Tuesday, April 14, 2015

Addiction: Truth and Myth

 I spent the first several years of my clinical career working in substance abuse treatment programs. On the front page of my website, I note this fact and state that I "frequently work with persons in recovery." If only this were actually true! What has happened over the years is that the people who've come to see me for my addictions treatment experience are mostly not in recovery. Most  have been people who are still abusing drugs and/or alcohol. But psychotherapy is not the best treatment for addictions, which is why I tried, in the language on my website, to suggest that I want to work with people who've already stopped using drugs/alcohol and are looking for relapse prevention and treatment for other emotional problems.

"Recovery" means that you have stopped abusing substances--you are now abstinent from the problematic substance and any other substance with a similar effect, and are engaged in a different lifestyle. What I have found consistently in the course of my career is that 90 percent of addicts/alcoholics need a 12-step program to remain in recovery. Sadly, most of the substance abusers who have come to my office, although they may verbally express an interest in going to a 12-step program, don't stick with it and thus they don't stop using drugs/alcohol.

Most abusers of alcohol and drugs who come to my office claim that they "know" they have a "problem." This may represent a change from the attitudes found before the 1970s. Before the 70s, most alcoholics and addicts lied about their problem and were frequently in denial about its severity.  Celebrities in the late 70s started to come out of the closet with their addiction problems. Now it's become socially acceptable to admit you have a problem with drugs or alcohol. But  most people who "admit" this fact still  don't really want to change.  This may not make sense to most people, not only because using drugs/alcohol in the face of death or other severe consequences doesn't seem logical, but also because the media promote the myth that people use drugs because they don't have access to treatment. Nothing could be further from the truth, as the 12-step program is free and available all over the country. In addition, most inpatient rehabs are desperately seeking patients and some have closed.

Why would someone continue to engage in addictive behaviors despite access to treatment? There are many possible reasons, some that are psychological and some that perhaps could be better described as philosophical or spiritual, depending on one's beliefs.

Some recovering addicts have told me that before they found the 12-step program, they simply thought that they were destined to be drug addicts--it was their identity and fate. When they heard, in 12-step meetings,  the stories of people like themselves who had completely changed their lives, they realized they were wrong.  They realized they could choose their fate. They also realized that they needed help from others to remain free of drugs and alcohol. This may seem paradoxical, but all humans need both a sense of autonomy and self-direction and also social support.

 People with intractable addictions--those who go to 12-step meetings but still don't arrest their addiction--may be people who are too narcissistic to accept their dependency on other people. This makes them unable to use the 12-step program. Others can be persons who just don't see a meaning in life. Ordinary activities that give others' lives meaning, such as the sense of pride in working for a living and doing a job well, mutual interpersonal relationships, and greater causes or beliefs, are meaningless to them. Without a sense of meaning in life, it's hard to see a reason to stop drinking or doing drugs.  All experienced substance abuse counselors know there is a percentage of the population who cannot be helped and who will not recover from addiction.

Initially in private practice, I thought I would screen out all active addicts, and instead insist that they first attend 12-step or an inpatient rehab, or both. I changed that position when I realized some of the addicts and alcoholics coming to my office had severe depression or anxiety that needed to be treated. I didn't think it was right to deny treatment to someone for one disorder because the person refused treatment for another. I can say that I did help some of these individuals, whose depression and anxiety did improve, even though they did not completely arrest their addiction(s). (The fact that these individuals did not stop using drugs or alcohol despite recovering from their anxiety and depression shows that a popular theory, the "self-medication theory," is wrong. The self-medication theory, believed by many psychotherapists, holds that drug and alcohol abusers are simply self-medicating depression and anxiety and will stop their behavior if they take medication and go to psychotherapy. If this were really true, addiction would not be the vast social problem that it is). Recently, I've come to realize that active alcoholics and addicts present liability concerns for my practice. Therefore, I've decided to go back to my original position of requiring that addicts/alcoholics be in recovery before I will agree to see them.

Thursday, April 2, 2015

Evaluating Risks Part 2

I decided my last post needed a follow-up. In the last post, I discussed how employers can conduct psychological screening that could help them identify potentially suicidal and homicidal employees. For jobs that give people the power to endanger the public, I believe such screening is necessary. I noted that I discovered, through reading recent media reports, that airlines don't usually conduct such screening on pilots, which is incredible considering that pilots have the lives of hundreds of people under their power. However, it has occurred to me, after reading additional media reports,  that some people may misinterpret employment-based psychological screening as something that keeps individuals from getting the mental health care that they need. The "argument" I've been reading is that people won't obtain mental health care if they think it will lead to loss of employment.

The Americans with Disabilities Act, passed in 1990, forbids discrimination based on disability, under most circumstances. Businesses have to show that employing a person with a disability would impose an unreasonable burden in order to be able to "discriminate" against such applicants or employees.This law means that you can't be fired for a mental health problem or even a substance abuse problem unless it makes you unable to do your job even with treatment and reasonable accommodation. Therefore, if you need to take a month off work to go to a treatment center, your job has to allow you to do so. If you need to leave early one day a week to see a therapist, your job has to allow you to do so.

If, on the other hand, despite your treatment you continue to do drugs and this impairs your work performance or causes disruption to other employees or clients, or creates a hazard, you can be fired. If you come to work late every day because you're too depressed to get out of bed, because you either refused treatment or treatment simply did not work, you can be fired. I believe the ADA is a fair law that has worked well. Someone who is too disabled to work qualifies for federal disability payments but most people with disabilities can work if they receive treatment.

Duty to Warn

Therapists in the US have to abide by something popularly known as "Duty to Warn." If we have a patient who threatens to harm someone else or whose illness puts the public at risk, we are required to break confidentiality to take action to prevent the loss of life or injury to another person. I had to do a "Duty to Warn" some years ago when a psychotic patient came to my office with a plan to kill a relative. In addition, he showed me a recipe for making bombs. I sent him to the emergency room and I also called the police in his relative's town. These are the requirements under "Duty to Warn." Even though I believed the patient was unlikely to act out his homicidal ideas, it didn't matter because it was possible that he would. The hospital re-evaluated him and, if I remember correctly, changed his medication. The patient didn't lose his job (he was a doorman) and no one was killed. (There was no evidence the patient had constructed a bomb or that he was actually planning on doing so). The hospital agreed to continue his treatment on an outpatient basis as it was too much for someone in private practice such as myself.

A colleague of mine years ago had a patient who was a motorman on the subway. The patient had severe panic attacks. My colleague did a Duty to Warn because panic attacks can occur without warning and can be disabling, and the patient was responsible for the lives of hundreds of people on the subway. I don't recall what the end result of this was, but I imagine it was something similar to what happened with my patient: The patient probably took a leave of absence, went on medication and then went back to work if his treatment was effective.  In my opinion he should have been monitored by the MTA afterward to make sure he was complying with his treatment. I don't know whether this happened, however.

There are some people who are too sick to be able to safely work at jobs in which they hold the lives of others under their power.  Most people who fall into this category are substance abusers, and only a small percentage are people with other clinical problems. Most people with mental health problems are effectively treated and can do most jobs. However, our societies do need ways to screen out people with intractable problems from jobs in which they can put the public at risk.