Wednesday, January 7, 2009

Addiction Psychiatry

The exciting thing about addiction psychiatry is that it is truly biological, psychological, sociological and spiritual. When I left family practice in the country and community medicine for psychiatry that and immunology were the fields of discovery with the most apparent greatest depth and breadth.
I was not prepared for psychiatry to become a kind of second class pseudo neurology for poly "feel good" pharmacology. Comfortable with psychopharmacology , I still enjoyed the contributions of anthropology, epidemiology,chemistry, biology, neurosciences, developmental psychology, sociology, cultural, philosophical and theological considerations that were so much a part of my training. Individuals were seen as multifacetted diamonds in the rough. The coping mechanisms of the mentally ill, the deranged, the deviants, diseased and impaired, the outcasts and the marginalized were all understood as adaptation. If someone was particularly offensive my teachers taught me to ask how this behaviour had been necessary to the development of the individual. Alternatively I was asked what it was about my supposedly tolerant and civilized upbringing that would cause me to be so judgemental about this clearly human presentation. Was I really sure that my way was the best way? I was taught the story of the Diogenes the philosopher who asked by Alexander the Great, "is there anything I can do for you?" replied, "you can step aside so as not to keep the sunshine from me". Such self sufficiency as Thoreau at Walden Pond was as important to a psychaitrist's development as the book, "If you meet the Buddha on the road, Kill him."
It was the heyday of medicine and we dreamed of Canada leading the world in healing. We didn't see her as sending the little sister soldiers to big brother America's conflicts. Rather we envisioned Canadian hospitals ships and a space age medical corp, and peacekeepers world reknown for their daring rescues. We felt that as Canadians we could best serve the world by wedding the remarkable education systems and multicultural environment to the task of curing disease. The canadian medical system was foremost in the world not where it sits today with increasing waitlists and patients paying for everything but the most basic services out of pockets which of course the ill by nature of illness experience as sorely depleted
As psychiatrists we hoped to find the means to bring compromise and resolution to the world conflicts. We were immersed in systems theory as well as genetics, endocrinology and neurology. We had experience and authority in peace not war . We could share this we thought with regions who did not know the meaning of 'sweet boredom' of the peace we knew in Canada. We hoped to get to the core of the terror of schizophrenia and then apply this learning to the world at large. Paranoia as a paradigm explained so much of the greed, hoarding, war and hunger in the world. We had such high hopes. We were idealistic and humanitarian.
Then the beaurocracy took over or something. Suddenly administrations redefined healthcare as political expenditures and for profit models. The question became how do we promise the tax payer health care, give them something else and charge them for both. Politics was pigeon holing all doctors in the dinosaur realities of archaic reductionist fear driven paradigms. Truth became a things of the past. Overnight we'd gone from the sublime to the me Jane, you Tarzan world of brute force and big is better. Rather than serving as consultants with the genius that comes from long years of reflection, intense debate, and in depth experience with basic research and love of learning we were suddenly poorly paid slaves to the fickle self serving designs of pillagers who claimed survival of the fitness was the only true religion. There would no more be anything but "applied research and the university medical school was nothing more than a glorified 'trade school' and factory.
How could psychiatry serve the war machine? Would euthansia be a more humane 'solution' for the mentally ill? Wasn't it a shame that lobotomies were out of favour? Everywhere it was 'what's the bottom line", and ironically these superstar exhorbitantly expensive business "managerial" brains did not so much as create anything but steal by sleight of hand and word and deed. Financial wrangling was just that, the whole white collar casino of stocks and phony bonds. The answer to world peace was Vegas!
It seemed that the whole of psychiatry was being consumed by this corporate madness which made psychiatrists the distribution salesmen for the latest pill promise of happiness and the patient customer consumer who needed to be told what to do by slick marketting. Psychiatrists were suddenly expected to compete with the street drug dealers who had with cocaine, alcohol, cannibis, nicotine, opiates, and benzodiazepines. Some psychaitrists were demanding head office send them more than antidepressants if they were supposed to have any hope of a market edge as police were increasingly refusing to work for the pharmaceutical industry chasing down the competition. No wonder people preferred "alternative" psychiatry given the limits of the proposed paradigm of 'feel good' is 'good'.
Thank God, Addiction psychiatry came along and again said there's no such simplistic answer to life. No perfect pill. No quick fix. No instant happiness. Simple answers, yes. But no simplistic solutions that could come in a cereal box despite the marketting. The individual problems again were seen as community problems. The mind problem was a brain problem as well. Addiction was the microcosm for the macrocosm. The heart and soul were overnight restored to adult psychiatry.
Once more there was this place where relationship was as important as illusion and the question 'what is enough' was being asked had surfaced. Not just as 'resource management' but rather in terms of Maslow and Seligman. Moderation was again a central theme of medicine. A different kind of reasoning was being asked for in this era of emotional, spiritual and cultural intelligence. Collaboration and respect was demanded but not for the 'position authority' of insignia but more for the scars and tattoos of experience.
Not surprisingly an individual 'cured' of an addiction would re acquire that same addiction if they were subjected to the same environment so family, community, friends, work and schools all became involved in the psychiatric process. The term psychosomatics returned as mind body realizations derived from modern PET and fMRI scans.
Addiction psychiatry simply understood the hypothalamus, amygdala and nucleus accumbens a whole lot better. The 'war on drugs' had played a liars game with little to show for their multi billion dollar claim that they could make society safe. Diversion judgements instead worked as did drug free work zones, treatment centres, 12 step programs and mentorships, education, motivation therapy and new medications as well as old time detox. Addiction psychiatry worked!
The joy of addiction psychiatry was that the debate and discussion was again occuring at all levels. And most importantly the addicts and the recovered, the children and the adults were encouraged to participate in the dialogue and solutions. There were none holier than thou. There were no pompous 'healthy' people in addiction psychiatry just those who were healthier and a little further along life's convoluted journey. A famous addiction psychiatrist said to a heroin addict, "I don't know what it's like to be addicted to heroin but I'm having problems myself with my addiction to worrying." The "my brain is better" and "your brain is sick" paradigm of pharmacist psychiatry held no sway where everyone could see the continuum clearly. The very foundations of desire and relationship with one's fellow man in the pursuit of happiness and resources was being questioned once again. The mechanisms that were associated with overeating were little different than those associated with alcoholism. The essence of pleasure was again being explored while what was happiness was a challenge to a world gone mad. Was love only lust and the soul only the brain or was there something more. Evolution and devolution competed openly in addiction psychaitry with the discussions not presumed to be known 'a priori' by those above everyone else's pay grade.
Daily in clinical practice, one on one, the addiction psychiatrist had to answer "who am I to question this man's addiction to death when I myself may be no better in my addiction to life". Thanatos or Eros? The teeter totter tug of war or dance of love. Here the healing began. At the front lines. And I loved it after the sterile stupidity of one shoe fits all. The healing was in the process.


