Addiction: A Whack-A-Mole Proposition

I change. I know that sounds pretty vague and elementary, but it’s the truth. The problem is that I don’t always change for the better, or into something I have not previously been. I guess you could use other words–like morph, or cycle–but the reality is that reality is not static. Sometimes things that seem like progress are actually growth and sometimes they are the re-manifestation of some earlier incarnation that was not necessarily the goal or desirable outcome.

It is common knowledge in the drug/alcohol recovery community that addictions are swapped for other addictions with amazing rapidity. The nature of my addiction is that I unconsciously gravitate toward those things that allow me to become more fully engaged with myself and myself alone. In this state, other people become incidental to my immediate goals. It can be shameful to admit, but insight and an admission of my awareness are the proverbial first steps toward changing the things I have come to loathe in myself. I have very recently realized that I am currently mired in such a cycle.

Addiction is misunderstood and deceptive. What is usually touted as an addiction is actually the addicted person’s current object of obsession. Rather than saying that someone is “addicted to alcohol,” it is more correct to term that their addiction is “currently focused on alcohol.” Different people may condemn that statement as either misinformed, incomplete, or flat-out wrong, but I stand behind it. This is why so many people in recovery do the addiction shuffle. There is a principle in physics called “Horror vacui,” commonly stated as “Nature abhors a vacuum.” The removal of the object of someone’s addiction creates such a vacuum that can then easily be filled with any number of other behaviors or substances.

Addiction is a complex and dynamic physical, spiritual, psychological, and emotional phenomenon that is best viewed as an inherent part of a person’s makeup. To reduce it to a mere substance or action is to belittle its true power. Alcohol is merely a liquid that has a certain effect on such people. Cocaine is a powder (or other form…) that stimulates people in a specific way. A slot machine is a bunch of electronic components slapped into a pretty package. The point is that these things are just a few of the stimuli that trigger a biological organism’s addictive tendencies that, when established in an individual, will yield surprisingly predictable results over any significant period of time. The actual addiction is what is termed the disease, condition, phenomenon, or illness rather than the trigger.

When I first came to 12 step recovery I noticed that recovering alcoholics can consume a prodigious amount of sugar, coffee, and cigarettes, the whole time while sitting in a meeting discussing how they have conquered their alcoholism. This is where what I am saying is controversial–many recovering alcoholics I know firmly separate “alcoholism” from the rest of the addiction spectrum as if it is hard science. Old-timers talk about how only ten percent of drinkers are alcoholics as opposed to the supposed 100% of heroin addicts you would get if you made people inject themselves with heroin on a long-term basis. I disagree with that reasoning as fallacious because it fails to take into account that you can become physically dependent upon a substance without developing an actual addiction to it. What is actually occurring is that old-timers and sticklers in AA, or “pure alcoholics,” still retain some of the residual fear from AA’s pioneers that allowing addicts to discuss their experiences with things such as drugs, shopping, sex, and gambling will threaten AA’s immediate purpose and water down the message in a way that could be harmful to the overall program. This is understandable, but increasingly archaic thinking in a world where there are so many more things to which addicts are drawn than 75 years ago when AA first came on the scene.

Among my friends in recovery I have personal, firsthand knowledge that I sit in AA meetings with people that are or have, during their abstinence from alcohol, been actively addicted to one or more of the following: illicit drugs (heroin, cocaine, marijuana, crystal meth…); legal drugs (caffeine, nicotine, Benadryl); sex; gambling; shopping; the internet; exercise; food; starving themselves; television; tattoos; piercings; and, adrenaline (extreme activities like skydiving, racing, motorcycles…). The common thread is that there is a key process, or innate force, that drives each of us to seek out such things. Addiction is the individual’s constant, restless search for something that will facilitate an in-the-moment euphoria, effectively (but temporarily) nullifying the individual’s ability to experience his/her uncontrollable but all powerful negative reality (self-hatred, self-loathing, shame, fear, anxiety, depression, suicidal thoughts…). Drugs and alcohol are mere facilitators of that process. When we discuss powerlessness over alcohol, we are really professing an inability to control our insatiable compulsion to escape ourselves.

Until these things are widely disseminated and are understood on a societal level, addicts will continue to be enabled by friends and family and can even be harmed by those in the recovery community that are intensely protective of their own brand of recovery. I am an addict. I run 40 miles per week. I meditate. I buy too many things. I drink more than my share of coffee. I listen to loud, aggressive music and I drive fast. I do these things because I enjoy them and because, in the scheme of things, they are the more desirable and less harmful alternatives to the drugs and alcohol from which I have been abstinent for over 16 years.

