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.

Genius and Psychosis

Thanks to very fine teachers I used my time in training on call studying the long history of psychiatry.  I read the original works of Jung and Freud , Reich, Adler, and later Frankl, Menninger, Erickson.  It was in their personal writings that so many of the most profound insights were recorded. I love R. D. Laing living with Schizophrenics and the original community projects and other experiments that clarified modern ideas of mental illness.

 Today too much emphasis is placed on the ‘evidence based’ scientific study since it’s inherent limitations are the money and selection of the research that such studies so commonly are designed for.  Clearly the Grant Study like the Framingham study, prospective studies with profound insight are a step above so many others.

I liked the original observers who questioned matters like ‘secondary gain’ and considered the ‘advantages of insaneity’ and why it persisted.  What ‘value’ did these states have.  The disease model has been so fixed on eradication without consideration of the benefits.  The studies of distribution and the genetic studies of the turn of the century showing a crazy aunt or uncle in the attic of all the greatest of the New England seaboard were that kind of insight.

I liked the the studies which showed the relationship of genius to Schizoprehnia.  What was the difference between the grandiose idea of the manic depressive and the grandiose idea of the great creator, statesman or artists. 

Today there’s a beurocratic emphasis on the median and mediocrity whereas that was not always the case.  I fear that the end of the world is more likely to follow such stultifying reductionism than it is to any cataclysmic world event.  There’s a wearing tedium to this safe thinking and safe behaviour and emphasis on safety that has been shown associated with the fall of great eampiers and not associated with the greatest breakthroughs. Science is the world of wonder and daring whereas too often the politics of today is based on fear rather than belief. 

In my own work with geniuses and with schizophrenics and manic depressives I’ve I saw  that often the only real distinction was in the outcome of the ideas as opposed to the variation. Both the ideas of a mad man and the ideas of a genius are equally frightening and alien. This explains the common concept of ‘awe’ before encounters with God.  It is difficult to maintain an open mind and more easy to take the safer route of being closed minded.

Yet to the mediocre genius is wholly alien.  

Now having met folk who feel that eating their neighbours would be a great idea there’s limits to one’s open mindedness especially if one is the close most proximal neighbour to this ideology.  Yet that’s less a concern than the tendency to reduce the possible to the limits of the mediocre especially where there is fear and frank cowardice.  

Every day we live with miracles that would have had us shot, locked up or burnt at the stake were it not for risk taking and open mindedness.  I thinkit’s  important to embrace genius and also to have the humility to recognize that genius is commonly so much beyond the scale of one’s own conception. It’s childlike in wonder.  It’s birthplace is curiosity and I would add love.  

I truly am thankful to have had the privilege to have known genius, rare and wonderful and struggling to relate in a world where they are not the masses. To the majority, their genius was not so much as blessing as a curse.  

