September 14, 2011

Clean: A Psychtember Review

Patient: Clean by Amy Reed


Olivia, Kelly, Christopher, Jason, and Eva have one thing in common: They’re addicts. Addicts who have hit rock bottom and been stuck together in rehab to face their problems, face sobriety, and face themselves. None of them wants to be there. None of them wants to confront the truths about their pasts. But they’ll all have to deal with themselves and one another if they want to learn how to live. Because when you get that high, there’s nowhere to go but down, down, down.

Axis 1. Characters

Since Clean stars five main characters, it takes a little bit to figure out who's who in the cast of characters and get a handle on what each character is like. Kelly and Christopher are the two teens telling the story, but we get excerpts from the other three perspectives throughout. Of course, more page time is devoted to Kelly and Christopher, so we get to know those two the best. 

Kelly, Christopher, and Olivia all come across as complex, multi-dimensional individuals, with rather unexpected stories of how they became addicted and ended up in rehab. I felt the closest to Kelly; her observations about the others were at times entertaining, at others heartfelt, and it was easy to connect with her way of viewing the world. I couldn't relate as well to Christopher, and found his voice somewhat inauthentic for a teenage guy. Both Kelly and Christopher wax introspective and thoughtful at times, with some of their insights seeming a bit too advanced for their age; occasionally it feels like an adult voice slips in here. With Kelly I could buy it most of the time — once we get past a bit of a shallow exterior, she actually seems like a smart girl who has just developed some very bad methods of coping with her emotions and problems. However, I found the mature nature of some of Christopher's reflections a bit too unbelievable.

Olivia fascinated me the most; there's more going on with her than just an addiction to diet pills, and I would have loved seeing the issues she's facing in greater depth. I don't feel like I really understood her mindset, but I certainly wanted to know more about her. Jason was a more stereotypical character for this setting — a "tough guy," with a "tough guy" father who clearly wields the power in their home — but even though his story is simpler compared to some of the others, it's still rewarding to see him learning and changing. It was Eva, actually, that I felt I couldn't really pin down or understand. She writes her "personal essay" excerpts in third person and her style is dramatically vague; apart from the neglect her father shows her, we aren't really told a lot more of her story.

Axis 2. Premise/plot

I liked the premise of a rehab facility bringing together different individuals and forcing them to interact. However, the method of showing the group therapy sessions using a screenplay format removed some of the potential chemistry between characters for me as a reader. Somehow, without all the body language, the group dynamic wasn't quite there, and the quick back-and-forth between characters with no intermittent description made it more difficult to visualize the scene and keep track of who was speaking.

Now, this book is all about the characters, so don't go into it expecting a riveting, action-filled storyline. If books about individuals coming to personal realizations are your thing, though, then Clean's for you. Addiction's always been one of the areas in mental health that particularly interested me, so I enjoyed discovering how these five teens had gotten to the low point they're at. However, one of the strengths of Clean is that it isn't just about the addictions. There are a lot of themes touched on — family pressures, sex, friendship, bullying — and many shared emotions: fear, regret, guilt, need.

Axis 3. Writing Style

Having five main characters — whose viewpoints we see in one way or another — is ambitious, but Amy Reed pulls it off quite well here. The format is an unconventional one; typical first-person narratives are combined with excerpts from "personal essays," a "drug and alcohol questionnaire" and conversations written in screenplay style. As mentioned above, though, we don't get to know all of the characters on the same level.

In terms of pacing, like most character-driven books it's quite slow-moving, and I felt that it dragged a little in the middle. Many of the scenes or excerpts are very similar, making it feel repetitive at times. I also found that the dialogue really varied for me, between being quite authentic (lots of swearing in here, which many teens are prone to) and sounding somewhat cliched and/or unrealistic as the teens underwent their personal revelations.

Axis 4. Psychological Accuracy

I appreciated the variety of types of addictions covered in Clean. Hard drugs, "soft" drugs, alcohol, diet runs the gamut (although no gambling addictions, unfortunately). The different ways in which each teen got hooked on a particular substance demonstrate how anyone can become an addict, serving to dispel the misconception that it's due to a lack of willpower or some other personality "flaw." The emotional aspects of addiction are portrayed quite well, but I was surprised not to see more of the physical signs. There isn't much mention of withdrawal symptoms, which I'd expect to appear in at least one or two of the main characters. I thought they would be experiencing more cravings, although I suppose it depends on how long they've been sober (and they are admittedly receiving some medications while they're in rehab.) Kelly does show signs of genuine craving, for "a line, a shot, pills, anything to leave this world for somewhere upside down." Still, the emphasis appears to be more on causes and effects of addiction than the actual in-the-moment experience of it.

