Tag Archives: outdoors

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Why care for addicts?

I posted this in November, 2015. I am reposting it.

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Why care for addicts?

Children. If we do addiction medicine and help and treat addicts, we are helping children and their parents and our elderly patients’ children. We are helping families, and that is why I chose Family Practice as my specialty.

Stop thinking of addiction as the evil person who chooses to buy drugs instead of paying their bills. Instead, think of it as a disease where the drug takes over. Essentially, we have trouble with addicts because they lie about using drugs. But I think of it as the drug takes over: when the addict is out of control, the drug has control. The drug is not just lying to the doctor, the spouse, the parents, the family, the police: the drug is lying to the patient too.

The drug says: just a little. You feel so sick. You will feel so much better. Just a tiny bit and you can stop then. No one will know. You are smart. You can do it. You have control. You can just use a tiny bit, just today and then you can stop. They say they are helping you, but they aren’t. Look how horrible you feel! And you need to get the shopping done and you can’t because you are so sick…. just a little. I won’t hurt you. I am your best friend.

I think of drug and alcohol addiction as a loss of boundaries and a loss of control. I treat opiate overuse patients and I explain: you are here to be treated because you have lost your boundaries with this drug. Therefore it is my job to help you rebuild those boundaries. We both know that if the drug takes control, it will lie. So I have to do urine drug tests and hold you to your appointments and refuse to alter MY boundaries to help keep you safe. If the drug is taking over, I will have you come for more frequent visits. You have to keep your part of the contract: going to AA, to NA, to your treatment group, giving urine specimens. These things rebuild your internal boundaries. Meanwhile you and I and drug treatment are the external boundaries. If that fails, I will offer to help you go to inpatient treatment. Some people refuse and go back to the drug. I feel sad but I hope that they will have another chance. Some people die from the drug and are lost.

Addiction is a family illness. The loved one is controlled by the drug and lies. The family WANTS to believe their loved one and often the family “enables” by helping the loved one cover up the illness. Telling the boss that the loved one is sick, procuring them alcohol or giving them their pills, telling the children and the grandparents that everything is ok. Everything is NOT ok and the children are frightened. One parent behaves horribly when they are high or drunk and the other parent is anxious, distracted, stressed and denies the problem. Or BOTH are using and imagine if you are a child in that. Terror and confusion.

Children from addiction homes are more likely to be addicts themselves or marry addicts. They have grown up in confusing lonely dysfunction and exactly how are they supposed to learn to act “normally” or to heal themselves? The parents may have covered well enough that the community tells them how wonderful their father was or how charming their mother was at the funeral. What does the adult child say to that, if they have memories of terror and horror? The children learn to numb the feelings in order to survive the household and they learn to keep their mouths shut: it’s safer. It is very hard to unlearn as an adult.

I have people with opiate overuse syndrome who come to see me with their children. I have drawings by children that have a doctor and a nurse and the words “heroes” underneath and “thank you”. I  have had a young pregnant patient thank me for doing a urine drug screen as routine early in pregnancy. “My friend used meth the whole pregnancy and they never checked,” she said, “Now her baby is messed up.”

Addiction medicine is complicated because we think people should tell the truth. But it is a disease precisely because it’s the loss of control and loss of boundaries that cause the lying. We should be angry at the drug, not the person: love the person and help them change their behavior. We need to stop stigmatizing and demeaning addiction and help people. For them, for their families, for their children and for ourselves.

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Beach encounter

Yesterday B and I walk about a mile and a half of beach on Marrowstone Island. We see five other people total. There are long stretches with no one in sight anywhere.

Way down the beach there is a sand cliff. A coyote runs half way across the exposed face and stops. It looks precarious. We watch it. “That’s weird,” says B. “They don’t hang out in plain sight.”

It scrabbles and runs the rest of the way across. It stops and turns and sits. Watching us.

I laugh.

B. frowns. “They don’t DO that.”

“I think it’s listening to us. We’ve been singing and laughing.” We are goofballs on the beach. Wordplay. We’ve both been coming up with advertising songs. Horrors, ear worms.

“They don’t do that.” he says, “Can you take your camera out slowly?”

I have my Panasonic FZ150, 24x zoom. I get some shots. B is acting nonchalant, hunting for agates again. He finds more than me from both practice and I am busy taking pictures and being distracted by other pretty rocks, not just clear agates. He is disciplined. I am a generalist.

I get lovely shots. We zigzag back and forth on the beach, trying to look at ALL the rocks. “If you are hunting like this, other animals think you are foraging. Birds and animals will ignore you. I can get really close to them.”

The coyote is watching us. “He’s listening to us, really!”

“Maybe he wants to know what we are foraging for.”