Persuasion and Behaviour Change

All behaviour is considered to have been innate or learned.  Having a dog is a real lesson in ‘innate’ behaviour, seeing how the lessons of breeding herding and hunting behaviours pass on ‘genetically’ so to speak.
In addition behaviour is learned.  You can influence all behaviour. This was the work of Skinner with conditioning and work with lab rats and mazes.   Complex human behaviours changed and are understood in a variety of ways.  Social sciences in general focus on understanding behaviour with a view to changing behaviour.
Naturally there are judgement calls.  A behaviour is described as positive or negative, healthy or unhealthy, useful or unuseful.  Each of these words is ‘packed’ with meaning.  It’s a window to understanding the ‘meaning’ of a behaviour for an individual.  It’s a way of finding a handle into ‘changing’ the behaviour as well.
Freud said there was a life and death wish.  It’s paraphrased today as ‘You’re on the up elevator or down elevator’.  “You’re going forward or backwards’.  Barack Obama said you are on the right side or the wrong side of history.
My friend who was in a concentration camp said the most potent behaviour change device was hunger and food.  My patient who was tortured described pain and stopping of pain as the most significant behaviour change he had known. Quantanamo was a study in ‘behaviour change’.
Administrators, employers,  police,  jailers have  a whole slew of options others don’t.  Working with adolescents one sees the power of money.  Kids will do a whole lot of things for money but once the money stops they stop the behaviour. They are not stupid.  The relationship are conceptualized in regards to ‘power’ and at the most basic derive developmentally from childhood with the ‘parent/child’ construct.
But as every parent knows one can ‘teach’ a child to do a behaviour but to have the child maintain that behaviour against distraction is a different matter.  In the ‘good old days’ a medieval parent ‘owned’ a child, like a master might own a slave.  There was the full range of choices for how to go about changing a behaviour. It was frowned upon if you killed the child, or slave or horse for that matter.  Doystoyevsky has a marvellous story about killing a horse and the whole discussion that follows is elucidating.
Behaviour change is also tied to the concept of ‘internalization’.  Can a learned behaviour change persist without the presence of the rewarding agent or the torturer.
To understand a behaviour such as ‘tidiness’ there is a need to grasp that each behaviour is not obviously superior in and of itself.  The nature of ‘culture’ is that there have been thousands of different ways found by humans over the length of our time here finding ways of doing things and after tens of thousands of years there remains preferred and not preferred ways by culture to achieving the same end.  Human behaviour is complex.
Changing behaviour in therapy begins with the idea of the least harm and least invasion.
In therapy with a psychiatrist in the community there is no ‘master/slave’ relationship and there is no ‘parent/child’ relationship.  The power politics of the relationship can be conceptualized in many ways and commonly a truth for a ‘group comparison’ is extrapolated to the individual context.  For instance aboriginals in a certain area of Canada are poorer relative to others so their power is diminished but in another area they are commonly richer and more powerful than most so that the power dynamics change.  This is lost in modern political correctness politics with their fixed debates.  The fact remains a female empress is more powerful individually than a male sharecropper just as a black president is more powerful than a white janitor.  It’s hard for people to see these distinctions because of their own inherent biases.
When a person comes for therapy they may see that the therapists is there ‘servant’, a kind of glorified ‘cabana boy’ who does their bidding.  A princess has many servants and the doctor and therapists are just another one. Her relationship with them all is ‘master/slave’ , ‘parent/child’, ‘employer/employee’.
The professional is in an interesting position because he is a ‘servant’ but he has obligations to the ‘profession’ and this is seen specifically in the complex arrangements for ships doctors relative to ships captains.  The whole dynamics of physical health are exploded to a whole other level when it comes to mental health. I do a whole lot of competency assessments for mental health and dearly miss the simplicity of the assessment from a physical health perspective.
Where you have real power everything is relatively easier. The rich can buy good behaviour. The physically threatening can bully good behaviour.
In therapy there is a ‘schtick’ a relatively naive and frankly ignorant notion that the therapist has ‘power’ as if the world is 1950 and ‘authority’ is respected and police are never questioned and children do as they are told.  I am daily aware that the world is mad and individually I hear of teachers who are only able to spout dribble because they are never in the field.  I talk with my military friends and we laugh at ‘academics’ because it’s all so easy when you are not in the thick of it.  It’s so obvious to anyone who is a Monday morning quarterback and our society is brimming over with everyone wanting to be a ‘consultant’ or an ‘analyst’ or a ‘judge’. No one wants to be in the ‘fog of war’ or actually do the hands on face to face work. It’s the least paid. The soldier in the line is the least paid. The most paid is the ‘oversight committee member’ who ‘reviews’ the behaviour.
Therapy can be about change or ‘collusion’.
The rich paid for psychologists to agree with them.  Today a fortune is made by divorcing people who hire counsellors who agree with them that their ex is a toad.
There is a fortune to be made in ‘agreement’ with tyranny.  There are countless tales of the deaths of advisors to kings who told the truth but didn’t live to see their genius.  The emperor has no clothes is the most eloquent of all the tales.
As long as a person is doing something having another discuss and talk about that behaviour indefinitely is not unpleasant.  The problem arises when there is an expectation of ‘stopping’ one behaviour and starting another.
One conceptualization of behaviour change that has served me well is to see a person on a mountain clinging to a couple of crevices and to move forward having to let go of their temporary safety and risk reaching for another hand hold. I love watching goats traverse such perpendicular surfaces.
I treated a hundred cutters. These are people who have learned that ‘cutting’ themselves with razor blades is rewarding experience.  It’s been likened to masturbation in the literature.  A slow crescendo to the ultimate release of blood flow.  It’s controlling and rewarding and attention seeking or secretive. It’s just one of thousand ‘behaviours’ I’ve treated over the years.  The words “I’ve treated’ don’t do justice to the experience.  Encounter is better.
Right now I more often have recurrent encounters with people who stick needles in their arms with unknown powders in the hope that the substance is heroin and not fentanyl. They know people who have died. Their motivation to change despite the risk of imminent death is little.
The cutter is a whole lot easier to treat.  Acutely suicidal people and violent people , perverts and such were more challenging.