There is not enough time or space to delve into the spiritual aspects of recovery in this post, but I do not want to leave any reader with the impression that it does not exist or is some kind of myth. I will address it in another post in the near future as I feel it only correct and responsible to do so. My main point is that, in addition to the role of spiritual progress in combating addiction, sometimes we addicts just need to find the things that we can live with as viable alternatives to those that helped us create so much destruction in our lives and the lives of others. Until next time.



Your Patients Deserve Your Humanity

I was recently assigned to a hospice patient that had been seeing another social worker, but hadn’t been having much of a connection. When the team decided that he might open up more to another man, I was the obvious choice. While his stepson was very much involved and visited the long term care facility every day, it is often difficult for a patient to confide in someone so close and emotionally invested. I agreed that it was a good idea and put the man on my schedule.

Shortly after, I made my first visit and was warmly greeted by both patient and family. The man had led a fascinating life and spoke about his past experiences with a cheer slightly incongruent with his current physical condition and prognosis. I found his attitude to be a breath of fresh air in a field where encounters gravitate toward the negative more often than not. At some point during our discussion I asked a seemingly innocent question about how his day had been going so far. To my surprise, he responded that he had slept late, but wished that he hadn’t woken up at all. He delivered this tidbit in a rather matter-of-fact, decidedly drama-free manner. Throughout the rest of our time together he reiterated in several different ways that he was essentially waiting impatiently for the end and that it could not come soon enough. I was baffled.

At our next team meeting his nurse, aide, chaplain, and previous social worker all reported that they had had the exact same experience with this patient and that they had simply not known how to respond. The man’s behavior and statements were a definite source of discomfort for all parties involved. I met with him three more times with the exact same results. I racked my brain for ways to bypass his defensiveness in order to find out what was going on beneath the surface, refusing to accept his bravado. Only today did I receive a glimpse of the explanation for which I had been seeking.

As I sat down across from him at the dining room table, he began our conversation with a point-blank question: “When this all starts to happen, how aware of the process will I be?” This admittedly took me off guard as I am very conscious of the fact that anything I say could easily be misconstrued as medical advice. It is for this reason that I always preface my responses in such situations with a reminder that I am a social worker and that such inquiries are better directed toward the nurse or doctor. Being exceedingly pragmatic, the man explained that, while he understood this, he would like any information that I could provide him. He went on to explain that almost every medical professional by whom he had been treated had danced around the question and had failed to allay his fears. I sensed an opportunity.

I began by addressing the reason the answer to his question was important to him. It seems that one of his doctors had explained in detail how he would eventually bleed to death, but that there was no telling when this might happen. This left the patient literally sitting on a time bomb (his tumor) that would one day detonate with no warning. At that moment I saw this man, whom I and so many of my colleagues had insisted was unfazed by his impending death, drop his tough exterior and reveal his fear and anxiety regarding the inevitable deterioration of his condition. It made perfect sense that he would have many questions for which he feared there would be no answers. Would the process be painful? Would he know he was dying? Would he lose consciousness, or could it just happen in his sleep? I then understood that there were larger forces at work that were contributing to his suffering rather than alleviating it.

His doctors had been noncommittal in their answers because they were uncomfortable that they could not, with much accuracy, provide him with a sufficient explanation. The one doctor that did take time to explain what would physically occur skirted the topic of how this would affect the patient on a psychological and emotional level. The man had given up on receiving any satisfactory or comforting information and had decided to embrace his anxiety as the undesirable but unavoidable response to a medical community that had neglected his emotional comfort as a result of preserving its own.

Too often we avoid our own discomfort at the expense of our clients/patients. It is the ability to live in that uncomfortable space while maintaining a clear desire to address a patient’s needs that will determine our effectiveness and competence as practitioners. In this case it only took four visits to get to a place where the cathartic process began to appear in the distance, if only as a faint light at the end of the tunnel. He and I both received a bit of hope born from the fact that we had dropped some level of pretense and were having a dialogue that he had thus far been denied. What comes in the future remains to be seen, but the significance of these circumstances was not lost on me. My eyes have been opened to the grave consequences that can result from well-meaning professionals avoiding difficult discussions. I am confident that this will inform my practice and benefit many future patients. Until next time.



Hospice Series (Part Three): Hospice in the Home

The original idea of hospice was to help patients stay at home and receive comfort care and pain management without having to go to a facility. Although services have since branched out to include care in several different settings, many families (understandably) prefer to have their loved ones stay in the home as long as possible and, preferably, until end of life. This requires a team of professionals working together in order to deliver optimal services under conditions that are often less than ideal.

