I was contacted by Paul, a physician practicing at a local hospital. He was concerned that Nancy, whom he hoped to marry, was alcoholic. When they were getting to know each other, there were periods when Nancy seemed unavailable in person or by phone, but it was only after they had moved in together that he realized the reason for these periods of absence. He soon became aware that Nancy went on drinking binges and sometimes did not show up the next day at the law office where she worked. She once threatened to kill herself when she was drunk.
Paul turned to her parents, but they preferred to minimize the issue, apparently not wanting to tarnish their daughter's image. He pleaded with Nancy to go to AA; she said she'd think about it.
Nancy had been in treatment a few years with a reputable psychiatrist, whom, I later found out, had tried to discourage her drinking. It was the problem this therapist had encountered that is typical of those confronted with addicted patients. Although it must have been clear that his pleas were doing little good, the psychiatrist was unwilling to speak with Paul because of the need to preserve the "integrity" of Nancy's analysis.
A few weeks after Paul and I met, Nancy herself came to see me at Paul's behest, and I tried to get her to look at her problem. She said, however, that she was quite comfortable in her analysis, and that it was offering her valuable insights. Further, she did not think it useful for me to speak directly with her doctor. When I pointed out that her continued drinking argued for additional intervention, or at least some visits to AA, she contended that her relationship in therapy should be enough to deal with her problems.
For many alcoholics, years of treatment have meant that they had achieved "insight" but that their drinking continues. Stories of therapy like hers abound at meetings of Alcoholics Anonymous. Ironically, though, these addicted people could have been treated effectively by those same therapists if the psychology of addiction were more widely understood and more effective care was implemented.
Substance abuse is as great a challenge as any clinical issue that has emerged in the past decades. Addictive illness is among the most prevalent psychiatric disorders.
A major study, the Epidemiologic Catchment Area Study, shows that the lifetime chance of an American developing an abuse or dependence disorder is 15 percent for alcohol and 6 percent for other drugs. These are the most prevalent disorders among men of all age groups and the most prevalent among women 18 to 24. The cost of alcohol and drug problems is greater than that of all other mental illnesses combined—144 billion versus $129 billion in a year.
Most mental health professionals are ill-prepared to help the alcoholic or drug abuser achieve recovery even though addicted people and their families regularly turn to them for help. Further, few alcoholics and addicts are willing to go to Alcoholics Anonymous until they've suffered very long, and most drop out before becoming involved. How can we engage and treat these people more effectively?
Most effective addiction treatment entails either self-help, peer support, or both, and these are hard to come by in office practice. To address this strategic deficit, I have developed an approach that engages the support of a small group, some family, some friends, to meet with a substance abuser and therapist at regular intervals to secure abstinence and help with the development of a drug-free life. The evolution of this new approach did not come easily, but through careful attempts to manage many patients over the course of their rehabilitation.
I call it network therapy. Family and peers become part of the therapist's working team, not subjects of treatment themselves. Such an approach is warranted by the unique characteristics of the substance dependence syndrome. Social supports are necessary for overcoming the denial and relapse that are so compromising to effective care for the substance abuser.
Nancy's resistance to seeking help for her alcoholism was typical of the way denial shows itself over the course of the disease. A few months after I saw her, she became annoyed at her psychiatrist for "pestering her" about going to AA, and dropped out of treatment. The drinking continued, and later that year she lost her job because of unreliability. Paul was ready to walk out as well, but he said he would give her one more chance if she saw me, "the doctor who said she had to stop drinking."
Nancy came in saying that her problem was that she needed "to get a handle on the depression" she had felt since losing her job. I was not about to let her ventilate her feelings in isolation, and fall into the same trap as her first therapist. I told her that since drinking played a role in her problem, it was important that we get some support for her, to help her look at her situation. I asked her to bring Paul and a friend to our next session to discuss the issue. So began her network therapy.
Two network members were certainly more revealing about the extent of Nancy's alcoholism than she had been. They described how it had often left her in awkward social situations, and feeling incapacitated in facing the next day. I encouraged Paul and the friend to voice their feelings and concerns, to soften her inclination to avoid the problem. The impact of this network session moved Nancy to acknowledge that she had a problem with alcohol. The network members helped me to prevail on her to accept the idea of abstinence.
Tags:
absence,
addiction,
alcoholics,
alcoholism,
behest,
binges,
insights,
integrity,
intervention,
local hospital,
nancy,
periods,
recovery,
substance abuse
