The Myth of Abstinence
Our ill-logic dehumanizes the treatment of addictions.
Compulsion as pathology often provokes coercion as treatment--but for the patient freedom is not an empty concept; it is his treatment goal, and should color the process of treatment for the clinician.
The burgeoning of alcohol and drug rehabilitation programs in our society and on our television sets not only represents increasing acceptance of addiction as disease but presents us with the impression we have reliable principles of diagnosis and treatment. Because we do not have the understanding and technology we wish for, we tend to become defensive or authoritarian in applying what we have. The pressure of commercial competition magnifies unrealistic claims and intensifies pressure on the suffering patient to become "well" in order to gratify the wishes of family, society and treatment institutions. We tend to forget the freedom to become more well implies the freedom to become more ill, for freedom cannot be bound to one direction only, nor is wellness only along any one dimension.
No patient is more sensitive to the ways he is treated than the person who has become compelled repeatedly to alter his awareness and responsiveness with drugs. Ironically, the "self-centered" addict will seem to pay little attention to the instructions of the clinician while he focuses intensely on the clinician’s attitudes (nonverbally and unconsciously expressed).
The goals of treatment are for the patient's sake. They are what he chooses for himself. Like each of us, he is conflicted, so that his choices are not always clear nor conscious. None the less, it is the patient who will choose the goals.
Some methods of treatment take the form of "structure", constraint on what appears to be uncontrolled behavior. What is uncontrolled about ritually repeated behavior? Rather than imposition of structure, it may be revision of structure the patient seeks. If we will only assume for a moment the patient has some purpose in these stringently repeated behaviors, that may give us access to understanding, looking to allow the patient access to some measure of freedom eventually.
It may be an error always to assume a standard of initial total abstinence in the context of our drug-preoccupied society, for sometimes transitional stability may be enhanced by titrated maintenance (such as methadone or buprenorphine [Suboxone] maintenance or ongoing administration of prescription drugs to interfere in the effects of illicit drugs or the depression which comes from detoxification [long-term withdrawal], or the treatment of a depression which promoted the drug abuse in the first place). Independence from destructive and compulsive use may be necessary but it may be inadequate to “just say no”.
Any formal process of treatment is between the patient and the clinician, it is interpersonal. The keystone of the process is the clinician reliably and continually knowing that the patient's hidden compulsive aim is toward more stable health and comfort. There can be no healthy result from treating a patient from out of your disdain for him. The patient’s compulsive self-destructive pattern of thought, feeling and behavior is real, but derived from an underlying drive to be himself intact and free. Because he may not comfortably be able to relate to a single personality as clinician, the patient may be helped more smoothly in relationship to a whole clinical environment--treatment team, therapy group or therapeutic community.
Although abstinence has great value as a goal in every case, it is not a treatment tool. Physiologic stability and acceptance of the person of the patient are prior conditions of treatment. Physiologic stability may require passage through withdrawal (or it may not), but the treatment of the patient must begin with the acceptance of that person.
The myth that addiction treatment begins or is based in abstinence alone is misleading and dangerous. It may lead us to reject and disrespect a person whose ailing is as worthy as another's. If the process of acceptance of the patient (not acceptance of destructive behavior) is difficult for us to stick with, imagine how much more difficult it is for him. If we think we design "programs" because they cure afflictions, we should consider those who left them early or did not come at all into the shadow of such “benign” coercion.
As we learn more the intricacies of the neurobiology of addiction, the potent and long-lasting effects of drug administration, common predispositions to drug dependence, we are tempted to see the whole spectrum of compulsive afflictions as brain disease which is inexorable once the processes have begun--that is once drug has first been administered. It is true that the majority of drug experimenters may not develop problematic addictions, yet it is easy for us to say to young persons, “Don’t even experiment with those poisons—Just say No.” The majority of us will expose ourselves to some of those drugs anyhow.
When someone has already acted out the addiction dance, since we don’t know how to relieve that person of this curse, again we say, “Just say No” as if that were a helpful suggestion, rather than our shamed admission of our own powerlessness over his addiction. Because our culture is drug-preoccupied we will always look for the pill to cure dependence on pills. So, when we have told them not to do it, and when we have administered the latest nostrums to cure them, what shall we do next?
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Let us abbreviate to these few some common errors in clinical assumptions: (1) that the compelled patient is hedonistically self-indulgent; (2) that the person who has apparent lack of internal "discipline" needs "external" discipline; (3) that society can provide correction to reduce the obvious risks and damages of such suffering; and (4) that the beginning of treatment for addictions is the institution of abstinence.
