Tuesday, December 16, 2014

Addiction Intervention

Intervention refers to the active process of direct participation in the life of an addict. There are actual addiction intervention services and people with extensive training specifically in this process.  A television series of the same name was highly educational, not the only 'interventionist' approach, but certainly a well scripted example of a  acknowledged professional interventionist approach.

Before AA began Bill Wilson was being an interventionist in what would later be called '12 step calls'.  He himself was approached by Ebby who as an 'evangelical' Christian reached out to help his friend.

Personally, as a psychiatrist I have no difficulty with the notion of 'intervention'.  It can be a concern when abused as was the case in police states like Communist Russia.  When I was a member of the Psychiatrists against Political Abuse of Psychiatry we were advocating commonly for scientists incarcerated in asylums for disagreement with the political regimen of the day.

In traditional medicine a patient comes to a doctor with a complaint and the doctor prescribes a medicine which the patient takes or doesn't take.  Only in 'public health' is the intervention approach taken or in life threatening emergencies.  I remember a women walking in for a routine obstetric visit and me wheeling her up to the delivery room with the help of the nurse after my examination revealed she was nearly fully dilated.  She delivered a healthy baby in the delivery room within the hour. If I hadn't 'intervened' she'd have delivered in my office.

In psychiatry it is normal for me to sign a committal paper for a dangerously in sane person. Once I've done this the police will escort the patient to an asylum for their and the community's safety.

Generally speaking everything in medicine and psychiatry  is voluntary and driven by the patient. This is the same in addiction medicine. Patient's 'seek' help. They commonly admit that they've been told by their boss or family that they should see a doctor but their decision to see me is their own.

Many addicts and alcoholics simply curse everyone and leave.  This is called the 'geographical cure'.  Having burnt all their bridges they move on to a new set of potential victims taking their disease with them.  Geographical cures are notoriously inadequate treatment for serious addictions.

The disease of addiction and alcoholism is associated with minimization and denial.  Denial refers to the refusal to see that alcohol or drugs aren't the solution but rather the source the problem.  Denial is most apparent to a physician treating the myriad physical consequences of alcoholism and addiction, such as pancreatitis, cancers, ulcers etc.  I heard the statement "I don't have a problem with alcohol, I can quit anytime I want to" on liver failure ward from a yellow skinned 'flapper'. In end stage liver disease you ask a person to put their hands face up and over their heads and because of the associated neurological disease the patients hands 'flap'.  Commonly alcoholics in denial come into emergency vomitting blood whereas addicts will be picking bugs out of their skin and seeing CIA agents hiding in trees. Addicts in psychiatry wards  insist that all they need is to be released from the psychiatric ward to get a little more cocaine and that will stop the aliens attacking the world.  

In the days of Freud alcoholism was considered worse than schizophrenia because the alcoholic could have periods of lucidity that would fool them and those around them for a time into believing the person was cured.  In contrast schizophrenia was a steady deteriorating disease at the time without the episodes of apparent recovery.  The first reproducible 'cure' for alcoholism came in 1935 when the first 50 men in Akron Ohio remained sober following the steps that later would become the program of Alcoholics Anonymous.

Now we know that if a person developing addiction or alcoholism can stop their substance abuse in  the early stages (while they still have a job and some vestige of family left) then the success rate of treatment is roughly 80%.  End stage addiction and alcoholism associated with isolation and deteriorating physical disease have as poorer  prognosis.  This is to other  'end stage diseases' whether they be in mental illness like schizophrenia or physical illnesses like cancer.  In the last decades there has been considerable success in 'staging' alcoholism.  The well known John Hopkins University "Are You an Alcoholic?"  20 questions survey is less frequently used as a diagnostic tool today but it remains an excellent staging tool.

Some would say making the diagnosis of 'alcoholism' or 'addiction' is the first 'intervention' .  While I've never been attacked for diagnosing cancer which I've done frequently I've been physically attacked, repeatedly threatened, had my home windows broken and my car windows broken, and had multiple complaints to the College of Physicians and Surgeons for diagnosing addiction.

Because of the denial associated with the disease of addiction and alcoholism, Prochaska developed 'staging' for the 'readiness to change'  noting 'pre contemplation', "contemplation', "determination' , and "action' phases.  Making the diagnosis to someone in 'pre contemplation phase' is a potentially threatening scenario but thanks to a lot of trial and era and experience 'motivation therapy' 'interviewing techniques' offer some excellent tools for practitioners.

