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.

John 8: 42 NIV Study Bible

"If God were your Father, you would love me, for I came from God and now I am here. I have not come on my own but he sent me.  Because you are unable to hear what I say, you belong to your father, the devil, and you want to carry out your father’s desire. He was a murderer from the beginning, not holding to the truth, for there is no truth in him. When he lies, he speaks his native language, for he is a liar and the father of lies.  Yet because I tell the truth, you do not believe me! Can any of you prove me guilty of sin? If I am telling the truth, why don’t you believe me? He who belongs to God hears what God says. The reason you do not hear is that you do not belong to God.”
The message of Jesus Christ is that God is not some old white hair guy or gal sitting on a cloud directing the universe. The Cosmic Christ is God Immanent.  God manifested himself in the world.  His son, his image, his word are here and now with us.  That word is the word of truth.
To me that is as true as ‘scientific truth’.  The Creationist knows God first manifest himself in Nature before the Fall and before the Cross.  Within nature there is the perfection and messages found in the matter of fractals, in the triangle, in the hologram.  There are immeasurably signs that man and nature did not just happen but were conceived.  A monkey given time simply could not compose as does Bach. The Big Bang theory, a foundation of science, states that there is a ‘finite’ time from creation. Within that time, a monkey simply could not compose as Bach.  Countless other matters of creation could not have ‘evolved’ simply because there is not the amount of time for evolution to occur. Further the idea of mutation doesn’t take into account that most mutation is devolutionary not evolutionary.  Understanding science and string theory and quantum physics scientists see the hand of God. Even Einstein, a theorist, said ‘God does not play with dice.’  This life is not ‘random’ but there is purpose.
I believe my purpose in life is truth.  The language of truth is fundamental.  The deep evil of political correctness language, the language of the demonic, is that it confuses truth.  “My truth”, says the devil.  Of course we all know that there are many perceptions and many angles of vision and experience. Yet in the end, we agree on truth in science. It’s called objectivity. My truth is subjectivity.  Together we know more than as one. Together we can.  The irony and hypocricy and utter deceit of the left and politically correct is their fixation on the ‘consensus opinion’ of ‘climate change’ yet they themselves insist on the language of ‘my truth’.  The very truth was the thing of ‘consensus’ not an individual claim. The devil lies. The devil is deceit. There is a yes and a no.  We know all is grey but the ‘aha’ moment gives us insight and discernment so that no everything isn’t true.  There is truth.  It is from God. It is the truth of science and gravity here on earth. It is the truth of right and wrong. There is morality.
Smoking marijuana and drinking excessively there is a blurring of the world. Everything is okay.  This is not enlightenment but devolution to a lower level of non discrimination. A child puts everything into his mouth and learns that poisons are not to be taken. The drug addict is so accepting so ‘chill’, so ‘cool’.  ‘Take it easy, Man, everything is cool.”  No it’s not. That’s the devil speaking. That’s a lie.  Everything is not ‘cool’.  Maybe in some metaphysical way it is but right here and now the killing of a child would not be cool. Ironically if I offer to taken the drug addict’s drug, suddenly this generous easy going guru of enlightenment becomes more truthful. The same with the politicians and rich men and women who are generous with the goods, labour and money of others.  It is not that they are evil but they do seem to heed the devil more than they heed the father. They are leaders who lead from behind not those who charge with the troops.
The historical Jesus said he was from God and that God sent him.  Fundamentally I don’t know how I got here.  I know from stories I was born to my mother but I don’t even remember it. I don’t remember my time in the womb. I have a birth certificate.  I presume that I exist as Descartes so simply stated, “I think therefore I am”  (Cogito ergo sum).  But I don’t know if I spontaneously occurred or was sent. It’s an act of humility to consider that I might not have the capacity to ‘self create’.  I know about sperm and eggs and that whole biological cycle but it’s all ancient and truly mysterious and difficult and unpredictable and even sketchy in parts that there is today no ‘consensus’ on the ‘start’ of human life.  The abortionists, great lovers of the devil, rich ruthless men and women who are the greatest of murderers and deceivers who have argued that it is not murder to kill even a full grown child in the mother’s womb about to be naturally born. These men and women for money would kill babies and toddler if they could convince the world that they were good.  The devil is the great deceiver.  But no we don’t quite know with utter certainly if God invests the fetus with life at the moment of egg meeting sperm or perhaps later in the womb. Indeed religionists say that each life is ‘predestined’. This means that God meant for the birth to occur. God mean for the egg to meet the sperm and life to follow. God did not mean for abortion to occur.