First, private residences are not equipped to handle specific medical situations that would otherwise be routinely handled in a hospital or nursing facility. As a result, hospice agencies typically receive more after-hours and weekend calls to respond to the needs of home patients. In addition, these families are often tasked with doing most of the “heavy lifting,” such as providing bathing, bathroom needs, and cleaning up their loved one following an accident. This can quickly take a toll on all family members directly involved.

Secondly, special equipment such as hospital beds and oxygen concentrators must also be placed in the home to meet a patient’s particular needs. Most houses only have room for this equipment in the living room, thus effectively making the patient’s illness the center of the family’s emotional and physical existence. The ubiquitous presence of hospital beds, medication trays, and nebulizers (to name a few) serves as a constant reminder of the grave changes taking place in the family dynamics as well as the impending loss that will inevitably come.

Next, such families will usually be in need of more extensive hospice care including a social worker to assist with family issues that, while stretching back far into the past, are magnified by the present-day stressors involved in having a terminally ill loved one. The more family members involved typically means more opportunities for disagreements, hurt feelings, and decisional conflicts that arise from fear and guilt regarding the patient’s care. It is not uncommon in such situations for different family members to privately request that information from the hospice team be directly provided to them and them alone as they view themselves as the most responsible party. This can lead to rifts between the hospice workers and other family members as it is best practice to have everyone on the same page and to build as much trust and rapport with the entire family rather than allow one member to undermine the others.

Lastly, many times family members will want to keep the patient at home even when all indicators point to facility placement being the best option. This is born from guilt which clouds the family’s ability to rationally assess what is best for their loved one. In such cases a social worker will usually work extensively with the family to ready them for such a decision. It is a grueling process that can lead to much self-doubt and many hurt feelings no matter how well it is handled.

In closing, it is important to remember that it is entirely possible for hospice services in the home to go well, but the aforementioned pitfalls must be addressed in order to adequately prepare such families for potential complications. In the end, such education is the most responsible course of action and will be most effective when dealt with upfront rather than waiting until potential emergencies arise. Until next time.



Suicide Solution: Why Some People Pay the Ultimate Price

When I was 12 years old I had my first brush with suicide. A family member had attempted it once previously and was successful on her next try. While any survivor of suicide will inevitably feel the sickening absence of their loved one, I experienced an additional loss, that being the opportunity to discuss, process, and make sense of what had happened in my young mind. The event became the elephant in the room throughout my family, the dirty little happening that, while it was never explicitly stated, was not to be discussed. As a result I was simply left with the impression that my family member had committed suicide because she was crazy. No further explanation was provided or offered. I did not receive any counseling or education regarding mental illness and was, therefore, left to draw my own conclusions with an adolescent brain that was ill-equipped to do so.

There are many myths regarding suicide that are perpetuated by people that view life from the perspective of not understanding the intense and unique emotional suffering of the desperate individuals that go through with this most destructive of acts. Following the tragic death of Robin Williams in 2014, Henry Rollins famously condemned him in the press, stating that he had lost respect for Williams and that he could not understand how someone that had so much going for him could have even a single bad day. As a mental health professional I can confidently state that, while I am by no means offering any sort of formal diagnosis of Robin Williams (and that it would be grossly irresponsible and unprofessional for me to do so), the actor’s behavior off-set and stage hinted at symptoms of ADHD and mania (which is almost always accompanied by minor or severe depression). He was also reportedly dealing with the diagnosis of a grave physical illness.

The truth is that none of us will ever truly understand the depths of this entertainer’s pain. It is impossible to fully put yourself in someone else’s shoes and, in my experience, the people that actually take their own lives are the least likely to let on that they are suffering. I learned this the hard way when my life fell apart at the age of 23. I had been an active addict for several years and had stopped using abruptly, only to find that all of the psychological symptoms I had been unknowingly medicating began to manifest themselves in my sober life. From the outside my life appeared to be perfect. I had a decent car, good grades, a nice wardrobe, a loving family, and a pretty girlfriend. People were shocked when I entered 12 step recovery as they had trouble seeing me as a suffering addict in need of help. For the first four years of my sobriety I rarely shared with people outside my immediate circle of friends and I stayed in the same codependent relationship in which I had wrought so much emotional destruction. My mental anguish was so severe that I would have gladly given all my worldly possessions if only someone could immediately alleviate my fear, depression, and anxiety.

