The Pastoral Clinic: Addiction and Dispossession along the Rio Grande

“Loss and mourning provide more than a metaphor for heroin addiction: they trace a kind of chronology, a temporality, of it. They even provide a constitutive power for it.”

Central to Garcia’s argument is that addiction does not exist in isolation. She suggests that addiction is part of an interlocking web of factors, including an overwhelming sense of loss. In the Introduction, she establishes the idea that loss creates a framework for addiction and continues to inform it over time.

“They were moments of rupture and of shared singularity. These were moments when I could imagine the possibility of a new kind of care.”

As Garcia reflects on her first night working at Nuevo Día, she realizes that caring for patients with heroin addiction requires more than medication and clinical treatment. In her Critique of Conventional Approaches to Addiction Treatment, she imagines a new kind of treatment that embraces the humanity of patients and their need for connection and community. Garcia argues that institutional life forces patients to endure continued vulnerability during a time when solidarity and support are needed.

“Lucretia recalled a small window in the hotel room that offered a view of the Jemez Mountains—a place she fondly remembered as a child. The view of the mountains helped, she said.”

Interwoven into the stories of patients that Garcia follows throughout the work are their connections to and losses of land. While experiencing a low point of addiction and loss, Lucretia finds hope in the view of the mountains outside her hotel window. They remind her of a time when she still felt secure in her sense of place. The theme The Connections Between Land, Loss, and Experience explores how space contributes to the experience of addiction, mourning, and recovery.

“‘The clinic is just like la pinta [jail],’ Marcos invariably said when talking about conditions of everyday life there—the food, arguments, and restrictions on movement or telephone use, feelings of boredom or frustration.”

Marcos’s comment in this passage contributes to one of Garcia’s Critiques of Conventional Approaches to Addiction Treatment. The researcher argues that institutional care too closely mirrors the life of drug addiction, forcing patients into a cycle of vulnerability and hopelessness. Marcos compares drug treatment to prison; in both scenarios, he is stripped of his autonomy and personal identity.

“While patients in the clinic talked frequently about ‘la vida afuera’ [life outside], there really was no such place. Life outside thrived within the clinic’s walls.”

Another critique of the institutionalization of addiction treatment is how closely clinics like Nuevo Día align with the practices of illicit drug use. Patients do not know how much medicine they will receive, when, or what kind. The instability of medical treatment and lack of funding mean that they rarely have all the resources they need for successful recovery.

Patterns of ‘legitimate’ medication use in the clinic mirrored the use of illicit street drugs…the attendants who dispensed medications, including me, were sometimes called dealers.”

This passage is an example of The Institutional Shaping of Identity. As the patterns of addiction treatment reflect illicit drug use, patients’ identities are solidified as “addicts,” even as they actively seek rehabilitation. By referring to medical professionals at the clinic as “drug dealers,” patients maintain the same routines and cycles they experienced outside of recovery treatment.

“This pattern of familial, intergenerational heroin use—common in the Española Valley—stands in sharp contrast to the mainstream notion of heroin addicts as isolated from family or community.”

Throughout the work, Garcia challenges the idea of those with heroin addiction as isolated and disenfranchised individuals. Instead, she argues that The Connection Between Land, Loss, and Experience includes the familial and cultural ties that bind people together, even in the context of drug use. Families become the site for both care and enablement, further complicating how addiction functions.

“Though in clinical parlance returns to detox, such as Alma’s, are considered a ‘relapse,’ a framing that correlates to an understanding of an addiction as ‘chronic disease.’”

In Chapter 2, Garcia challenges The Institutional Shaping of Identity, especially through an understanding of addiction as a chronic illness. Garcia argues that framing addiction in this way leads individuals to believe that they will never truly recover and that overdose is the inevitable conclusion to their narratives. The term “relapse” implies that they have no choice but to return, and the frequency of recidivism supports this claim.

“Alma turned to me in exasperation and, in a language the counselor couldn’t understand, said, ‘Es que lo que tengo no termina [It’s just that what I have has no end].’”

Alma’s story pervades Garcia’s work as she considers how loss and addiction intermingle to form a type of inescapable melancholy. Alma has been through detoxification multiple times, and she feels her participation in yet another drug treatment program offers her no hope. Garcia wonders whether The Institutional Shaping of Identity contributes to Alma’s belief that she cannot escape her addiction.

“What if we conceive the subject of melancholy not simply as the one who suffers but also as the recurring historical refrains through which sentiments of ‘endless’ suffering arise? How to attend to these wounds?”

Here, Garcia emphasizes The Connection Between Land, Loss, and Experience by calling for an understanding of addiction that encompasses the complexities of individuals’ lives and experiences. Rather than viewing depression as an outcome of drug use or drug use as a reaction to depression, Garcia argues that melancholy is tied to culture and history. Unpacking how these factors influence and inform one another is necessary to break the cycle of addiction.

“Alma said, ‘It’s not that I wasn’t ready…it’s that there’s nothing to be ready for.”

Another part of Garcia’s Critique of Conventional Approaches to Addiction Treatment is the way institutional care ignores the role of the future in patients’ lives. After leaving individuals in an ongoing cycle of patient-prisoner limbo, conventional practices fail to consider what patients face once they leave treatment facilities. When they return home, they return to the same structures and homes within which their drug use thrived before treatment. If they face prison, they face a system that supports and incentivizes repeated offense and the stripping of identity.

“The fear of forgetting is a powerful sentiment in the Hispano context. In the realm of addiction, many addicts described to me their fear of forgetting loved ones who died from a heroin overdose.”

