Psychiatry and Alcoholism/Chemical Dependency
It is not without trepidation that I undertake this address. The subject is highly charged emotionally, with varying degrees of zeal on both sides, as well as some turf-protection concerns. I sense something of the attitude “Don’t talk logic to me, my mind is made up,” and so by remarks are apt to elicit some disapproval from both sides of the aisle. Nevertheless, here goes!
Perhaps my own training in psychiatry is not representative of psychiatry as a whole. Yet, I think that my generation of psychiatrists were trained similarly to myself, and I suspect that even though some changes in psychiatric education have occurred in the past quarter century, they have generally not been that significant in regard to alcoholism and chemical dependency.
During my four years of medical school I do not recall having a single lecture on addiction. I see it as strange that a disease such as Rocky Mountain Spotted Fever, of which I have never yet seen a single case, warranted two hours of lecture and laboratory, whereas substance [use] problems and their consequences, which are responsible for 40% of all general hospital admissions, did not merit even one hour.
Three years of intensive training in psychiatry did nothing to overcome my ignorance of addiction. I was left to surmise that alcoholism, like any other behavioral symptom, could be treated by uncovering its source in the life history of the patient and helping the patient understand it. For the overwhelming majority of [those with alcohol use disorder], this approach simply does not work.
Some authorities divide alcoholism into two categories, primary and secondary. Secondary alcoholism refers to those cases where the person began drinking due to a depressive or anxiety disorder. Primary alcoholism is where no preexisting disease can be demonstrated. These authorities say that 80% of alcoholism is primary, and only 20% secondary. If this is true, then looking for underlying psychological cause is misleading in 4 out of 5 cases.
Searching for the cause of pathological drinking is further complicated by pitfalls. Alcoholic drinking produces many problems, both emotional and physical. The [person with alcohol use disorder] invariably reverses cause and effect, and attributes the alcoholism to the problem rather than seeing the problem as a consequence of the alcoholism. He may say, for example, that he began drinking heavily because his family abandoned him, whereas the fact that is the family left him because they could no longer put up with his drinking.
Furthermore, the [person with alcohol use disorder] is beyond doubt the world’s expert in rationalizing. He can give very plausible reasons for his drinking, and unless one is alert to this, one may easily be taken in. Rather than trying to refute the rationalizations, a better approach is to point out to the [person with alcohol use disorder] that whether one jumps off the Empire State Building for a good reason, for a poor reason, or no reason at all, the result is the same. Similarly, alcoholic drinking is lethal, and giving reasons for drinking, even if they were valid, will not impress the undertaker in the least.
Even in those cases where alcoholism is thought to be secondary to another disease, the conventional psychiatric approach may be inappropriate. Psychiatric treatment may involve medications, psychotherapy, or both.
[Persons with alcohol use disorder] are notorious in denying the extent of their drinking, and can do so very convincingly. The [person with alcohol use disorder] may tell the psychiatrist that he does not drink at all or drinks very little, while he is in fact imbibing copiously, stopping only 24 hours prior to his appointment with the psychiatrist. The latter has not way of knowing the true state of affairs, and continues to treat the patient. He is often bewildered why the antidepressants are not working, and may switch from medication to medication, not knowing that receptor sites in the patient’s brain are blocked by alcohol, and that no medication can reach them.
Psychological treatment of an actively drinking [person with alcohol use disorder] is worthless. Alcohol and related chemicals distort emotions. In fact, this is the very effect sought by the [person with substance use disorder]. Analyzing the emotional responses of the active drinker is totally futile.
Imagine, if you will, bringing your automobile to a mechanic with the complaint that it is not functioning well. The mechanic discovers that there is gravel in the carburetor and brings this to your attention. You tell him to mind his own business, that the car belongs to you and that no one can stop you from putting a handful of gravel in the carburetor twice a week. However, since the car is not operating smoothly you want him to fix it.