The first step is always , in medicine, ‘observe’. To this end I ask a whole lot of questions about the behaviour.  When did it begin. What’s it like. What are the pros and cons.  What would it be like without the behaviour.  Generally we talk about the behaviour more than anyone ever before has.  I remember days of sitting in the stink of rooms smeared with faces asking an endless number of questions about the shit smearing behaviour.
Adolescents, borderline personality disorders, psychopaths, sociopaths, schizophrenics and rich and powerful people and people in jails and prisons will commonly stonewall you.
The term ‘therapeutic alliance’ is critical to therapy.  The patient and the doctor agree not just overtly but at the deepest level to work together to change the behaviour.
However if the person is in the office because of the police, or employer or insurance agent or because the wife or husband wants them there, the therapeutic alliance might well never occur. Duplicitous behaviour is common. Malingering is common. Factitious behaviour is common. In general a whole lot of people are happy to ‘go through the motions’.  They will do anything ‘but change’.  Alcoholics were happy to spend an hour a day with a therapist as long as they could have their drink after the session.  Workers sit daily or weekly in a therapists office to remain off work or collect their pay.
It’s naive to assume everyone wants to change.  Most people don’t want to change.
Whatever they are doing worked for them at some time and would work now if you just got out their face.
A whole lot of people have given up hope that they can change.  A whole lot more don’t see what the problem is.
The question is therapy is always ‘whose problem is this’.  It’s like who wants the bed made in the whole and who benefits from a made bed and even if both people benefit who can win the war and get the other person to be the one to make the bed. Commonly the only person who has a problem is the therapist.
Increasingly therapy is parallel behaviour in which the therapist is doing an academic procedure and the patient is going through the motions.  The two collude to get paid or rewarded for this unusual dance interaction.  If the therapist doesn’t ‘test’ if there is change then with endless resources this dance can go on indefinitely.
I will never forget a psychiatry resident in our psychotherapy training treating a psychopath thief who they saw for 3 years weekly all the while the theif continued to steal and amass a fortune all the while the therapy ‘interpreted’ their behaviour and discussed their ‘behaviour’. I thought of the psychiatrist seeing the mob member and considered that was okay since the mob member was paying for her ‘services’. He continued to ‘whack’ people but his marriage improved.  MAD comics once put out a funny issue describing the therapy of therapist and Hitler, and therapist and Stalin. But therapy is medicine and a ISIS jihadi executionist beheading people might get a head ache doing his job. No one would fault the pharmaceutical industry or pharmacist or the local doctor for giving him as aspirin so he could continue his work with less of a headache. So Tony whacked people and the psychiatrist paid by Tony helped him with his relationship with his wife and the other mob leaders. He gained ‘insight’ into what he was doing and his sleep improved.
When I work in the jails I’m working first for the jailer.
When I work in the government health care services, since the person I’m seeing pays taxes, I’m working for them but the Minister of Health and Medical Service Plan is paying.  When I’m working for a person seeing them for that but they have ‘private’ or insurance from another source I am working for them plus the government and always for my profession and responsibly for the community.  Commonly someone else wants my patient to do something they don’t want to do so they use therapy appearances to procrastinate.
A lovely lady didn’t want to get women to have sex with her husband . She didn’t mind threesomes per se but she drew the line at going out to bars to find willing women to bring home.  He was rich and powerful and she felt a whole lot of humiliation with this position.  After a bout six months of him paying me cash with the hope of treating her ‘depression’ she told him she didn’t want to do that. He stopped paying me and kicked her out and got a woman who apparently was more willing to provide this service. “My” patient got over her depression and may or may not in future get women for the next man.
In the US I was paid directly for services.  It was a lot clearer who I was working for.
When I was on salary to an organization it was a lot clearer who I was working for.
Increasingly as a therapist I’m being paid by several different people with competing designs and I’m already managed by a half dozen beaurocrats and others with competing plans. The government is always confused.
The patients are confused.  Do I really want to change. Is it worth it.  Should I give up picking my skin.
I use morbidity and mortality statistics to judge myself whether I’m doing anything. Increasingly I’m going through the motions like so many others. I used to really work at change but l was taught always to question who was doing more work you or the patient. Increasingly the third party is doing the least work. They don’t care. They fume and have temper tantrums and cut off funding or services but there’s just a whole lot of bullshit in the system these days that no one seems to want to change. Everyone wants to talk the talk but no one wants to walk the walk.
Harm reduction is the craze.
Divorce facilitation is marriage therapy.
I don’t want to go on and on about this but it’s the reality.
I rarely see a person who really really really really wants to change.  Those people change when they discuss the matter with there family, friends, or gp. By the time a person gets to me they have ‘failed’ in ‘changing’ for years and for dozens of therapists. Commonly the come to me and they are already seeing at least two or three other healers who are hoping that they can all blame me for their collectively not having changed anything in anywhere for five to twenty years.  I see really chronic negative behaviours.
And all I can do is ‘persuade’.
In contrast the administrator or employer can ‘punish’ by taking away their job.  I can’t even ‘fire’ a person without getting in trouble with some authority.  Look at the difficulty landlords have with eviction.  It’s no different than a ‘seat’ in an office. Once that person is allowed to ‘sit down’ hell can freeze over before you can move them or you can move them but at risk to your life and livelihood.
I used to be able to do things like talk about things, but today “I don’t want to talk about that’ is quickly followed by ‘If you insist upon talking about that I’m going to make your life miserable for years and cost you millions.”
Really.
People pull out guns and show me where they want the discussion to go. Others pull out knives. More and more people tell me the name of their lawyer.
Change my behaviour at peril.
Truly there are more who are truly perplexed by their inability to change a behaviour. “I thought I could stop cutting myself but I can’t. I used to be able to hide it, cutting under my clothing but now I’m cutting my hands”.
Education doesn’t work. But we all do it.  “Have you tried…."
Insight - this is ‘why'
What is the benefit , when and where,