Garcia grapples with the question of memory and escape. Heroin is a means of escape for those who use it; many describe how it is the only relief they can find in their everyday lives. Yet, Garcia recognizes that heroin use is also a way to immortalize and honor the dead. This understanding of addiction causes the researcher to question the role of memory in recovery and whether there is a way of regaining the past rather than marinating in its losses.

“Every hundred feet or so, I would spot a descanso on the side of the road and couldn’t help but imagine my own demise.”

Garcia uses an emic perspective to situate herself in the culture and experiences of her research subjects. As she confronts descansos along the highway—small memorials commemorating people who died of a drug overdose—she cannot help but feel the personal reflection they evoke. These symbols remind her of what her research subjects face every day—the continual reminder of what has been lost and the potential fate that awaits them.

“It is through the experience of melancholy that Alma and Joseph are, in my view, living a moral life—that is, a locally and interpersonally engaged life, however precarious these engagements may be.”

After contemplating questions about memory and experience, Garcia determines that melancholy is an appropriate reaction to loss and that continually re-engaging with the past is a moral understanding of one’s personal history. Garcia considers The Connection Between Land, Loss, and Experience and how it may be harnessed to develop better treatments for heroin addiction.

“A young woman named Jennifer admits that although she knows how to avoid the bacteria that can lead to the painful skin inflammation, she takes comfort in her heroin-related wounds (and thus presumably induces them). She says she feels as if coronas sustain her connections to the family members she has loved—and lost.”

In this chapter, Garcia details how familial relationships support internal systems of drug addiction and create bonds of community, standing in contrast to the accepted narrative of individuals with drug addiction as isolated users. Intergenerational and familial drug use binds loved ones together, even as drug addiction places strains on relationships and resources. This is symbolized by Jennifer’s description of her wounds as “coronas”—crowns—elevating them to a higher meaning. Garcia also argues that there is an element of care that exists within shared drug use; family members buy drugs for one another to alleviate pain and withdrawal symptoms.

“Addiction solidifies the relationships between some members while breaking or refusing relationships with others. Indeed, this is the very structure of kinship.”

Garcia expands her argument that the family can serve as a framework for addiction by suggesting that addiction and love become intrinsically connected to such a degree that it becomes impossible to separate them. Bernadette’s relationship with her mother is bound in love, but that love is defined and historicized by their shared drug use. In this way, addiction begins to mirror love, and individuals find it difficult to compartmentalize their experiences.

“The classification of inmates in specific identity and housing divisions has always been central to prison management…the rise of religious forms of classifications is fairly new.”

This passage combines two themes: The Institutional Shaping of Identity and the Critique of Conventional Approaches to Addiction Treatment. The privatization of institutional treatment and the drug court system means that conservative political influence has begun to shape prison structures. For example, Garcia tours a prison where inmates are rewarded for participating in evangelical programs. This structure leads to identity formation and abandoning historical and cultural associations with religions like Catholicism.

“Current sentencing laws remain based on male criminology, for men have historically been viewed as the ‘normal’ subject or perpetrator of crime.”

One Critique of Conventional Approaches to Addiction Treatment is their basis on men’s experience with drug addiction. Garcia asserts that women with drug addiction are often nonviolent and pose no threat to society, yet they are treated in the same way as violent male offenders. Her exploration of mother-daughter relationships is an attempt to expose the unique qualities of female drug addiction and its ties to belonging.

“The disease that she kept secret from Carlos fostered in her a familiarity with needles that made her, in his eyes, unusual and attractive.”

Sarah’s story draws attention to the ways that conventional medical treatment mirrors illicit drug use. Sarah uses heroin to alleviate her multiple sclerosis symptoms; because her legal medication is taken in the same manner, she is used to intravenously taking drugs. The lines between legal and illegal drug use become blurred as the two parts of the divide reflect one another and contribute to Sarah’s self-treatment.

“Her pursuit of the question of suicide intentionality was based on a commitment to not let overdose-related deaths be routinely mislabeled ‘accidental poisonings.’”

At first, Garcia is taken aback by a nurse’s cold assessment of drug overdose and its ties to suicide, as well as her feelings about the inevitability of relapse. However, Garcia soon sees that the nurse is working to change institutional care by forcing people to look at the reality of addiction and suicide. By identifying overdoses that are tied to intentional death, she exposes another aspect of the nature of drug addiction and the hopelessness it instills in people.

“I wanted to ask her, ‘How could you not know?’”

Although Garcia works to maintain objectivity with her subjects, she struggles at times to understand their choices or why they fail to see how their addiction impacts others' lives. Lisa continues to use heroin after introducing her daughter to the drug, even after watching her daughter die from an overdose. Lisa wonders how she could have failed to see her daughter’s pain, and Garcia wonders the same. Garcia’s work as an ethnographic researcher means that she must constantly remain vigilant over her own opinions and how they might shape her understanding of her research subjects’ experiences.

“Perhaps what struck me most about the closing of the clinic is how, in many ways, it mirrored the experience of addicts: dismissal by institutions that had the power to remake (or undo) their lives; day-to-day instability; feelings of vulnerability and failure.”

Once more, Garcia reveals how institutions shape the identities of individuals with drug addiction and mirror the complications and abuses of everyday life. Garcia argues that the instability brought on by ineffective management and a failure to consider the contextual implications of care trap individuals in a patient-prisoner cycle from which there is no escape.

“Hispano heroin addicts frequently said that they had little or no chance of recovery, and they would often explain their pessimism in biological terms. Their addiction, they said, was in the blood, like a virus, something they could not eradicate or recover from, even if they wanted to.”

The association of addiction with a virus is further evidence of The Institutional Shaping of Identity. By framing addiction as a chronic illness, individuals with heroin addiction believe that their use of the drug is inevitable. Garcia suggests that future care must center on a new narrative that instills a sense of hope.