These errors in clinical behavior are not unique to the treatment of addictions, but find their destructiveness in all clinical situations. They arise as common myths inadvertently perpetrated by clinicians in forms which have been crystallized in the unspoken messages: "Your suffering is your fault. You cannot change it. I can change it. To be a good patient you must be well. (Stop suffering now, stop complaining.)" In other words, "You must be well to become our patient. We don't treat sickies."
The patient can hardly feel other than, "But if I were well, or well able to care for my own illness, I would never think of coming to you. I would be fruitful and multiply, replenish the earth and subdue it. What kind of a doctor are you, anyway?” Erroneous assumptions often are reflected in the misbehaviors of clinicians. Even when they are not prominent, they are reflected in the patient's reactions of shame and evasiveness. Let us analyze these interrelated assumptions and their implications, knowing our work will not give the "true" answers, but may help to clarify the real questions.
"THE COMPELLED PATIENT IS HEDONISTICALLY SELF-INDULGENT"
We are human. We are either ourselves subject to significant compulsive intoxication and need to hide it, or we use some great energy to avoid it, or we are well and comfortable enough to have difficulty understanding that compulsion is suffering.
The society from which both patient and clinician grow sees the conditions of addicted patients as alien and bad. It is necessary the clinician see that the circumstance of another person belongs to his own life, has coherent determinants we from the “outside” can never completely comprehend or control (nor can he from the “inside”). When a person compulsively changes her senses and responses with drugs, eating, sexual activity, et cetera, we are tempted to "cop out" with the assumption that she does it purposely, consciously and for the sake of her own immediate pleasure.
In fact the compelled patient has undergone some unusually intense pain or deprivation earlier in life, developed a response to this suffering which was positive and helpful at some time (although it may have been inadequate, destructive and expensive very soon thereafter), and now that response has developed beyond any recognizable good for her. He has already been subject to innumerable internal and external attempts to make changes. He does not enjoy, but suffers. His symptoms are respectable because they represent the best he has been able to do to this time. They are his, but they are not his fault. They are not faults at all, but honest attempts at adaptation to a complex life-history and environment.
All of us have trauma in our backgrounds, but not all of us become addicted. (Perhaps some day some of us will mature enough and heal enough to raise children without pain and distortion.)
"THE PATIENT NEEDS DISCIPLINE"
The compelled patient repeatedly acts in ways which are destructive or undesirable to him (or to the environment upon which he depends). He has not succeeded at avoiding or eliminating these behaviors, so we assume we must impose upon him such discipline as will compel him to change. "Counter-compulsion" may be used as a treatment tool, but it is not the process of treatment, and certainly not the goal. The patient himself may choose to coerce changes or to impose shame or guilt to intervene in dangerous or painful patterns, but external imposition to program behavior is not treatment. Ethical clinical behavior means working for the welfare of the patient as the patient chooses it. The compelled patient has mixed feelings with intense polarization of ambivalence, but a treatment not chosen by the patient is neither ethical nor will it be effective. Clinicians may complain that the patient's choosing seems murky at best as we peer to see it through his ambivalence. The clinician must read "choosing" from subtle clues, cautious not to project onto them the clarity of his own wishes or convictions.
There is danger the clinician will not see the distinction between treatment goals and treatment tools. Sometimes, sad to say, the clinician exercises his own personality disorders to coerce patients for his own purposes rather than for the patient's sake. The addiction therapist who becomes preoccupied with controlling patients is no less sociopathic than those who sell them drugs for criminal and selfish reasons (e.g., profit or sexual exploitation).
Examples of acceptably successful application of "counter-compulsion" or other "carrot/stick" approaches confirm they are tools which may be used, not goals which are to be sought for all patients or for any one patient:
1. "Contingency contracting" is promoted by Doctor Crowley1 for treatment of cocaine addiction and treatment of addicted health care professionals who wish to keep their licenses. It is an adjunct to psychotherapy, used only with the patient's full choice, temporarily to counter the destructiveness the patient and his community cannot tolerate. It is not promoted as a "cure" for these problems.
2. Compulsory ingestion of disulfiram (Antabuse) is actively promoted by some courts to reduce the destructiveness of drunk driving. Its imposition is not treatment but an alternative to jail sentences. When disulfiram is chosen by a patient as a treatment tool it can establish a period of non-toxic experience within which different patterns of health can be developed. The most powerful tradition in the rehabilitation from compulsive alcoholic disease, Alcoholics Anonymous, does not take a position against disulfiram, but maintains skepticism toward all medication.
