As I’ve gotten older I’ve become more open to using interventions I should’ve used earlier in my psychiatric career. Especially for persons with addictions I’m more open to trying naltrexone, and even , in appropriate situations, benzodiazepines in a controlled fashion where I see evidence for crippling anxiety/panic symptoms.
This does leave me open to occasionally feeling ‘scammed‘; where a patient leaves me feeling like my openness to trying to help was taken advantage of. It happens.
I console myself by going back to other’s wisdom such as William L. White’s chapter Some Closing Reflections on the Lessons of History in Slaying the Dragon: The History of Addiction Treatment and Recovery in America.
An example on “What works? “:
“Addicts make numerous attempts at aborting active addiction, and success and failure are all too often measured by a single intervention rather than combined or cumulative interventions. It is always the last attempt that is judged to be successful when, in fact, what may have proved the crucial factor was time, experience, maturity, the sudden opening of some developmental window-of-opportunity for change, or the cumulative effect of numerous interventions. What history tells us is that the early reports of such breakthroughs in the understanding and treatment of addiction are notoriously unreliable and should be treated with great caution and skepticism.”
I know that I’m going to get taken advantage again at some point by a patient who has addiction issues, but it’s still worth it. Trying to help individuals who are locked in powerful struggles is tricky and there’s much we still don’t know. Persons with addictions are wrestling, torn between what they know and what their brain tells them they “need“. As always it comes back to the issue of ambivalence:
“The history of addiction as experienced by America’s addicts is a history of ambivalence. Addicts simultaneously want – more than anything – both to maintain an uninterrupted relationship with their drug of choice and to break free of the drug” …
“…one of the constant rediscoveries in this history is that espoused motivation to be drug free at the time of admission to treatment is not a predictor of positive treatment outcome. … There has been a growing recognition that motivation is best viewed, not as a precondition of treatment, but as something that emerges out of an effective treatment process. Motivation is increasingly being viewed, not as something inside the client, but as something that emerges out of the interaction of the client’s intimate social network, the therapist and the broader treatment milieu.”
The work is more marathon than sprint. Change takes time, lots of time. Don’t get cynical and start thinking “people never change“. Don’t you believe it! Personality stays reasonably intact over longer periods of time but life happens, everyone experiences losses, joys, changes and traumas. People do change, it’s just that we’re not good at predicting when.
In the meantime clinicians and agencies should stay focused on building dual disorder capacity. The goal should be what Dr. Ken Minkof wrote several years ago: “universal competency, including attitudes and values, as well as knowledge and skill”. Please consider having a look at my post RUCCISC? from 3 years ago. Dual disorders is such an important issue for ACT clinicians there should be an education session devoted toward one of the many aspects of it every 4-6 months.
Shalom Coodin MD FRCPC