Carroll’s Second Law of Psychiatry: The patient is the one with the problem.
I was at one end of a table in one of the best addiction treatment programs in the country, and at the other end was one of my counselors. For those unfamiliar with the addiction treatment system, addictions counselors are the footsoldiers of righteousness in an ongoing battle against the darkest evil of the human heart. It’s mainly a bachelor’s level job, filled by young idealistic people on the way somewhere else or more experienced people who are often on a mission; and armed with that four-year degree and accompanying inadequate salary they stand in the gap between redemption and some of the worst human depravity you will never hear. This also provides them with some absolutely bitchin’ happy hour stories.
My kind of people.
This particular counselor was a young fellow, whip-smart; quiet and calm and dedicated. We were discussing a patient who, while so far testing negative for drugs, was floundering – not showing up to groups, missing counseling sessions. Not often, but consequences were piling up. Consequences that could eventually lead to the patient exiting the program. Which meant almost certain relapse.
I asked my counselor what was going wrong. He told me a story of how he had messed up the case. He hadn’t paid close enough attention, he had missed a couple of opportunities to remind the patient of groups, he hadn’t appreciated how frustrated the patient was getting with how regimented and unyielding the place was.
There were a lot of people in the room, but this story was being told to an audience of one. In the scales balancing justice and mercy, I was the linchpin. I was either going to tell my counselor to drop the hammer on the patient and require him to do more groups, show up for his counseling and so forth; or cut him some slack and give him some room to get himself together before he lost the one thing that was holding him together.
I’ll be honest with you (that’s a later post): This is not the least bit paraphrased nor edited. I said:
“Smart Quiet Passionate Counselor I Really Like (not his real name), you have been manipulated.”
A minor digression (you’ll see that to which I am up soon): In disorders of learned behavior, the patient, to one degree or another, wants to do something that is bad for him. That’s not to say he doesn’t want to stop it, by the way. You can want your cake and hate your waistline. Conflicting goals and desires is the human condition. For most of us, thankfully, it’s just chocolate cake – not crack cocaine. Judging by the line at The Cheesecake Factory, it’s a good thing, too. We could have a full-on Walking Dead situation.
So you are dealing with this fundamental glitch in human nature – that immediate, reliable, transient jolt of yeah, baby can take over a human life and steal a human soul. Little decisions to do some little thing over and over again, until your life organizes itself around that little thing; raising the pipe to the lips, the powder to the nose, the cigarette from the pack. Reducing a human life to a bad EDM set on endless repeat.
So that little thing starts taking up more and more life space – time, money, attention. That means other things get slowly crowded out – like responsibilities, family. Slowly, insidiously, decision by decision, cop-out by cop-out, lies and manipulation creep in. Again, that’s not to say somebody starts out wanting to be a liar or a manipulator.
People early in recovery have to manage such a load of self-loathing it’s hard for others to fathom. Imagine coming out of a haze one day, looking around, and realizing that not even your parents are willing to put a roof over your head in winter because they can’t trust you in their house.
Then imagine that you know they are absolutely right.
It is a monstrous thing to acknowledge you sold your soul ten bucks at a time for two decades, and it’s going to cost a hell of a lot more than money to get it back. The folks who manage that, who come back from that, are a fascinating bunch. They have probably taught me more about the good in human nature than anybody else. They are the reason I’ve stayed in the addictions world for so long.
That early blast of shame and remorse, though, comes just from seeing the things you know you’ve been trained by the drug to do. Yet more insidious is the ice under the water. All the little things that you do that serve your addiction, that you don’t even know serve your addiction.
Back to my counselor.
I started asking questions about our patient.He was a likeable, pleasant guy. He had put together several stints of abstinence, maybe six months at a time. Early in these periods he would be a model citizen; uncomplaining, reliable, enthusiastic at whatever occupation he found himself. Then stuff started to go wrong. Once people liked him and he was doing everything right, he started to slide. At which point all these people found ways to fill in for his minor, completely understandable mistakes. Until the occasional mistake turned into the continuous lateness, missed commitments, and then relapse. After which he became an unreliable cloud of lies and excuses, and left all those people sick of his bull@#^* and unwilling to lift a finger for him. Cut to scene of gaunt, ill, haunted looking guy with nobody and nothing, ducking into a boarded up house in West Baltimore.
Now here in front of me I have my counselor. The counselor of a pleasant, reliable patient who’s doing the right thing, mostly. A counselor who just keeps forgetting little things like reminding that patient about the group he missed last week, or to be on time to those appointments.
Addiction is a vicious, sneaky bastard. Sure it will magnify your weaknesses. Its true evil, however, is in its capacity to turn your virtues into vices. It twisted our poor patient into spending all the goodwill he obtained early in his recovery to have other people cover for him while he relapses. In the process, it cost him every single one of those people.
What might happen, one wonders, if somebody who cared about him were to redefine the situation for him? To not accept the role of the one who helps him by bailing him out; and instead to ask how did he get me to act just like his old boss, his mother, his sister? How did he turn me into the guy begging for mercy on his behalf while he gets closer to a relapse?
What if, in fact, that is his relapse? Relapses, you see, happen well before the money and the pills change hands. They are a departure from the behavior pattern of recovery, and a slow return to the behavior pattern of using.
It’s a lesson hard learned. Doctors, counselors, therapists, the lot of us want to help. Patients, mostly, want help; at least the ones who keep showing up. The addiction, though, it wants to come back. It wants to turn you against each other. It wants to twist your head around into thinking that giving it room to sink its hooks into him deeper is helping him out. It wants to convince him that asking for a hand up from that nice counselor is a way to get back on track, instead of a way to go further down the wrong road.
Anthropomorphizing much, doc?
Yeah, I am. I’m an obstreperous cuss. It’s my job to see what’s happening. One way I can do that is to decide to be an opponent, not a pawn. I hate to get beaten. It keeps my eyes clear.
He’s been playing the game by the enemy’s rules for too long. That’s why he has me. It’s my job to show him that. It’s only when we’re both playing the right game that we can be on the same side.
The first question we want to ask is, “How can I help you?” It probably should be second.
The first is, “How is this your problem?”
[…] The first is the everyday talking-to-someone level. Then there’s the inward eye, watching constantly what you’re feeling and thinking, looking for something fishy. Am I angry? Sad? Pitying? Is it more than it should be? That’s the countertransference. Last is the version of yourself that stands six feet to the left and watches. What is it about this interaction that is triggering that feeling? That’s the process, the secret dirty trick of all psychotherapists. After that last part, it is time to employ the Second Law. […]