topic of a particularly heated moment. “It’s always something else, but this is one way to release that bad energy.” Each screaming fit ended with a hug, apology, and forgiveness between residents. And as I got to know the guys better I learned that truly the yelling was simply part of the process – scheduled and predictable like everything else – and that they had incredible respect and affection for one another.

In fact, most of the sessions had a much greater psychological value beneath the physical surface; like rotating house roles to promote leadership development and self-esteem building. Or enforcing a system of daily “pull ups” – confrontations with other residents when they break any house rule to remind them of the connection such an error has to the outside world. My pull ups included dropping a grain of rice on the table at lunch (“careless”), rolling up my sleeves without permission mid-session (“missed communication”), and moving my stool aside with my feet instead of my hands (“easy way out”).

By Wednesday I was becoming fed up almost to tears with what felt like unfair pull ups, and increasingly frustrated that my language barrier was causing me to commit even more errors than I would have in my normally less than graceful demeanor. Being reprimanded publicly, repeatedly, was exhausting and I began to wonder how this snow-globe of an environment could possibly prepare a recovering addict to go back into the unpredictable world outside.

But before I let my emotions get the best of me, I realized that I was missing the point, and committing the error of putting my “personality before progress.” This is a simulation, and the residents know that better than me. One new resident entered midweek, checking himself in due to a relapse after 8 years of sobriety. Between his withdrawal sweats, shivers, and sickness, we talked about his decision to come here, his desire to get back to work and life, but his realization that he needed to recover first. “Of course this is nothing like the real world,” a roll of his eyes seemed to say. But it is a rest stop, a chance to build strength, skills, and focus before going back into tumultuous environments. Overcoming addiction largely means taking responsibility for ones own feelings, thoughts, words, and actions. Refraining from blaming others, aware of personal choice and consequence.

When I was mad they kept accusing me of doing things wrong, the truth is – even despite my language barrier – I was just not being diligent or careful enough to listen and follow the rules. Perhaps it was even hitting a little too close to home, I began to think. Even if I have never been a drug addict, I have certainly been ‘addicted’ to things, like work, that I use as an escape from confronting with honesty other problems in my life. Focusing on helping others to avoid thinking about helping myself. I read voraciously the few English materials lying around the house, and I pondered myself to sleep every night, curled up under a musty blanket in the chilly mountain air, peepers chirping in a choir just outside my window, the TV in the next room mumbling away. By Thursday I realized that I could not change the rules of this house, only how I react to them.

So I finally stood up to my fear of sounding foolish and I participated more – I gave pull ups to other residents and graciously accepted theirs. I asked questions in sessions and even led two about HIV/AIDS, including my experiences in Africa and America. By Friday morning I had one resident ask me to get him a Keep a Child Alive bracelet so the cause could be his Higher Power, and another resident awarded me the title of Resident of the Day. We closed that morning meeting as we close every meeting, with the Serenity Prayer: “God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”

Easier said than done, I couldn’t help but think every time we prayed. For most situations in life difference is often gray, because we can’t always be sure what we can and cannot control. Oftentimes the things absolutely out of our reach are the things we attempt to control to the point of foolishness, and the things we can change we pretend we are not up for the challenge.

I can’t change the fact an earthquake killed hundreds of people. I can change my daily attitude about being more patient. Some decisions are black and white, and require little wisdom. But can I or can’t I change the problem of AIDS? Sure, I can give my all to support those living with the disease and help prevent future cases, or I can study hard to become a policymaker, a doctor, a case manager. But I can’t keep a patient alive who has no will to live, and I can’t stop desperate people from becoming drug addicts who then contract HIV. Or can I?

I can’t change the way a person values their life so that they live less recklessly. Or can I? And even if I can… should I?

My co-worker and I rushed to the hospital last night after an alert from one of the case workers. One of our clients was in a coma from an HIV/Hepatitis-C/Tuberculosis co-infection. She had reached a level of desperation amidst managing her own illness, that of her HIV-positive child, the pain of a husband already passed, and a monster of a heroin addiction still in the recovery process. Without telling anybody, she gave up, and stopped taking her anti-retroviral medication two weeks ago.

By the time we arrived by her bedside she lay awkwardly, her chest heaving erratically, with bubbling foam at the corners of her oxygen-mask-enclosed mouth, and her eyes rolled back into her trembling head. My co-worker leaned closely towards her cheek to whisper in her ear, aware that she was indeed conscious even if not able to respond. I imagined he said something bolstering to get her through this moment, like “don’t give up” or “you will make it” or “we’re all here for you.”

Walking out of the hospital I asked about his comment, and he replied peacefully, “I told her that if she wants to survive, she needs to be strong and keep surviving. But if she wants to let go, to just let go.”

Early this morning, our client let go.