Recovery: Whose job is it?

Big Book of Alcoholics Anonymous

“You will be most successful with alcoholics if you do not exhibit any passion for crusade or reform. Never talk down to an alcoholic from any moral or spiritual hilltop, simply lay out the kit of spiritual tools for his inspection.””

Commentary

When we are teaching junior doctors and counsellors we advise them to watch themselves carefully to see if they are putting more effort than the patient into ‘rescuing or curing’ them.  Whose job is it?  I can’t make a person drink the medicine. I can give them the medicine.  Indeed it’s been said that I will hold their head under the water to make them drink but that after a while even with that approach even some would drown rather than drink.

Addiction is in part a pout.  Enablers are treating alcoholics and adults like children when they are adults.  Perhaps proto adult,  Adolescent really, but to be adult you don’t start ‘babying them’ for their own good. You offer them resources to ‘recover’, not to persist in their addiction.

I remember hearing these two addicts discussing social services, “I’ve now got a place, there’s free meals at the church, and I’ve got a bus pass, now all my disability money can go to drugs.’  

Giving money to an addict is actually giving money to his dealer.  One of the most successful ‘harm reduction’ policies which worked for years until some aetheist interfered, was a local priest who took checks from addicts on Welfare Wednesday check day, then doled their money back to them daily. I have a patient whose sister gives her brother $10 a day because when he had $20 he spent it on crack. His dealer actually approached him each day to ask if he had $20.

Adulthood is ‘accountability’.  

The brain disease of addiction is that it causes the forebrain or judgement to be impaired. A person loses the capacity for ‘delayed gratification’.

 “I want it all and I want it now.”

There is a regression from adulthood back to adolescent learning.  In recovery we describe the person as "40 going on 15." It seems there’s an emotional delay that occurs once a person becomes addicted. Most people learn to ‘self soothe’ without drugs and alcohol. The alcoholic or addict may act juvenile but they’re always very canny.  Their capacity to think is not impaired in that sense. The fatal flaw is their inability to carry through with plans.  They have all the ideas of the ‘adolescent’ or ‘child’ but lack the capacity to complete tasks, overcome adversity, work together, delay gratification.  These are all adult skills.  Drugs disrupt learning 'adulting'.

I treat mechanical brain injury, when a person drives a motorcycle into the wall hitting their head and chemical brain injury, when a person dumps drugs and alcohol on the chemical circuit board of the brain.  The behaviour and function are very similiar though fortunately for the alcoholic and addict initially the damage is reversible if they abstain.  The recovery process are the same.

In ‘detox’ treatment, empirically it was necessary to establish a barrier if only slight to access.  Years ago when I was heading a detox we would admit a person who while drinking had remorse and wanted to ‘go on the wagon’.  As the drugs cleared their system they ‘changed their mind’ and left. Today most detox require a person to be seeking detox for 24 to 48 hours. The success is greater.  The greater the commitment the greater the success. Even with Suboxone a person must be in ‘withdrawal’ before the treatment can begin. If this medication which is a combination of opiate and antagonist was given to a person ‘high’ it would just throw them into painful withdrawal.  

The treatment of choice for addiction and alcoholism is abstinence.  Harm reduction has always been considered a valid ‘stepping stone’ or ‘entry’ point to recovery.  Recovery is the whole ‘process’.     

When you feel you’re doing more work at their recovery than they are, it’s time to back off.  Alcoholism and addiction are in part escapism. The adult with every drink becomes more childlike, seeking the tit or womb.  They become legless and incompetent.

With an injured person in the emergency we as doctors provide immediate care and take over the function for the person in the first day but even if we put them on respirators and bypass machines we are always working to get them off.

The survival post surgery is best in those who get up and walk on their own.  Why would we think differently in treating mental illnesss. The aim is to restore a person to full functioning. Yet there are enablers and those who ‘appear’ to care. but are really negative not believing in the possibility of recovery for an individual.  They are the enablers who infanticize the alcoholic or addict and provide them everything.

I wonder when I see what my mechanical brain injured patient is given versus the chemical brain injured person. When the latter is getting ‘more’ something is wrong.  The recovery from mechanical brain injury, if severe, still can occur but it’s slow. Fortunately the person isn’t continuing to hit themselves in the head with a hammer like the addict who continues to relapse.

If they  are alcoholic or addict continues to drink especially then we are the problem not them. We are enabling them to do more brain injury and more destruction.  Limit setting is adulting.

Unfortunately as children mirror adults, addicts and alcoholics mirror their caregivers.  When caregivers are unable to set limits, have rules, be themselves disciplined in their ‘giving’, then the addict or alcoholic doesn’t learn. As a life guard my first lesson was not to let the drowning person pull me down with them.

The original AA members when they went out to talk to an active alcoholic found that if they went alone they were as likely to start drinking again themselves.

We’ve seen many of the institutions established in good faith to help alcoholics and addicts take on the emotional maturity and behavioural developmental stages of the alcoholics and addicts.  The institution is pulled down by the drowning alcoholic and addict.  

There are caregivers and victims.

The joke in the church was that it should be called ‘sinners anonymous’. It was also said that we should not  ‘judge’ another because they ‘sinned’ differently.

It was found in Al Anon, the organization for friends and family of alcoholics, that ‘enabling’ and engaging in the ‘self delusions’ of alcoholics,’arguing with them’ , ‘coercing’ them etc was counter productive.  The Al Anon learned instead to ‘detach with love.’

The “holier than thou’ approach to addiction simply doesn’t work. The ‘I am the doctor, you are the patient’ doesn’t work either. What has worked quite miraculously is the approach of “I’ve had your problem" and "I’ve got a little further ahead while I’m still working on a problem.”

I asked a doctor how he had climbed Mount Everest and he told me that there was a club in Switzerland where people who had climbed Mount Everest gathered. He’d gone and learned from them.12 step programs have been similar clubs.  These are people who were spiritually bankrupt but now are rich on life. 

The job is not to ‘feed’ the alcoholic or addict for life’ but rather to ‘share the spiritual tools with those who want to learn and want recovery’.  The "Stages of Change" was developed by Prochaska to address the Motivational level of individuals who had various diseases.  As a caregiver one offers the ‘options’ and encourages ,but doesn’t do the work for the individual and doesn’t enable or ‘carry’ the person other than briefly.  

One of the problems with lack of resources in the area is that many ‘acute’ resources have been commandeered by the ‘chronic’ .  Hospital beds that are specially established as an ‘acute’ services are being used by mismanagment government for ‘chronic beds’.  Lack of chronic low cost housing results in losses of millions as the mismanaged constipated system backs up and high priced acute services are wasted on ‘chronic’ care.

Perhaps this is evidence that the ‘system’ and ‘institution’ has become more drunk or drug addicted or ‘diseased’ than those for who the service was intended.