3. Now naltrexone is available by prescription, and its long-acting injected form, Vivitrol. It is a long-acting opiate antagonist which will be promoted by some law-enforcement and drug treatment institutions to enforce opiate abstinence from persons who fall under the authority of the courts. Like disulfiram, naltrexone may be chosen by a patient as a crutch to use indefinitely. Even if it proves effective as a tool for behavior limitation it will not be treatment.
4. Weight Watchers works. Presenting a rational dietary regimen in a setting of social rewards and punishments will appeal and apply to those who value acceptance from the group above the impulse to overeat. Changes come from reduction of caloric intake and reduction of emotional charges (positive and negative) attached to food. A patient may achieve these goals through various group and individual programs.
5. Compelling seems the proposition the addicted patient must come into a hospital for a twenty-eight day program or for a year or more in a therapeutic community. Abstinence enforced in a controlled environment for a time may be a comfort for the patient. Clearly it is not wrong. It also is not “right”. It is a reasonable tool as it is offered for the patient's sake, not for commercial purposes alone.
6. Urine monitoring for the detection of intoxicating substances is required in licensed methadone treatment, is used voluntarily in contingency contracting, and is required in supervision programs by many corrections and regulatory agencies. It is also used by some parents to monitor their children. Patients may moderate behavior out of fear of punishment, or attempt to evade detection defiantly or surreptitiously, or may focus pride on "clean urines" as a positive aspect of rehabilitation. Urine monitoring is a neutral treatment tool, its use not in itself productive of good results.
"WE CAN IMPOSE CORRECTION”
Faced with the patient's apparent need, we wish to meet that need. We believe the society must somehow provide correction for the problem, that we must provide tools for that correction. Laws, regulations and societal expectations imply that treatment of those conditions should curtail the problems and result in cure. Howard Shaffer calls this "the Brain Police". We cannot do it. We cannot afford the error of trying to do it. That would result in frustration for us and damage to each of our patients.
To be on the patient's side as a clinician means that I cannot be against him. I can be with him by acknowledging with him the realities of the society he lives in and the realities of his being his human self. If his family, employer, the authorities, or his own brain and body can no longer tolerate his disorder, it is a kindness for me to care about his perceptions and feelings, to support him in making and acting on difficult choices. It is my profession to offer him techniques with which to accomplish changes he chooses. These do not constitute me working as an agent for others, but as a resource available to the patient. I can consider the needs of others, the demands of society, without giving up myopic loyalty toward and acceptance of the person who is the patient.
As a clinician I cannot impose correction on any individual patient nor on any group of patients. I can offer goods of skillful diagnosis and treatment only as the patient chooses (which may begin as a cloudy-looking choosing). No matter how sincerely he and I may wish me to cure him at the outset, it cannot be done so quickly. Improvement will come in his development as a person in relation to me, the treatment setting, his human environment, and a sense of his own life-history.
"THE BEGINNING OF TREATMENT IS ABSTINENCE"
I have emphasized that some tools of treatment resemble coercion, structure, containment, control. In order for these tools to be used in treatment for the patient's sake there must be the opportunity and the attempt to allow him to internalize new structure as a part of health and well-being which he chooses. The same tools applied for parties other than the patient constitute either social control or exploitation, not clinical treatment. The professional who exercises either social control or exploitation of the patient must know he is not a clinician, must let the patient know he is therefore not a patient. This can be done in honesty, as when a forensic psychiatrist says, "I am not here to make you better or more comfortable, but to evaluate you for the sake of the court which judges you."
When a patient recognizes his compulsion as a problem it is easy to tell him to set it aside, but that is like telling the patient with diabetes to stop having that condition. Before he can set it aside he must know what it is and have something to serve its purpose better. If we respect our patients and know that they do not do what they do for no reason, we help them respect themselves first, then help them take more effective ways of being themselves.
If the drug is immediately destructive (as alcohol or overeating can be) we are more pressed to interfere with it earlier, but we cannot. If the drug is itself not so destructive, but the conditions of its use (illegality, needles, social instability) we may seek some stable compromise within which to continue it (or its equivalent) or to taper its use (e.g., methadone maintenance). No matter what the method of intervention, it cannot succeed without the patient's choosing. If we do not recognize this simple truth we will engender the patient's defiance as he tries to protect himself against being overpowered. If we recognize it is the patient's long-lost self-respect which is to be addressed we will begin and persist in feeling and communicating so in our attitudes and actions. I cannot give a recipe for successful addiction treatment, but one thing it can never be is the debasing or punishment of the patient.