The complaints are never 'supposedly about' the diagnosis.  Alcoholics and addicts are not so direct.  All too often inexperienced, inadequately trained, or simply negligent 'complaints officials' have been royally duped.  The idea that  'one can make a diagnosis of addiction or alcoholism' without some patient getting angry is the greatest fallacy of the inexperienced and negligent.   My favourite forensic psychiatrist working in the jails after a life threatening attack said, "I'd always been told if I worked long enough in forensic pscyhiatry with the most dangerously insane people, there would come a time when I'd feel my life was in danger.  That was it."  The patient had been strangling the man with his own tie when his secretary intervened.

The joy for me working with front line workers in general is that they lack the ignorance and arrogance that is stinky and pervasive among the effete  Monday Morning Quarter Backs.   If you make enough diagnosis of alcoholism or addiction you will get a complaint.  Indeed the complaints department is increasingly one of the principal reasons for the collective failure of the medical system to address what has been called the 'public health crisis of the century'.

Diagnosing alcoholism and addiction, because of the stigma and the history associated with the disease, is commonly taken less favourably than diagnosis of cancer. When I diagnose cancer the patient may question the diagnosis,  express sadness and may well want a second opinion but they won't be  'angry at me'. If they are angry it's because I didn't make the diagnosis sooner.

In contrast with the disease of addiction and alcoholism the first reaction is commonly 'defensiveness' and the second is 'kill the messenger'.  Patients are commonly 'angry' at the diagnostician if only because they've been able to see a long list of 'enablers', negligent physicians.  Commonly the alcoholic or addict due to the psychopathic tendencies associated with progressive disease have been actively lying to clinicians and experience the 'diagnosis' as being 'caught'. A trained diagnostician will ask how many are "two beer" since 'two beer' is the knee jerk answer of the alcoholic confronted by the question of 'how many beer do you drink'.  "Two".  I suspect there are those who do drink 'two beer' and I feel genuine sorrow for them because they probably don't know that 'two beer' is alcoholic code for 2 'cases of beer".

It was common among 'enabling' doctors for them to be the least competent clinicians missing the diagnosis sometimes because they themselves suffered addictions.  It was even joked that you only had a drinking problem if you drank more than your doctor, especially if your doctor worked in government services.  I intuited early a colleagues later diagnosed severe addiction because he never diagnosed addiction in patients I'd subsequently see with advanced disease of alcoholism and addiction but rather diagnosed them as Bipolar or Adult Attention Deficit Disorder.

If you see a psychiatrist  he may even miss the diagnosis of alcoholism or addiction because of the overall poor teaching of addiction medicine and addiction psychiatry in the general programs.  The psychiatrist commonly  diagnosis 'depression' instead. In the workplace a person  with a diagnosis will be expected to take a medication and see a counsellor at most. However if you receive a diagnsis of alcoholism you can be denied work in safety sensitive areas, be required by union contract to attend a 1 to 2 month inpatient treatment centre, have 3 meetings a week of follow up and get random urine testing for any number of years following the diagnosis. Given the denial involved in addiction, the diagnosis of 'depression' by the negligent or incompetent or addicted physician won't have any effect on the alcoholism or addiction.  However if you receive a diagnosis of alcoholism or addiction from a caring and conscientious well trained clinician then the treatment will most definitely cut into your drinking and drugging.  So naturally the simplest thing to do is get a lawyer or make a complaint to the College of Physicians and Surgeons about the character of the doctor.

My favourite complaint of this nature was from a pot smoking pilot who swore at me and threatened me when I said that they would need to have a urine test for drugs.  They insisted they had a 'right to smoke pot' and I countered they might but that if they were smoking pot they couldn't continue by law to be a commercial pilot.  The proceeded to complain to the College of Physicians and Surgeons in an attempt to have my license rescinded.  The severity of their cannibis addiction was that they would rather destroy a physician and risk the lives of thousands rather than stop smoking marijuana. In their complaint which never mentioned their occupation or their chemical dependency on marijuana, they objected to being sent by Transport Canada to a psychiatrist and addiction medicine specialist who had a Bible in his office. I had a Bible on my bookshelf beside the Koran, Bhagad Vita, Plato and countless other philosophical, theological and psychiatric texts.  The College of Physicians and Surgeons investigated me for a year about my religious affiliation.  Not long after a similiarly 'impaired' pilot caused an accident which took countless lives. Transport Canada said to me after the whole ordeal that they routinely had difficulties of this nature.