In this scenario there is a life purpose, that is God and there is the death purpose that is the Devil’s.  Freud called this ‘life wish’, eros and death wish, thanatos.  The devil is murderous. This dichotomy of good and evil is of this world , where truth and lie exist.  There is night and day. There is evidence of particle and wave.  Flow and stasis.  Right and wrong. Truth and lie.  The language is not ‘my truth’ and ‘your truth’ but rather ‘my perception of truth’ and ‘your perception of truth’ otherwise these politically correct nut bars would have us saying ‘my light’ and ‘your light’ and the pc police would have you arrested if you insisted at midnight in utter darkness that ‘its’ night’ not ‘day’.
Language is the first casualty of war.  And don’t get me wrong, I believe there is a war.  The devil is in the detail. The politically correct speakers are demonic. They are liars. They would try to convince us that ‘black is white’ so we will accept that ‘your money is my money’ and ‘your life is my life’.  Political correctness in all it’s forms is evil.  
Jesus Christ was without sin. To sin is to ‘miss the mark’. It means ‘to sin’ is to err.  My intention when I shoot my rifle at a target is to hit the bullseye.  When I miss I have ‘sinned’.  To those who argue that all is ‘determined’ and ‘all is fate’ and that they have no accountability and no responsibility then there can be no sin. Yet I have observed these sinners all my life and they are very specifically willing to accept praise and reward for what they do but unwilling to accept punishment and blame. They are above the law. Their truth is narcissism. Their father is the devil.   They ‘change history’ to agree with what they want because they do not want to admit that their ‘purpose’ was other and that good came regardless of their intent. They would argue that ‘good things’ happen and ‘bad things happen’ and they were ‘lucky’ and you were ‘un lucky’.  They deny they ‘fix’ the games because they are liars.  The devil is a murderer and a liar.  If all is ‘accidental’ then the devil doesn’t have to be accountable.  They never accept responsibility for their behaviour but would rather ‘deny, deny, deny, lie, lie, lie’.
Now  the old language of the Bible is nonetheless a valid language. I can use the word ‘karma’ instead of ‘retribution’. I can put the language of Jesus into the California message of the Secret. I can talk about the first law of physics as God and the second law of physics as the devil. I can show the opposing forces in the universe physically and ask why there would not be opposing forces in man. I feel there is a ‘good’ way to do something and a ‘bad’ way.  If I want to build something I can do it with ‘efficiency’ and ‘least waste and destruction’ or I can cause the most havoc and crisis to achieve my end.  The idea of good and bad, or good and evil is throughout our world and our society. We question the decisions that serve the fewest and celebrate those decisions that benefit the most.
Increasingly there are bankers and financial folk who trade in companies and acquire drugs that cure and yet they price them at maximum profit and show no interest in the outcomes of their decision and how they would affect a sick child.  There is a back lash.  It’s karma. It’s Jesus. It’s Christ. Life’s a bitch.  But there seems to be a connection between kicking and mule and being kicked back.  We know in war that more people are killed by ‘friendly fire’ and the ‘stupid decisions of leaders’ than by the enemy bullets.  This push back is everywhere. This is ‘truth’.
Now the politically correct would lie and lie extensively.  Truth is truth. It’s not a possession. The new consumer society would say this is ‘my planet’. This is ‘my galaxy’. This is ‘my creation’. They sound like little children because they have not morally or emotionally developed. They are not diaper trained either.  Jesus recognized that the world was full of children and he loved the children.  So he said, “forgive them for they know not what they do’.  They are the tool of the devil. They are deluded. They are the zombies who are taken over by political correctness and other godless lies.
Of course it’s not ‘cool’ to think of the Devil as a serpent. Just like it’s not cool to think of God as a white haired elder out on a cloud. Just as God is immanent so is the devil. The devil is that which is inside you that is destructive. God is that which is creative. God and the devil are two voices inside each of us.
Jesus is asking which you will call your Father. There is choice. And you will be accountable.