Drugs are marvellous. Prozac in combination with therapy is twice as effective as therapy alone.  When prozac didn’t work and a dozen other as like drugs didn’t work one could punish the patient with ECT which would at least cause the patient to forget whatever it was that they were thinking about when they are cutting or it might well have not punished them but simply increased the serotonin which seems low in people who cut themselves.  But what happens when all the pharmacopeia has been used and they’ve had ECT and they’re still cutting.
That’s what’s happening today.

I see people who have tried ‘everything’ to stop their drinking, their cutting, their wife beating, their child fucking, their refusal to leave their homes, their inability to get on planes, their inability to work, to have sex, to eat, whatever.
All of what used to be seen in the hospital where the doctor had power and status and a ‘team’ is now seen in the community by an isolated practitioner who lives in fear about what the next angry person is going to do when you suggest, ask, hope they will change their bullying behaviour.
Patients take pleasure in ‘proving’ they can’t change. “See I told you no one could change me."
People said I should see you but I know you’re not going to help me."

No one listens to me.
No one helps me.
You’re just another stuck up asshole who thinks you know so much , well you don’t know me and no one is going to change me.

The world is full of toddlers and everyone with a connection to the internet is having a temper tantrum on the floor of the supermarket and getting a gang of other people who like doing whatever they do, including not going to work, including getting everyone else to pay for the, including being physically incapable of getting out of bed, including wanting their arms cut off, including having sex with animals and really thinking everyone else has a problem because all they need is more money and to be left alone and not judged and if you judge them you are just like everyone else.
The world is having a pout.
We’re on the verge of war.
War is a failure of diplomacy. No one seems diplomatic these days. Increasingly they bully and lie. Deceit in my experience is at an all time high. People say one thing then do another and I’m always wondering do they know that. We need cameras and recordings and I have done that, I’ve recorded every session and played back what people said and did but it’s just upset them and made them angry.  You’re bullying me they say when I record what they say and play it back.
Borderlines are the norm.
Everywhere I look I see the fear in peoples eyes.
Somedays I miss sitting in locked rooms with people who smear shit on the walls.
I’ve always understood that behaviour.