I was called 'too confrontational' whenever I made the diagnosis of alcoholism because "making a diagnosis of alcoholism" was synonymous with 'confrontational".   I was also called 'insensitive' and one woman alcoholic said I didn't 'listen" to them when they were insisting that their boss expecting them to come to work every day.  She wanted to talk about anything but her DUI and her addiction and thought that if she could just distract me to focusing on her boss "rigid' behaviour.  I listened and eventually it became clear that her 'solution' to her problems was for me as a physician to write her a carte blanche letter which she could use whenever she wanted because  she just "sometimes" (weekly or more ) needed to have a day off  from work after a heavy drinking session. It's discouraging to know how many colleagues would have provided just such a letter out of fear more than anything.

Intervention is the act of 'confronting' an alcoholic or an addict with their disease, how it's hurting their health, how it's affecting their work, how it's affecting their family and friends. The common intervention pattern (as seen on television) is a 'group' or 'family meeting' with or without professionals in which the person is invited to come and "listen'.  At this meeting each person expresses what they see, to the loved one, and then what the disease is doing.  With that the group or family asks for actual committment that the person will go to a treatment centre or rehab center or detox.  The cornerstone of the 'solution' is an actual 'action' taken by the alcoholic or addict, not just 'talk'. Addicts and alcoholics love to 'talk' about detox, rehab or treatment but usually a 'written contract' or threat of consequence is necessary before they will take action.  Some consequences that have been highly effective in the family have been "if you want to see your kids, you must attend treatment and have random pee tests.'

In the work place, treatment and 'accountability' go hand in hand. "If you want to keep your job, you must follow the treatment program and under go urine testing for a minimum of three years."   The best accountability measures are attendance at support meetings such as AA/NA/Smart, and active urine testing.  Sometimes it is set up that a person go direct to rehab on the same day as the family intervention.  When people generally speak of 'intervention' this is what they are thinking of.  I tend to use the word 'intervention therapy' more broadly. In any 'intervention' the person is being 'told' what is expected rather than it being only a 'suggestion'.   Intervention therapy is sometimes called 'accountability therapy'. Interventions are commonly associated with expectations of action and consequences or accountability.

Treatment centres and rehab centers are one in the same. They are an 'active intervention' in a person's life. Their first and major effect is to remove the alcoholic and or addict from their 'environment' of addiction.  Alcoholism and addiction are a 'culture' of addiction. There's 'ritual' involved. There's the 'friendly ' bar tender, the 'dealer' on speed dial, the using friends and the drinking buddies.  The initial intervention involved in going to a treatment centre was for 28 days, with treatment centers providing counselling, group therapy and recreation and even work without the added drug or drink.  This 'inpatient' process with drug testing and 'rules' and 'conventions' 'normalizes' the routines of addicts and alcoholics.  They are socialized into a 'healthy lifestyle' beginning in rehab.  This can go on for 1 to 6 months.

An intervention which ultimately involves a recovery house where a person lives with other addicts or alcoholics in a clean and sober environment with expectations to attend groups and even have urine testing not uncommonly can go on for a month to 2 years sometimes more.

Interventionist therapy was used for children kidnapped and 'brain washed' with crazy Jones type religionists or jihadist radicalization. Removing the individual from the source of the 'insane thinking' was recognised as a first step to the person 'resocialization'.  The effectiveness of the 'interventionist approach' has been by those who see drug and alcohol abuse as a 'disease' and that it is indeed 'highly contagious'. Those who are most successful at staying abstinent for five years or more are commonly associated with a group of non using or non drinking individuals who support their recovery and abstinence.  In contrast to highly effective interventionists there ware the minority of politically correct wishy washy laissez fare drug and alcohol counsellors who consider drugs and alcohol a 'life style choice'.  The key to good intervention is knowing clearly the outcome planned and desired and having everyone on board to this clearly stated goal.

In motivation therapy the initial contact, best by a clinician, is an expression of concern and a question such as 'do you think you might drink too much.'  "Do you feel marijuana might be the reason you can't hold spit in your mouth today but used to be a straight a student?"  Family members and friends can ask but if denial is strong the person will wave off the question but only become angry if one persists.  Intervention is usually saved for a person careening out of control or with multiple relapses or one whose going through money rapidly, risking their health, beginning to be on the verge of losing their job or any number of signposts.  In intervention it's obviously beyond the 'question' stage and the individuals, family and work all know there's a problem with alcohol and drugs whether the individual knows or not.

Intervention has been lifesaving for many.

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