The mechanic is certain to think you are daft. He will say “Let me clean out the carburetor, and for heaven’s sake, don’t put any more gravel in it. Then drive that car for about 100 miles. If it is still not operating smoothly, I can then check it to find the cause. However, there is no way I can even try to check it if you foul up the engine with gravel.”
I simply cannot fathom how any psychiatrist can come to a conclusion about a patient’s emotional status while the latter is putting potent chemicals into the brain. The only common-sense approach is to insist on a [substance-free] period of time before a valid psychological assessment can be made.
In my book, It Happens to Doctors Too, I recommend withholding any psychiatric conclusion until at least six months of abstinence. A dear physician friend with many years of sobriety was critical of this. “Abe,” she said, “if you had seen me when I was 18 months sober, you would have given me 11 psychiatric diagnoses. The fact was that my head wasn’t screwed on straight until I was sober two years.”
Some patients insist on searching for the cause of their pathologic drinking. This has been compared to someone standing on the sinking Titanic while others were getting into lifeboats, saying “I’m not getting off this until I can understand why this happened.”
Although the [person with alcohol use disorder] has an abundance of rationalizations, he is always on the lookout for more.
Therapeutic approaches which focus on the faulty parenting and early life trauma are apt to be exploited by the patient. “Poor me. With all the emotional deprivation and trauma that I suffered as a child, it is little wonder that I need a drink.”
Let’s cross the aisle to the other side. There is no doubt that AA has been very effective , and is the backbone of recovery. The success should not prevent the awareness that there are some conditions which do not respond to the program.
This is ample evidence that some types of emotional problems are due to chemical imbalances that are correctable only with appropriate medications. Some mood disorders require treatment with lithium, some depressions require anti-depressants, and some mental illnesses require anti-psychotic drugs. When a proper diagnosis has been made, it is wrong to deny the person use of appropriate medication because of a history of alcoholism.
I have treated several patients who developed severe depressions after years of sobriety. I have told them to apprise their sponsors of their treatment, and have on occasion consulted with the sponsor. But I have had to instruct them not to discuss their treatment with anyone else because some people will tell them that they have violated their sobriety by taking medication for depression.
[Persons with alcohol use disorder] are not immune to any number of diseases that are not within the recovery domain of the program. It is of course important that a psychiatrist treating a [person with alcohol use disorder] understand the nature of alcoholism and the restrictions on addictive-type medications, but when such understanding is present and the patient is receiving appropriate treatment, it should be understood that this is not an interruption of sobriety. Patients with depression are more than ever in need of the invaluable support of the fellowship. They should not be abandoned.
Not too infrequently a person who admits to having an alcohol problem may be resistant to joining AA, and wishes to be treated with psychotherapy on a one to one basis. I truly feel sorry for this individual, because he is not taking advantage of what I feel to be the most effective and even enjoyable method.
The good that can come out of an alliance between the psychiatric profession and the treatment establishment is inestimable. The mutual distrust must be overcome. Psychiatrists must become more familiar with the workings of AA, and learn more about the facts of life of addiction. Remember that in the 16th century Paracelsus gathered his students at the University of Basel, built a great bonfire, and threw in all the sacred medical texts. “Go to your patients,” he said. “From them you will learn medicine.” The psychiatrist who wishes to fully understand addiction should frequent meetings of AA, NA, and Al-Anon to become familiar with the approaches and perspectives of the most widely used and successful recovery program for this condition.
The treatment establishment, which has at times categorically rejected psychiatry, should be aware that the atmosphere is changing, and that more psychiatrists are becoming familiar with addictive diseases and the prevailing recovery programs. The existence of dual-diagnosis cases must be recognized, and the need for specific psychiatric treatment for those conditions which are beyond the scope of fellowships and counseling by non-psychiatric counselors.
The time has come for dispensing this claim to exclusive rights. Psychiatrist, psychologist, addiction counselor and recovery fellowships can and should work together for the optimum benefit of patients.