Chronic Relapsers Misinformation

These are some rough estimates and truisms.. 10 % of people will have problems with an illicit substance. A proportion of those who avoid problems ‘spontaneously’ quit.  The earlier one quits substance abuse, the greater the success rate. Drugs and alcohol and other addictions are ‘fun’, ‘fun and trouble’ and finally just plain “trouble’.
Abstinence is the most successful ‘treatment’ for addiction. The WHO advocates that all harm reduction approaches should only serve as stepping stones to abstinence. There have been countless horror stories associated with ‘controlled drinking’ and clearly to date there are no good stories of ‘controlled crack’ use. The whole ‘control’ movement is as historic as ‘just say no’.
In studies of those who do ‘abstinence based’ therapies up to 80% achieve 5 year or more recovery. Dr. Marc Gallanter’s Harvard studies of doctors in recovery in AA shows 80% recovery up to 50 years after the last drink, decades of abstinence.  I personally know hundreds of people who once had severe addictions that cost them health, jobs and relationships but today are decades drug or alcohol free with successful careers and relationships.  Most of them are members of 12 step programs or churches.  Indeed addiction is described as a ‘spiritual disease’ by some and ‘cancer of the brain' by others.
The first ‘remission’ marker is one year.  The DSMV considers a person in full remission with a year of abstinence.  Most others including Dr. Vaillant of Harvard saw that the disease effects were significantly present for 5 years of abstinence when finally  a person potential for relapse was no greater than an as yet unidentified person’s risk of developing addiction.
In a famous Montreal study, 50% of those who returned to drinking, were able to avoid returning to their previous level of drinking, somehow maintaining ‘harm reduction’ without descending into their former abyss.  Interestingly a Holland study showed that people abstinent for 15 years who returned to drinking, 70% were able to maintain ‘harm reduction’.  While one in two odds of redeveloping a life threatening illness aren’t actually encouraging, and even a 30% chance of devolution at 15 years doesn’t look bright, this does suggest that the original disease appears to ‘burn out’ with abstinence over years.  The modern research on neuroplasticity and adaptation certainly takes into consideration the increasing information of the effects of ‘intoxication’ on the brain.  All research to date shows that those who achieve abstinence have the best life course, physical and mental health.
Note the word ‘toxic’ in intoxication. Addiction is associated with altered consciousness, dissociation and impaired mental capacity, the effects of which can last hours or days or , with marijuana for instance, weeks after the chemical brain trauma.  By contrast with alcohol, where there is social drinking where a person does not drink to toxicity (1-2 drinks)  with drug addiction, all drugs are used for the ‘effect’ :’chemical drunkeness”, “getting high”, ‘being stoned’.  People drank as a beverage whereas drug abuse is done to achieve 'toxicity'. Drug abuse alters consciousness. It impairs brain functioning. Enhancement of one function is countered by loss of other capacities as with drunkeness.
Addiction is like slavery.  A person is freed by abstinence but with relapse return to their slavery with the attendant lack of hope, lack of faith in their ability to get free, increased cynicism about their potential but more significantly increased negativity about ‘freedom’ itself despite the high success of those around them.  Their relapse and the associated depression that is usually concomitant in time is associated with severe 'cognitive distortions'.
Fruitflies were the great genetic tool of genetic research since they shared 70% of human DNA and had short life expectancy. Thanks to the overwhelming success and the extraordinary numbers involved in the recovery from cigarettes, Cigarette addiction and recovery have taught us as much about ‘addiction recovery’ in general as fruit flies taught us about human genome.
When people relapse they have already progressed through the Motivational stages of Prochaska from Precontemplation, Contemplation, Determination and into Action.  Unfortunately ‘relapse’ commonly throws a person back from the Action phase to the pre contemplation phase for a period of time.
In this phase they tend to be extremely negative and blame the treatment failure on a variety of usually inconsequential or irrelevant factors.  Rarely will they early acknowledge that they were no longer following a program.  Relapse is the outward manifestation of the 'thinking disease'  which is the precursor to actual substance abuse.  Mostly people begin by minimalizing their own previous difficulties with alcohol or drugs, begin to grandiosely believe that things will be 'different' this time round and delude themselves into believing that they can 'control' their drinking or drug use despite no personal evidence of their being able to maintain this in the past.