Only then was I able to revisit my family member’s suicide from a completely different perspective. To this day I wholeheartedly believe that I have been as humanly close to that path myself without crossing the line. I actually felt a kinship and closeness with my loved one knowing the magnitude of pain she suffered, albeit under different external circumstances. Emotions are the universal language that is experienced by all people regardless of race, culture, sexual orientation, culture, or socioeconomic status. We all understand joy and we all understand pain. We all feel loss and happiness. I no more blame someone suffering from unbearable emotional suffering for committing suicide than I would condemn a man on fire for jumping into a lake. The difference is that emotional pain is a soul-eroding illness that becomes increasingly and progressively worse as time goes by.

So what can we do for such people to provide them with the necessary life-saving interventions? The truth is that I do not have all the answers. I know that removing the stigma from getting help for mental illness will go a long way toward accomplishing this goal. On a personal level I have a habit of connecting with people in most places I go, establishing at least a minimal bond with them as a matter of course. My experiences in recovery and as a social worker make it damn near impossible for me to do so and I have ended up having many people confide to me that they are suffering in some way. Being present and engaging with those around you, even in the most seemingly insignificant of ways, can have a profound impact. Ask someone how their day is and then listen. I find that people want to be known, understood, and acknowledged and that most people have at least some psychological scars that still impact their daily lives years after the fact. I don’t advocate trying to be anyone’s therapist, but I do believe in the power of being caring and understanding. You never know how much the slightest gesture will affect someone when they are going through a tough time. Until next time.



Hospice Series (Part Two): Hospice Services in the Nursing Home

Hospice services can be delivered in several different settings including hospital inpatient, home services, assisted-living facilities, and nursing homes. This entry in the Hospice Series will deal specifically with the ins and outs of arranging services for loved ones in long term care facilities.

More than half of my patients currently reside in nursing homes. A significant percentage of my home patients will end up in such facilities once their loved ones can no longer handle the “heavy lifting” of their care by themselves at home. Hospice can be extremely beneficial for patients in long term care for several reasons including the following:

  1. Once a patient is living in a nursing home, their Medicare benefits are no longer paying their room and board as Medicare will only do so for a fixed amount of time and only for patients that are receiving restorative or rehabilitative therapies. The great majority of hospice patients do not qualify for such treatments as they are unable to participate and make the significant gains required by Medicare for continued reimbursement. At this point room and board are either being covered by private pay, long term care insurance, or Medicaid (or some combination of these). This means that Medicare will cover hospice costs at 100% with no additional charge to patients or families.
  2. Hospice patients in nursing homes typically receive more person-to-person contact than other residents. Hospice nurses will usually make 2 one-hour visits per week as will hospice aides. Patients will also have a social worker and chaplain making regular visits as well as potential massage therapy and volunteer time. This is likely the reason why patients coming onto hospice service may become a little more social toward their own family members as they are forced into interpersonal interaction with more people. Hospice is participatory for patients and families and keeps them more engaged with one another.
  3. In any nursing home, whether it be the nicest five star facility or a notoriously undesirable one, the patients that receive the best care and the most attention from staff are typically the ones that have the most visitors. While this may seem not to make sense on the surface, facility staff are kept on their toes as there is more potential for hospice personnel to notice dereliction of duty by such staff. Simply put, hospice provides several extra sets of eyes for families and tends to communicate anything of concern directly to a patient’s family. Nursing home staff know this and act accordingly.
  4. Nursing homes are unfamiliar places and a patient’s adjustment to them can range from disruption of normal lifestyle to extreme paranoia and emotional discomfort. Hospice staff offer a modicum of consistency that can provide comfort for patients as they tend to look forward to seeing the same faces on a regular basis. Patients also feel more important and loved by the extra attention.

The bottom line is that, should you find yourself in the position that your loved one’s physician feels that hospice is the desired medical intervention, you can take some comfort in the aforementioned facts. Once these are adequately and tactfully explained to families, they come to see hospice in the nursing facility as what I call both a “win-win situation” and a “no-brainer”. Until next time.



Getting Comfortable with Discomfort

One of the most important lessons I’ve learned as a social worker is that, in order to excel, you must absolutely get comfortable being present in situations that make your skin crawl. You will encounter people, places, things, and circumstances that will test the limits of your ability to maintain a modicum of objectivity, but how do you become comfortable with discomfort? From my experience, three things will help you learn how to do this:

  1. Time on the job. Repeated exposure over a long period of time will familiarize you with the unpleasant particulars you will face. I always say that, while nothing surprises me, some things do shock me.
  2. Having a strong sense of yourself and your values. This will help you notice whether your discomfort is more about you than your client’s presenting issues.
  3. An understanding that the process of learning this skill will never be over. You can refine this skill, but you will never perfect it.

