Mental Health Matters: Don’t tell an addict to ‘just say no’
Mental Health Matters
Here’s a mental exercise: Imagine you’re holding a five-pound weight. Keep your arm straight and hold it out from your side, parallel to the ground.
Notice the tension increasing as the weight seems to get heavier? Notice the tension turning to physical pain? Hold that weight in your outstretched arm just as long as you can. Experience the pain becoming unbearable.
Finally, your arm collapses to your side no matter how hard you try to keep it extended — willpower, if you will, overcome by gravity and physiology; a failure of will under the gravitational pull of necessity.
I was reminded of this “failure” when I mentioned that there were several recent fentanyl-laced heroin deaths in the Sacramento region plus an emergency room size number of heroin overdoses. The response I heard was that drug abuse and addiction represents a failure of willpower, an unwillingness to “just say no” to drugs.
Of course, the same logic applies to the legal drugs alcohol and tobacco. “Just say no” to alcohol and you can be spared an untimely end with alcoholic cirrhosis of the liver. “Just say no” to tobacco and you are unlikely to die an early death from lung cancer.
Great! I’m all in. Inculcate and teach mental discipline, and voila, no more problems of substance abuse. If only it were true.
Substance abuse is a form of mental illness, not to be confused with lack of self-discipline, deficient moral code or fractured willpower. Recall that mental disorders are behavioral, or mental patterns causing suffering or poor function in ordinary life.
You can no more “just say no” to mental illness as you can to breathing or a beating heart.
Ask a schizophrenic person to turn off their persecutory delusions, a morbidly depressed person to dress or bathe, a demented person to accurately recall what they had for breakfast, or an addict to turn down their next fix. Not possible, not happening.
There are, of course, differences of degree. In milder mental disorders, you can, with herculean effort, overcome certain behavioral or mental deficiencies. A mildly depressed person can, with effort, get up, get going, exercise and even hold a job. Similarly, a person with mild anxiety or compulsions can learn to quiet their anxiety and diminish compulsive behavior.
So too with the first few times you experience a fleeting ecstatic euphoria upon ingesting or injecting certain addictive drugs. But that’s long before the tolerance, cravings and withdrawal of drug dependency set in.
Identify the milder mental disorders early on, and you have a fair chance of “cure” or substantial long-term improvement either with formal therapies or other behavioral interventions.
On the other hand, try and explain to a delusional person how bizarre their thoughts are, and they’ll tell you that you’re the crazy person.
There are many reasons why “Drug Treatment” fails so often — some 80 to 90% of the time according to most research.
Criminalizing the behavior of ingesting certain substances is certainly one of them. By criminalizing a behavior, we stigmatize it for society in general as well as for the person who engages in it.
So, drinking is OK, but smoking marijuana or shooting dope is not. Asking for “help” when the problematic behavior is illegal can make a difficult situation worse.
But to get back to the “willpower” issue, drug addicts, like others with severe mental disorders, can’t turn off what their body demands. That’s why the addict is “dope sick” without the drug, and “well” only after injecting. That’s why the addict searches out the drug, craves the drug, not to get high, but to get “normal,” if only for a few hours.
That’s why you can’t tell an addict to come back next week or month when a rehabilitation bed or treatment slot becomes available. By then, the treatment window of opportunity has closed — or worse, the morgue is completing a toxicology report.
Drug withdrawal, whether alcohol, heroin or any addictive drug has unpleasant immediate consequences, ranging from mild to moderate discomfort to death, depending on drug and dosage. That’s why on-demand medically supervised detoxification is the first step in effective treatment, and why, in its absence, treatment fails almost before it starts.
Once detoxification is completed, but only then, can the addict begin the long, hard journey to unlearn the behaviors and mental sets that lead to drugs, and to identify the emotional pain causing or contributing to substance abuse.
Just don’t tell an addict to “just say no.”
Incline Village resident Andrew Whyman, MD, is a clinical and forensic psychiatrist. He can be reached for comment at firstname.lastname@example.org.