One of the prime criticisms of Alcoholics Anonymous was ironically the ‘god’ issue.  Addicts worship their alcohol and substance, living a ritualistic religion surrounding their death bound existence.  However in research with obese people, 12 step programs weren’t initially recommended but rather it was suggested that the grossly obese go to the gym. In contrast to alcoholics and addicts who are highly adept at ‘excuse making’ (the disease of alcoholism being personified as ‘cunning, baffling and powerful) the food addict, those grossly abese, simply said, “I don’t want to go to the gym’.  When advised to go to Overeaters Anonynous, they never mentioned the 'god problem's but  simply said “I don’t want to go out”.  It's refreshing to work with obese people in that they don't tend to waste their 'energy'  on 'excuses' despite their equivalent difficulties with stopping their compulsive food use.  At best they'll tell you they have a 'metabolic' problem.
It has long been known that alcoholics and addicts will go anywhere for a drink or drug and never complained about crosses in the room or pictures of the queen or president as long as their drug of choice was available there.  In the ‘contemplation’ phase of motivation they would complain about the colour of the paint if it convinced people they personally were the exception to the rule that recovery is good. The fact is, a person who has relapsed, has lost hope in themselves.
Psychiatrists long ago knew that with those who were ‘suicidal’ and had similarly lost hope in life, especially the chronically suicidal, needed the psychiatrist to ‘lend them their ego’.  We make decisions that suicide is not good for a person.  Similiarly those working in recovery who are successful maintain the idea that recovery is good for a person, much like thinking oxygen is.  Those who don’t, have been found to be associated with a very poor outcome measures as we saw with those who had a poor view of the suicidal. Outwardly the caregiver could go through the motions but at the covert and passive aggression level they were and are best recognized by their high death rates.
Much of the push for ‘harm reduction’ has been associated with a similar phenomena. The caregivers and those who promote harm reduction most are often ‘burnt out’ or always had a very negative view about the addicts and alcoholics.  One psychologist described this as 'caregivers and victims'.
It's even worse when those promoting harm reduction have an obvious 'conflict of interest'.
A recent Welsh study showed that Harm Reduction proponent counsellors  gave the success rate for recovery of their charges at less than 20% , but when these same people were in ‘abstinence’ based programs they achieved greater than 60% success.
This separation between those caregivers with hope and those without was also shown in cancer treatment.
Palliative Care is a program developed first for cancer therapy where the person’s disease was so severe and all alternatives for cure were tried without success and no successful treatment was known for the type of cancer the person had.  Palliative care is compassionate but it would not be if it was offered as a first choice or 'alternative therapy'.
Lack of success is not the case in addiction therapy.  Alcoholics anonymous has an 80% success rate 5 year and decades beyond but the ‘program’ is like the ‘birth control pill’.  If one takes the birth control pill once it is highly likely to fail.  This is the reason research did not identify the factors of high success in AA. Researchers simply asked people if they’d been to AA or NA. It’s common for people to go and not return, like those who asked if they used the condom for birth control might say they had but leave out that they’d only used it once in their life, and not the year they got pregnant.  The Navy Pilot program showed that 5 year 80% success with AA required a minimum of 3 meetings a week. The recent Scottish study which confirmed the 80% success rate included ‘home group’ and 3 meet ings and having a sponsor for instance to indicate ‘actual involvement’. As one person commented, a lot of people attend basketball games but you're more likely to find out how basketball is actually played and become good at the game yourself if you join the folk down on the court with the ball, rather than talking with drunk in the bleachers.
Relapse was associated with:
1) stopping or  reducing frequency of meetings. I often think this isn't different from any form of education since I meet people who despite having gone to university haven't read a book since and seem a hell of a lot stupider than people without a university degree continued studies.  With HIV treatment we need people to continue to take medication or they will die. We don't question the validity of the life saving 'medications' because people are 'noncompliant'.  We work on improving follow up and compliance but we are most impressed with our 'success' in developing treatments for HIV and Aids when at first there were no treatments. Since the 1930's we've made major strides in developing successful treatments for addiction and recovery.  Commonly people's lives are enriched in recovery and complacency returns.  Then stress occurs.  That's when all the 'tools of recovery' are thrown out.  I personally love the Dr. Martin Luther King quotation. "it's going to be a tough day so I have to spend more time on my knees".  When people have more stress, activity, change or success in their lives they usually need more 'recovery' activities, not less.