My more significant area of contention is with how Olivia's mental health problems outside of her addiction are handled. At one point she's referred to by Kelly as "the anorexic girl with OCD," yet most of her behaviour does not indicate obsessive-compulsive disorder. She likes to arrange her shoes in a row and alphabetize her books, she's very concerned about getting all of her homework done, she's a big fan of organization and lists, and most importantly, she is constantly striving to be perfect. To me, these scream obsessive-compulsive personality disorder (OCPD), *not* OCD. Yet I don't believe OCPD is actually even mentioned by name at any point. These are two different disorders and it always frustrates me when I see them getting confused, so I am going to lay them out here (most of the information is from my Abnormal Psychology textbook, but I also used this website)
  • Involves obsessive thoughts followed by compulsive behaviour to neutralize them
  • The obsessions cause anxiety, making the OCD ego-dystonic
  • The treatment is typically medication and/or CBT (exposure and response prevention)
  • Involves a pattern of fixation on order, perfection & control
  • Symptoms can include extreme perfectionism, reluctance to delegate, overconscientiousness, miserliness, rigidity and stubbornness
  • There are no specific obsessions or compulsions
  • The individual does not find the OCPD distressing, making it ego-syntonic
  • There has not been a lot of research done into treatment
It's worth noting that there has been discussion of including both of these disorders on an "obsessive-compulsive spectrum" but at the moment, in the current DSM (Diagnostic and Statistical Manual of Mental Disorders), they are categorized entirely separately. (In fact, in the proposal for the updated DSM-V, OCPD is still being included with the other personality disorders.)

Now, anorexia can be comorbid with either of these disorders (according to The Writer's Guide to Psychology), and my university abnormal psychology textbook cites a 20% overlap of OCPD patients who also have an OCD diagnosis. So theoretically, Olivia could have both, in addition to her eating disorder and addiction. However, not only do I find this to be rather a lot of disorders in one character (the interactions between them would be extremely intricate), but I also don't think Olivia demonstrates much evidence for OCD. There's one mention that she seems to have trouble with germs (at the bowling alley), which I feel was thrown in there in an attempt to demonstrate OCD. Perhaps the shoe- or book-arranging could be signs of OCD, if she actually had obsessions about numbers or symmetry. But the glimpses we get of Olivia's perspective don't suggest these kinds of unwanted thoughts and compulsions.

And yet, we're told by Christopher that she's taking medication for OCD which seems to have helped decrease her "crazy organizing." It's possible that both Kelly and Christopher are misinformed or have gotten confused, but really, Olivia's true problems should eventually be cleared up. While a bit more happens with Olivia's eating disorder by the end (in fact, I learned something new about anorexia!), the OCD/OCPD confusion is not dealt with.

Group therapy has been shown to be effective in helping to treating substance abuse, so that's in line with the facts. But I found the counselor Shirley to be rather changeable in mood and attitude. She'd be compassionate one moment, then she'd switch to "tough love," or try to relate to the teens, and even sometimes came off as sarcastic and condescending. The scenes we usually see Shirley in are written in the screenplay style, so we don't get any hints of her body language or tone, making her more difficult to understand. Perhaps her therapeutical orientation is eclectic, using a mix of therapy styles; I'm not familiar enough with rehab therapy to assess how accurate her approach was. However, to me she embodied several different versions of what people think of when they picture an addictions counselor (e.g. from movies or TV) — more a mash-up of various therapist stereotypes/representations than wholly her own person.

Validity Score: How psychologically accurate was Clean?

Axis 5. Miscellaneous

I enjoyed the humour that came through some of the character's perspectives, usually in the form of acerbic remarks and observations about other individuals in the program. It provided a lightness to balance the more serious nature of the teens' pasts and present situation.

And I liked the ending, it actually had me tearing up a tiny bit because it really captured the journey the characters have gone on. 

Patient's statement:

I think the idea is that if we realize we're not completely to blame, then maybe we'll start believing there's some good left in us after all, and maybe that will make us want to get sober. I mean, nobody just becomes a drug addict for no reason, right? Nobody just decides they're going to be totally lame and lose control and get bad grades and make their parents hate them. I get it, but it's just not going to work for me. All it does is make me feel worse, because now it's just that much more obvious that there's no excuse for why I turned out the way I did. No one ever abused me. No one in my family is an alcoholic. Nothing traumatic ever happened to me. The truth is, my parents are the nicest people in the world and I keep breaking their hearts for no reason.

Diagnosis: 3.5 shooting stars. Despite some of the inaccuracies, I did enjoy getting to know the characters and watching them change.

Note: There is some mature language and content in this one, so I wouldn't recommend it for the younger set.

For resources on addiction, go here.

For my interview with Amy Reed, and a giveaway, go here!


  1. Totally agree with your assessment on the OCD/OCPD confusion. That part struck me, too.

    A lot of this book seemed very real to me, which isn't necessarily right as in the best approach, but just it resembles what actually happens. Does that make sense? Like the counselor, I've seen people just like her, though I don't really think her approach is great.

    I've also seen kids talk as candidly about their psychological states as these kids, but more often than not they're just parroting back what they've been told. They get it, but they also don't fully get it.

  2. You know, I WAS going to read this one soon. But, given how I feel about OCD in books right now, maybe it would be wise to put this one on hold for a while! :P


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