For instance, my very first client at my first “big boy job” was a 15 year-old boy with significant anger issues to whom I would be making home visits. When I pulled up to his family’s trailer, he was sitting on the front steps smoking cigarettes with his family. By family I mean his mother, 12 year-old sister, and 10 year-old brother, all of whom were smoking. His home was infested with fleas from the seven dogs that crowded the living room, only a few of which were his family’s pets. The others were strays that had simply wandered in and were being tolerated by the family.

He had lit fire to a neighbor’s car because he was unhappy with the relationship between the man and his mother. While my own values and the way I conducted  myself in my personal life were completely at odds with much of what I was experiencing, I quickly learned this kid was a person with very real and alarming concerns that deserved a shot at help as much as anyone. I had to put my judgment on the shelf and realize it wasn’t about the life to which I was accustomed. The fact that I included this story from so early in my career, about 13 years ago, shows how deeply it affected me and how, so many years later, I am still conflicted about the way I handled the situation.

I could fill a book with stories of clients/patients that led me to places that challenged my ability to stay present while feeling extremely uncomfortable. Some of these situations involved people I was tasked to help in which I found very little about them to like or admire. However, I have made it a lifelong goal to practice Carl Rogers’ idea of “Unconditional Positive Regard” which states we must treat people as human beings regardless of things they have done. It is not always easy and it would be dishonest of me to say that I always succeed, but it is a work in progress. Remember, the things that make you the most uncomfortable are also your greatest potential learning opportunities. Do not shy away from them.

Most importantly, it is crucial to have a support person, whether it be your own therapist or a colleague with whom you can process such events. This will help you more clearly see what it is in you that causes your discomfort. Your continued effectiveness as a social worker depends upon your dedication to ongoing personal growth. If you do not have a support person, please seek out someone with whom you feel comfortable. It will make all the difference!



The Illusion of Balance

I often hear people talk about achieving “balance” in their lives as some sort of Holy Grail, like a permanent solution to the inevitable ebbs and flows they are experiencing in different areas. It’s become a bit of a cliché in society, so much so that we have the stereotypes of the workaholic, the parent that has given up their career (or at least put it on hold) to stay at home with the children, and the people pleaser that never turns down an obligation at the detriment of his/her personal well being, among many others. If we could just get everything firing on all cylinders in all areas of our lives, we would be perfectly in balance and, as a result, happier and more well-adjusted. Most people with whom I interact at least partly believe this is possible.

I’m here to tell you that it’s a bullshit myth or, as Morgan Freeman so eloquently stated in “The Shawshank Redemption”, a “shitty pipe dream”.

We all have multiple areas in our lives that require our attention. These include career, family, friendships, social obligations, volunteer work, hobbies, and many others. The myth is that we can create a life where we are getting a healthy dose of each of these things without our participation in some of them taking away from our time in the rest. Someday, we think, the stars will align, the magical percentages among these slices of life will add up perfectly, and we will have arrived. Everyone around us will marvel at how well we are managing all aspects of our lives and, in the process, becoming optimal human beings.

That all sounds very nice, but the fact remains that such balance would be mostly impossible even barring unforeseen external events, let alone with the potential for everything to be derailed by one of life’s whimsical and arbitrary interruptions. The plain truth is that, on the whole, we get out of something roughly what we put into it. The more energy I put into my marriage, the better my relationship with my wife is apt to be. Spending excess time in the pursuit of career development will likely enhance my professional standing. Paying more attention to my close friends will strengthen those bonds. It is exceptionally rare, however, that any one person has the time, resources, or energy to manipulate all of these conditions to his/her favor at the same time.

Thus balance does not really mean a fair relative satisfaction amongst the different spheres of our lives–it merely means that everything is temporarily going our way. This inevitably happens for short periods, and is usually due to factors other than our own direct personal influence. Sometimes things just click and we feel we are coasting through our days without any speed bumps. Other times it seems that, although we are desperately trying to keep everything together, we just can’t get anything to work out in our favor. That’s life. Balance, like stability and permanence, is an illusion, a mythical state for which we all strive, yet remains maddeningly elusive. I think the trick is to enjoy the times when everything is going well, to know when one area requires more attention than others, and to be mindful and present in our lives no matter what is happening. In the end even the difficult periods are worth it because they enrich our understanding and experience.

Until next time, stop trying to micromanage everything and relax into the rhythm of the universe. It’s much more beneficial to go with the flow than to fight upstream.