A way to debase any patient is to imply or state conditions under which you will reject him. By attitude or rule to say that he is a "bad" patient is to imply he is free only to get better, that if he gets "worse" he will be deleted from the statistics by which you intend to enhance your own reputation. If the patient is free to become more well he must also be free to become more sick. If there is to be any control, it must belong to the patient. The process of treatment is one in which he will reluctantly hand over some control for a time in order to have more for himself eventually. The goal of clinical behavior, even in the treatment of addictions, is to enhance the autonomy of the patient.
Those who are compelled to control tend not only to debase and punish patients who suffer addictions, but also to condemn clinicians who accept these patients. I protest that it is painful enough to support the patient in his struggle to stay alive without having to contend with cynicism from one's own colleagues.
Not-uncommon examples reflect flimsily camouflaged cynical condemnation of compulsive symptoms and those who suffer from or realistically respect them:
1. A bartender has been "cured" of alcoholism in a thirty-day inpatient program at a cost of eight thousand dollars cash. He soon seeks treatment at another clinic for the heroin addiction he continued during his recent hospitalization for alcohol dependence, about which no inquiry had been made, nor his needle tracks noted during that previous medical examination.
2. A physician is charged before the state authority with regard to prescriptions of controlled substances considered to be larger than standard. The assiduous prosecutor is asked by the judge if any of these drugs were diverted, used by anyone other than the identified patient, to which the prosecutor answers no. The charges are summarily dismissed.
3. A man with pain develops dependence on prescribed pain relievers. Because he travels between two cities he establishes a doctor to prescribe in each. He does not obscure his identity or address, nor could he, as he is a prominent public figure. He becomes the target of an ambitious assistant prosecuting attorney whose own office-mates learn of the charges only from reading the newspaper headlines.
4. A heroin addict is injured in a motorcycle accident. Surgeons and nurses minimize medication out of an unacknowledged fear of creating addiction (in an already-addicted patient!). Intolerable pain and withdrawal drive the patient from the hospital “AMA” (against medical advice).
5. A fifty-five year old woman has again entered inpatient alcohol treatment. She has been stable on methadone for six months following five years of unstable dependence on short-acting opiates procured to abolish arthritis pain. The ardent convictions of the treatment staff prompt them to force-feed her a drug-free lifestyle. She knows she will "catch shit" until she gives up methadone. I encourage her to improve her health (autonomy) by clearly choosing one or the other, no matter which of those choices she takes.
6. A sixty-five-year-old woman has suffered constant headache for fifty years, has long since been dependent on pain relievers. Her doctor tells her she is addicted, admits her to the hospital and withholds all medication. She is pained and shamed in “cold turkey withdrawal”, which intensifies the depression which has driven her headache.
None of this is to say there should not be structure in treatment. There is danger in the pendulum swings of compulsion and coercion that the patient may use the confusion as a smokescreen, abuse the clinician or clinical community for the sake of drug or to evade control by others. The time and skill of the professional are valuable and should be paid for by the patient. If he cannot pay or if someone will not help him pay, perhaps treatment will not be available for him. If the treatment setting cannot meet his needs, or if his freedom to get sicker will endanger the integrity of the treatment setting for him or for others, he may need help to find another setting, or the honesty that inadequate help misleads and harms him. We may need realistically to let go of patients whom we cannot help. (A band-aid is an unkindness to a broken bone.)
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A person becomes a patient as a result of her suffering, not her health or enjoyment. A person may gamble or use drugs or eat unusually much or little without becoming a patient, without complaining or having others complain about her. If our own egos are not severely flawed (so that we must actively defend them) we will not be offended by another person’s symptoms, but take seriously the messages we receive from him as he feels and acts his need for help.
We look to many approaches as treatment tools, but the one thing we cannot do without to help a person heal is human relationship; it is only through personal relationship healing occurs. We find many treatment adjuncts; but a central healing comes only through human therapies, formal or informal.
We have called these compulsive sufferings diseases of isolation. Sometimes the sick person is too sensitive or too disordered to be approached immediately and without buffering or attenuation. Sometimes the symptoms drive away any others with whom there might be sharing. Sometimes the only residual human company is with others who seek the same supply of drug, the same administration of drug, the same effect of drug; but there is no satisfaction to be had there, and there is no human company (for the other is as isolated as I would be).
Even though many treatment tools may appear coercive, the autonomy and health of the patient are always truly long-term goals of treatment, held in our minds as clinicians and reflected in our attitudes. Respecting freedom we run less risk of abusing patients or driving them away from any help. We are each human, and can help one another only by realistically accepting from out of our own humanness the humanness of the other.
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1 Thomas J. Crowley, M.D., "Contingency Contracting Treatment of Drug-Abusing Physicians, Nurses and Dentists" from NIDA Research Monograph 46, 1984.