 2) Returning to previous association with drug abusers.  Recovery has been shown to be as “contagious’ as addiction. Having one abstinent friend in ones friendship circle reduces the chance of relapse by 25%.  People who relapse commonly begin to associate again with 'slippery people, places or things'.  Dr. Bob and Bill Wilson recognized that alcohol was ubiquitous in their society so said that recovery had to occur in the community. However it was also true they didn't recommend people avoid people in recovery and spend their nights in 'speakeasies'. In treatment today people are advised to avoid crack houses, dealers, and especially paraphernalia, as we know that 'jonesing' something not seen so much with alcoholism, but common in cocaine addiction does occur for up to a year after abstinence.  This phenomena is like we see with PTSD and the 'trauma' of addiction and the associated lifestyle. People with addiction today are often starting their addictive lifestyles earlier and have a world of hurt by the time they get into recovery with much less life experience, education or positive communities to fall back on.  
3) Commonly people recover from addiction but then have ‘expectations’ which are highly unrealistic.  Expectations have been called ‘preformed resentments’ and while AA and NA and other recovery programs treat the disease of addiction they specifically describe the need for members to get outside help with other issues.  These issues commonly include financial management advise, job advise and job training,  relationship counselling, pastoral care, anger management and a wide range of ‘maturity’ issues which are not achieved by addicts whose addiction stunts emotional, intellectual and social growth.  A person who has been hanging out with ‘potheads’ may stop their addiction but it takes time to develop a strong and positive friendship network , the kind that gives meritorious advice that makes life in general more successful and rich.  Increasingly the isolation of addiction is associated with the isolation of the internet following the positive experience of recovery in treatment.  Internet addiction then leads back to chemical addiction.
4) Attending a treatment centre may help establish abstinence and break the slavery to addiction but commonly just as with education there is a need for more advanced treatment education. Some treatment facilities like Betty Ford have programs for continuing education and also are set up for return of ‘sober’ or ‘abstinent’ members to work on more advanced issues like ‘emotional sobriety’.
5) Commonly ‘cross addiction’ leads to relapse. This is especially true with sex and gambling addictions which then lead to a return to chemical addictions.

It is critical to recognize that the ‘excuses’ that addicts and alcoholics give for relapse are usually time and ‘disease’ specific.  I’ve asked people who achieved abstinence after several initial failures what was the key. Almost invariably  I have heard that they really didn’t want to stop their addiction but had only planned to stop for a while to get somebody off their back. It's hard to accept having a lifelong disorder. I see the same difficulties with diabetics. No one questions the benefit of 'insulin' but all those who treat adolescent diabetics have seen the same problems we see addicts have coming to terms with the limitations of disease and the need to learn new methods of self care.
Often people in recovery get success but then the ‘boredom’ of everyday living lacks the ‘drama’ of the previous chaotic lifestyle and they solve the ‘little problem’ by creating a ‘big’ problem. Anyone who has 'worked on long term relationships' knows how the 'little things' if not addressed can grow into bigger things.  So often over time the 'little resentments' and 'lack of honesty' and 'living a lie' grow to a point where they taint the good life and recovery and relapse follows.  Recovery isn't a white knuckle affair but a lifestyle which is 'happy, joyous and free' because life is to be 'lived' not merely endured. This has been called 'emotional sobriety' and 'spiritual awakening'. It was always recognized that people who drank or did drugs has an 'underlying' predisposition or greater level of anxiety or sensitivity and had to learn new coping mechanisms for fulfillment.  When a person becomes an addict it is 'normal' for them to drink, drug or abuse. It is not 'normal' to be abstinent for an addict or alcoholic. To be abstinent requires them to daily live a life which promotes well being beyond that available by their previous lifestyle which 'lead' to addiction.

The ‘treatments for addiction’ are to date superior than most of the treatments for physical illness when they are applied and managed as recommended.  The problem which occurs with addiction is the same as doctors are finding with all the chronic diseases or diseases of lifestyle.  Indeed the treatment of chronic disease is increasingly learning from the successes first seen in addiction. The advances brought forward by 12 step programs are actually being translated to ‘accountability’ groups and used in the "normal' work place.
