Treatment of drug and/or alcohol addicts is extremely difficult for those psychiatrists not specifically trained to handle such patients. Let me start by describing two patients with whom I failed miserably because, in my commitment to addressing the symptomatic side of the disability, I did not address the addiction.
The first case involved a 41-year-old single man, who was a son of very rich parents. The patient seemed to have had a lifetime of debilitating depression. He appeared attached to his elderly mother and had no friends, work, or real source of pleasure. All of that should have been enough for me to delve into the possibility of addiction, but he did not offer the information and I did not ask.
He described a terribly abusive childhood, mostly at the hands of his alcoholic mother, who beat and humiliated him constantly and essentially blamed him for everything–since his brother could do no wrong. The most pathetic sentence I can remember from his treatment was: “Every day when I got home from school, I tried to get from the front door to my bedroom in the hope that I would not rouse or encounter my drunken mother.”
He ended treatment by going into an alcohol rehab center.
The second case was even worse, because I knew when I started treating this patient that he was an alcoholic. He was a 42-year-old lawyer with a history of many rehab admissions and attempts to stop his use of drugs and alcohol. I was persuaded to take him into treatment by his father, whom I had known casually more than 40 years earlier.
His father, who was extremely intrusive, domineering, and controlling, took his son into his law practice. The father was such a hovering and demanding presence in his son's life that the treatment started by my attempting to help the patient separate from him. This turned out to be extremely difficult, and I was not paying enough attention to the drinking.
From time to time, his father would call to scold me and tell me about a drunken episode that had occurred over the weekend. I was so resentful of the father and committed to the patient that I did not take a strong, objective view of the regression as a good treater of an alcoholic would have done. Instead, I took a softer psychotherapeutic approach that was not absorbed in a positive way by the patient. I was going to be a better, kinder, gentler father figure for this patient.
Clearly, this is antithetical to the best treatment for an addict. He, too, left therapy for another tour through a rehab center, and I never heard from him again. I would like to believe that his silence stemmed from his father's rage at me rather than his own disappointment with my care.
Both of those cases illustrate the need for a general psychiatrist to have specific training in caring for the addicted patient.
I hope that today's residents fulfill the requirement to learn about addiction psychiatry. It should be something every practicing psychiatrist should learn and know how to do. The most important question to be asked is whether the use of drugs and alcohol is primary with anxiety and/or depression superimposed on the addiction because of the failure, dissipation, and uncontrollable craving. Or are the anxiety and/or depression primary, and is the patient using drugs and/or alcohol as self-medication?
Many patients whom I have evaluated start drinking early in adolescence because of the posttraumatic stress disorder (PTSD) suffered as a result of serious physical or emotional abuse as a child. I believe the first patient's problems were at least partly a result of his serious abuse as a child. But there is also the genetic element that cannot be discounted.
It is important that the clinician try to make the distinction as part of the patient's evaluation so that he knows what direction to take in the treatment. Regardless of the answer, the initial care must be directed to the cessation of substance use.
For the nonaddict, the most difficult thing to understand is the depth and extent of the craving. Because brain changes clearly take place in the addict that make this craving a biologically driven reality, it is very difficult for the patient to “just say no.” Willpower is an insignificant force, compared with the attraction of the patient's substance. We all know former smokers who, even though they have not smoked for 20 years, still desire a cigarette–especially when they are in the company of someone who is smoking. Similarly, the drug and alcohol addict cannot really control this desire. That's why Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) are so important and should be part of every treatment regime. The key to AA/NA, in my opinion, is the sponsor. The sponsor is someone who is a mentor, guide, and coach who is available 24/7 so that the user can call upon that person to help them suffer through the attack (of desire) and not succumb to it.