“Rocks.”

“He’s hungry. Or he’s young.” We don’t really know it’s a he.

I start singing. I zigzag closer and take more pictures. She is flicking her ears at the song.

“She doesn’t seem rabid.”

“There isn’t much rabies out here.”

“Bats.” I say. I’ve researched it twice in the last 8 years.

“Yes, but not mammals.”

I start a video and sing to the coyote. I sing The Fox, though I leave out the verses about Old Mother Flipperflopper and the hunters. Coyote flips her ears and turns her head. She is checking where B is since he is moving further down the beach. I finish the song and turn off the video. “Thank you!” I say.

We walk again.

When we turn around, there is Coyote. She has shadowed us down the beach, and she slips into the brush at the foot of the cliff. She is quickly not visible.

“Humph.” says B.

I laugh.

Later, we look up and a larger animal is coming toward me. We both startle, but it is in a submissive posture. A dog, not a coyote, with a red collar. We both thought it was a coyote for a moment. It comes up to me and is very friendly. Then to B. Then back to it’s owner, who limps into sight.

“Wow, I thought it was another bigger coyote for a minute.”

“Me too. I thought it was coming right after you.”

“It’s owner looks frail and old.”

“Our age.”

“No way!” laugh.

“Yes.”

I don’t think so, but maybe. I was more focused on the dog.

I find two clear agates, but come back with two windbreaker pockets with other rocks. B only finds one that meets his specifications. My two really aren’t up to the quality he wants. Well, one is borderline and one doesn’t qualify.

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Cognitive behavioral therapy

Dr. Aaron Beck, father of cognitive behavioral therapy, died this week, November 2021, at age 100.

Oddly enough, the best explanations of cognitive behavioral therapy that I’ve read is on a writing website. It talks about writing down all of the horrible thoughts and then going back and writing counter thoughts. Psychologists have been talking at me at medical conferences for years about cognitive behavioral therapy, but they never explained it. They said we could do it in clinic. I thought cynically that maybe I could if I knew what the hell it was.

And the explanation by the author is oddly similar to what I think of as the angel and devil on my shoulders. It turns out that I do do it in clinic.

When I react to some event, I let the devil out first. It has a fit about whatever is happening, writes poems, is reactive, paranoid and full of anger and grief. It often imagines over the top terrible things happening to the person or people that did whatever it is. Then the angel wakes up and says, wait. What are you saying? What you are imagining and cursing that person with is WAY worse then what they did. The angel writes the poems of forgiveness.

So I have been doing a homemade form of cognitive behavioral therapy.

However, I would say that it can be overused. We need to listen to patients carefully. If they are in an abusive relationship, it should not be papered over with cognitive behavioral therapy. A friend and I have been comparing terrible childhoods. His involved being beaten without reason.

I said recently that what people hit with in my family is words. They make grief and fear into stories, funny stories, that make people laugh. Shame and humiliation and reliving the feelings. I said that I am reactive and pay close attention to words. But I have reason, back to age 2. I said that books are my refuge because the words are not about me, they don’t shame me, they do not humiliate me, and if I read a book twice, it has the same words. Home, love and safe.

In my maternal family, if I said that I was not comfortable with a comment, I was told that I took things too seriously, that I have no sense of humor, that I can’t take a joke. Gaslight and then dismiss any objection. That is how one side of my family loves. I do not like it. Unsurprisingly, they do not love me, or at least I do not feel loved.

And my friend said, your family, your childhood, was worse than mine.

One of my talents in clinic is that I can listen to insane family stories. I can listen because my family is insane. They are cruel. At least, it feels like cruelty and horror to me. I didn’t ever try to find out if a family story is true. I listen and then say, yes. I think it is appropriate for you to feel angry/sad/horrified/appalled/scared/hurt/whatever.

Somehow that listening and validation is huge. I have people come in and say, “I NEED AN ANTIDEPRESSANT.” They want to supress the feelings. So I had time in my clinic: why do you need an antidepressant? Tell me the story. Fill me in. What are you feeling and why?

And more than half the time after the story, after validation, I ask, “Do you need an antidepressant?”

The person thinks. “No. I don’t think so. Let me think about it. I feel better.”

“Ok. Do you want to schedule a follow up?”

Half do. Half say: “No, let me wait and see. I will if I need it.”

Mostly they don’t need it. They have emptied out the awful feelings in the exam room and they aren’t so awful after all. I say that it sounds like a pretty normal response and I would feel that way too. Because I would. Once the feelings, the monstrous feelings, are in the light of day, they relax and evaporate, dissipate like mist, fly home to the Beloved. Goodbye, dark feelings. You are appropriate and you are loved.

Blessings, Dr. Beck, and thank you.