AA and NA introduced the concept of ‘anonymity’ as a ‘spiritual foundation’. They didn’t want people to speak of their personal success at a time when people’s relapse caused people to question the success of prevention and abstinence treatments.  Today there is overwhelming evidence of success of prevention and addiction treatment but increasingly vocal chronic relapser misinformation.
We used to hear “I stopped smoking but I didn’t feel any better’ in the first weeks of people quitting smoking.  They then used this ‘excuse’ to continue smoking.  However, now, with millions having lasted that first year of recovery we hear endless numbers of former smokers saying what a relief it is to them to be no longer be a slave to cigarettes. This is true of 80% of those who maintain abstinence from substances for five years.  Then those who relapse stand a very good chance of achieving long lasting recovery with appropriate treatment and relapse prevention programs developed for the individual relapser.

I liken this in my work to people with bladder infections. The vast majority get better with one antibiotic. A number relapse and the the antibiotic works again but there are those who need a different antibiotic and even those who we simply find it best to keep on antibiotics indefinitely.
The one week detox program has now had the 28 day program and there are recovery treatment programs which last 2 years. This was the same with mental illness where patients with similar psychosis were unsafe for themselves or others even with 1 week, one month or 3 months programs and they benefitted for a year long recovery in asylums.
All of these approaches standard in the scientific medical treatments are the same as we use with great success in the treatment of addictions.
Part of the success in treatment of mental illness was the recognition that substance abuse, like marijuana, alcoholism or harder drugs were all interfering with the learning and recovery process from mental illness. When I reviewed the suicide completion statistics in one program I found that though there were many who were at one time suicidal it was almost only those who had addictions
that completed suicide.

I’m commonly asked to see people suffering from depression or anxiety and almost all the time the family physician and especially the parents,( especially the mothers) , rarely know how severe the patients addiction to alcohol or marijuania, crack, methamphteamine or heroin is.  The patients tell me because I ask very directly and am highly trained in recognizing the signs of dissimulation that the alcoholic or addicts uses to ‘guard’ their ‘secret’.  
Relapse is treatable but the best solutions to treating relapse are to be found from those who once were ‘chronic relapsers’ and succeeded. I liken this obvious reality to our collective human experience with climbing Mount Everest. For centuries people ‘failed’ and we learned ‘how to fail’ from the ‘failures’ and eventually when people climbed ‘Mount Everest’ we learned how ‘best to climb Mount Everest from those who "succeeded."

Today the ‘harm reduction’ groups are arguing not only that Mount Everest can’t be climbed but that we should listen to people who either have never seen a mountain or may never have got to a base camp.

Lawyers, Doctors and Life and Death

It is possible to get a law degree on line or by mail order.  There is no limitation to the size of a class for lawyers.  The only limit to the classroom size is sound system.  Lawyers could be trained in stadiums and shopping malls. There is further no direct correlations between the well being and health of a community and number of lawyers.  Law is an arts degree, albeit applied arts.  .  
There are distinct limits to the number of doctors a community can produce because the process of learning medicine is hands on. It's a science and an art. Students must have A grades in both arts and science.  The learning of medicine involves dissecting bodies, touching abscesses and talking to dying people with contagious disease while worrying if you are getting the disease the dying person already has.  It's distinctly smelly and nauseating to be a doctor.
Lawyers avoid disease.  Their contact with disease is less that a check out girl's.
Doctors are trained in scientific reality.  There is gravity in their discussion.  Lawyers are trained in argument and are notorious for the 'emperor has new clothes'.  A good lawyer can convince you a serial pedophic murderer is not a bad guy and just didn't get enough cuddling and breast milk.
There is a surplus of lawyers and laws.  There is a shortage of doctors. There is a direct correlation between the health of a community and presence or absence of doctors.  Less than one doctor per 500 people there's a greater burden of disease in the community.
There is no correlation between lawyers and health and there is even further no correlation between lawyers and crime or justice in a community.
I like lawyers. I think they take amazing risks financially and rarely personally.
Who best to decide whether a person is dead.  Hands down a doctor.
Add a lawyer to the equation and there will be delay, increased cost and increased argument. Lawyers make the best critics and are by far the most litigious, political and argumentative.  Lawyers are wonderful where there are no limits on the overall costs of health care.  Lawyers are happiest to make the most money in any context.  They are even better where  time isn't  a factor (I was just in a court where the judge was trying a matter that had occurred over a decade ago when dinosaurs by scientific time sense had ruled the world).