detourcy said...

And why was it so?
It began some 30 years ago, perhaps with Neoclassical economics? New Institutionalist schools can be thought of as the outcome of the Chicago School's "economic imperialism" -- i.e. using Neoclassical economics to explain areas of human society normally considered outside them. In this sense, New Institutionalism can been seen as the precise opposite of the old American Institutionalist school, which sought to apply the reasoning of the other social sciences into economics.

Or perhaps it can also be related to the rise of the digital age? Simple 1101010 stuff. It's either 0 or 1, & all other solutions, such as 3/4 of this & 1/5 of the other, with some emotion & some revolt thrown in are not computable. Or they are, but the answer would be 42, on thorough computer modelling. A nice simple answer. Allows us to move forwards on the 42 principal & ignore the rest. It's not just psychiatry, which has been reduced to on or off. Or Axis 1 or 11. So maybe we had the industrial age, which ended in humans revolting against the Dark Satanic Mills & Ford production lines & humanity reasserting its values, but then those people, after achieving equity & recognition, say in the 70s, were replaced by 0s & 1s. Reductive again. Computers make diagnoses & treatment recommendations now, based on patients ticking boxes. Interesting that addiction psychiatry is saying there is more on different wavelengths than 1 or 0. Perhaps soon orchestral music will not be generated by boxes, but people playing different instruments again. Hard to guess.
IT is the opposite of knowledge. Perhaps after the power failures we'll have to revert to books & flutes & scrumpy & conversation & bicycle tyre pumps & boiled puddings.

detourcy said...

Sorry, I left out quotation marks from "New Institutional..into economics"

haykind said...

Thank you I'll have to look into the "new institutionalist" schools though I'd rather listen to mozart than muzak. However, good to know where the sewage leak is if one wants to address the bad odors. I don't think it's the digital revolution though. That would be bottom up and this is distinctly top down.