Note, doctors live in a real world of biology and chemistry where seconds and nano seconds in decision making affect life and death. They're like the soldiers in the front lines whereas lawyers are more like the historians who discuss battlefields on Monday morning.
Right now in Ontario there is a tribunal for resolving death.  They leave it to doctors in most cases but now doctors have the burden of everyone looking over their shoulders so when they want  to they step in and discuss death.  It's a doctor, lawyer, layperson committee. I'm always suspicious of the lay persons. Who are these people and what political favour got them in these truly cudo positions.
If a person is dead a doctor wants to stop taking care of them. If there was no limit to resources and infinite funding for medical resources a lawyer would gladly maintain a dead person as they are like 'dead files' in the legal sense.  "Cold cases' in the police sense.  But doctors are devoted to the living and if anything would rather the dead cases be transfered as quickly as possible to the pathologist or mortuarian.
Is a person alive?  A doctor knows betters hands down over a lawyer.  To a lawyer life and death is more like the Monty Python joke about the 'Dead Parrot."  "It's a pretty parrot. Are you sure it's dead." "Yes, it's dead, you sold me a dead parrot."  "N o, it's just sleeping."
In all aspects of my medical care i make decisions about life and death.  I've done amputations and discarded dead babies and pronounced dozens of people dead.
Today a lawyer wants me to discuss these decisons with him.  For that to occur there needs to be another room in the hospital with a bed and 24 hour 7 day week call schedule and lawyers will have to be on call in the hospital even though they'd like to do 'call' from their homes over the phone maybe with skype or television camera.  "Yes, doctor, he looks dead to me over this android iphone . "  The cost of a parallel lawyer on call system will ensure that thousands of babies next year will die because there will not be a surgical unit as theres now another law office in the hospital. There already are law offices in the hospital and administration offices. There's just no room for doctors or patients.
Decisions happen when there's a dead person and doctors have to move the dead person out of the room to let in the live person. It's called triage.
CBC had a freak show sexist person on the radio this morning saying the days are gone when doctors make 'paternalistic' decisions.  What is this 'paternalistic" decisions business anyway.  A leading doctor in the American Civil War was a woman who pronounced dead thousands of soldiers. In 1930 30% of medical school classes were female. Half my class were female.  My teachers were female doctors.  I was called before the College of Physicians and Surgeons over the politically incorrect though clinically correct life saving care of a female child and was judged by 6 women doctors, not a man among them.  They were all extremely parental but not a single maternalistic one among them was paternalistic.  The judges are historically paternalistic but it's still truly frightening when the national  media has this level of sexism front and centre in Canada a supposedly civilized modern or post modern society.  CBC Freak show.
Yet the law would call me offensive if I were to speak disparagingly of the worst evils of maternalistic medical care as it endeavours to deny the dead life saving measures
To the best of my knowledge everyone wants to cherry pick. Right now that's what is happening in the life and death debate.  Doctors are doing it and doing it extremely well and have for centuries. Now lawyers want in on the action, not pro bono, but for a remarkable fee, and doctors would gladly include them. All I ask is that doctors be assured that they get paid equal to lawyers and given the same amount of time in the decision making process about life and death because last I looked the law was principally about money.
Medicine is about life and death.
That said I really admire all my lawyer colleagues who do work pro bono. They exist and are a grand bunch of men and women. Many in their profession frown on them as much as doctors are frowned on who by others standards 'give it away for free'.
All manner of folk don't want to believe their loved one is dead.  All manner of folk want miracles.  Everyone feels good as the gift giver.  No one likes to give bad news.  I confess I'm a little miffed to think that others want the cream and get in on the high profile and cherry picked cases and 'special cases' where they get to say "lets keep your loved one, dead as they may be, a while longer on the life support equipment that someone else is paying for."  I want to be a patient 'advocate'. That's what a doctor by definition was but now the word 'advocate' is restricted to the lawyer.  And soon there will need to be two lawyers because being of two minds about all things they always travel in pairs.
My friends are great lawyers and I love their company so I really appreciated hearing that US doctors are now having lawyers accompany them 24/7 like bodyguards. The amount of money I miss billing for in the public health system because I 'm so distracted by trying to keep people alive would likely pay for a similiar service.  The last hospital I worked at I used to coffee clutch every other day with the hospital lawyer.  But the hard decisions were always in the wee hours of the night when you needed a lawyer at your side to tell you what to do and then for that same lawyer to go to jail with you when you made the wrong decision.  I want someone to have my back and if it's going to double or triple or quadruple the cost of health care, so be it.
Every dead person, not just the pretty or rich ones, should have the same benefit and given an MRI or a lawyer I'm sure dead people would want the lawyer. They certainly don't care for another MRI after they're dead but lawyers who have comforted me in trying times could well comfort the dead.
Now the decision about life and death is going to the Supreme Court of Canada. This is the same group that is pro abortion and said babies were dead and could be killed even better when they were in fact alive. There's one lovely lady who was aborted and chucked in the waste only to live and go on today to give talks about life and death.  Everyone who decides life and death decisions should know her.
The Supreme Court of Canada are all lawyers.  The question is whether dead people need lawyers when we cut away the chaff and just as I saw doctors need lawyers and as lawyers go in pairs and hence need lawyers, the judges will likely say the dead need lawyers.
I am indeed looking forward to being asked by the Supreme Court of Canada to teach the new law students about death. I'm looking forward to showing them where to touch dead people, how neck vessels aren't often as useful as groin vessels for getting pulses. Further it's a particular smell that one needs to become intimitately aware of .So I want to take the lawyers and those lay persons out to smell floaters first. Then I'm going to go round the morgues and get the nostrils of lawyers really geared up for the more pungent death smells.  Gangrene is particularly memorable. Dissecting dead eyes so I gained a real appreciation of the dead gaze and would think dissecting dead people's eye should be part of the curriculum for sure.  I really enjoyed that. Studying the urine and feces and any genital discharge from the body was alwasy helpful.  I haven't noted genital discharge  so it's not been part of my observation but it's said to occur.  I've not needed it for decision making but using a stethescope and listening to chests and also know how to know when EKG machines are unplugged or malfunctioning was important.    I've found that looking at the  feces and urine and smelling sweat helped my decision. There's a whole lot more to the decision making too and frankly I've never met a lawyer to date who is certified qualified or capable of reliably knowing death. I further expect that my training of lawyers will require them to do at least one more year of law school to accomplish what is the bare minimum of knowledge about life and death in a scientific world.  I could teach a farmer a whole faster that a city slicker lawyer but that's a whole other kettle of fish.
I've not made a mistake yet pronouncing people dead.   All my dead have stayed dead but a few of my colleagues, those who worked more with the dead,  who were way better than me at telling death, had their pateints miraculously come a live.
I'd think therefore a religious leader and a lawyer should be present and trained in the decision making about life or death.  I'd be glad to do a year of life and death scientific training for religious leaders and extend their educational requirements in terms of cost and time as well. So now I've got a lawyer, a religious leader, and a lay person and because of that sexist CBC attitude I'd like some representatives from various gender groups.  Transexuals, homosexuals and lesbians shouldn't be excluded.  As well, a random assortment of cultural groups or perhaps the whole United Nations could be present. .  Finally I knew when my grandmother was dead as a child. Most likely by luck. But I've known children who knew things were alive which old folk didn't. So I'd say we should have a child making rounds everyday with me.  It's a committee then and government loves a committee because then no one is accountable and everyone can pass the buck.  Of course the expansion of hospitals will cost billions so that my entourage will be able to go from room to room in the hospital. Probably twenty or thirty lanes will reduce likelihood of foot traffic jams between wards.
But I'm a private person and when I die the last thing I'd want is a committee about.  At most I'd like a doctor and a family member and if I don't have a family member I'd take a friend, a religious leader or a lawyer.  Hell, a cowboy or fireman would be good too but then I'm not fussy.
What I really think is that we should all accept that we need a living will and when we go for our driver's lesson we should have a box to check off.  When you're dead do you want to be dead and stay dead or do you want to come back to life.  Only some of the people I resuscitated thanked me. The others hated me till they died.  I'd prefer the lawyers take the ones who hated me for resuscitating them while I'll be glad to continue to care for the ones who are grateful that I saved their lives.