A response to Lance Dodes: The Pill and the Pendulum

By Michael G. Brock
MA, LLP, LMSW
 
Lavitt next asks if Dodes is presuming a relationship between AA and the rehab industry that doesn’t really exist. Dodes says, “It exists in terms of rehabs basing their treatment models off of AA. It does not exist in the reverse...Rehabs do advertise their programs as being 12-Step programs...a majority of the rehabs are based on AA.”

Dodes is correct regarding this question. Although AA has done nothing to encourage this relationship, many of these treatment centers are founded by AA members, such as Betty Ford and Eric Clapton. But many, if not most, AA members resent this deluge of people referred to AA, who don’t necessarily want to be there, but are sent by the courts, employers, treatment centers, spouses, children and anyone else who can’t think of what else to do with their addicted loved one. Some of my clients have been told by AA members that if they don’t think they are alcoholic then they don’t belong at a closed meeting[i], and though this may not be the best approach given the realities of the age, those are the rules.

Clients of mine who are committed members of AA tell me they have sat with people at meetings whom they didn’t know and who had nothing to say. At the end of the meeting they all pulled out their attendance slips for signatures—the only reason they were there. That was a waste of everyone’s time, so now they rarely sit at a table where they don’t know some of the people. One or two people who are not particularly invested cannot spoil the meeting, but several of them can and do ruin it for those who really want to be there. At some meetings the chairman will ask who has attendance sheets to be signed, sign them, and send them on their way at the beginning of the meeting. But that is also a questionable strategy, for a couple of reasons:

• First of all, the courts are sending these people because they want an alternative to putting them in jail. Sometimes it’s AA, sometimes therapy, sometimes both. But they are hoping the people who come to their attention because of substance abuse problems will hear something they can relate to and decided they want it for themselves. If you lead a horse to water, maybe he’ll decide he is thirsty.

• Secondly, in the early days of AA some “unsavory” people wanted admission to the fellowship. It was put to the group conscience and involved a heated discussion. Ultimately, it was decided they could not, in good conscience, turn anyone away; AA had to be open to all. People who want their slips signed are people who may need help and don’t know it. Judges want to let them see an alternative to the life they have and to decide if they want it. But I have told clients sent to me by the courts who wanted to complain about the legal system, or who insist they don’t have a problem that they don’t have to be there; they can do the time. Some of them choose to do it.

Early on, Wilson was offered the opportunity to professionalize his recovery concept, but he was convinced in a “group conscience” meeting of the early AA members that this would be the wrong way to go. Subsequently, the eighth tradition of AA codified the conviction that the organization should remain forever non-professional, and the seventh tradition that AA should be self-supporting and decline outside contributions. There was a major concern that “money, power and prestige” would create internal strife and detour AA from its primary purpose of recovery from addiction.

Wilson did hold the copyrights to the book “Alcoholics Anonymous” and “The 12-Steps and 12 Traditions of AA.” Income from these books, plus a small stipend from John D. Rockefeller for both himself and Akron physician and co-founder Bob Smith in the beginning allowed Wilson the resources to market his recovery concept full-time, and for Smith to focus exclusively on treating alcoholics at Akron General Hospital, where other doctors were happy to refer him their alcoholic patients, and where the first AA group was established. By the time of her death, Wilson’s widow Lois had become moderately wealthy from book royalties. However, had Wilson ignored the objections of the group (and Rockefeller) about professionalizing AA, he could have conceivably become much richer.

Most treatment centers I’m aware of follow the 12-Steps, host meetings on their sites, and are generally set up as AA boot camps. The idea is to detox people, get them away from their environment (including drinking or using friends), and indoctrinate them with AA before turning them loose in their own communities and their own free-standing AA meetings. Typically, treatment centers are set up to run about 28 days, but there are some that run much longer. Some clients follow up with half-way houses, and some treatment centers that cater to drug addicts can have inpatient stays that last months. Interestingly, healthcare professionals have somewhat higher drug abuse rates than the general population[ii], and treatment centers for doctors tend to run longer than one month. Impaired professional programs in most states involve regular urine tests for up to five years and a requirement to follow up with 12-step meetings.

It is worth noting that in the glory days of substance abuse treatment (the 1970s and 1980s) most insurance companies would pay for at least one 28-day stay, and maybe a few of them, but that came to a halt many years ago, and now most insurance-covered stays are 7-10 days the first time, and maybe a three day detox the next. Insurance companies got tired of paying for the revolving door and found it very hard to measure the results of what they were doing.

The science of measuring recovery has always been nebulous for many reasons, not the least of which is the difficulty of obtaining reliable data. The darker side is that there is a sense in our society that neither mental health nor substance abuse conditions are valid health concerns deserving of treatment. For all the talk of mental health parity that frequently goes around in political circles, both the number of inpatient and outpatient treatment days for which insurance companies are willing to pay continues to decrease, along with reimbursements to providers. The importance of this trend is that more of the burden of helping these patients falls on the kind of self-help groups that Dodes disparages for their religious content.

Dodes is engaging in class warfare without apparently having any awareness of what he is doing, because he is criticizing a resource that has been consistently available while other resources, especially the one he proposes as a better alternative, is decreasing in availability. How are people who work 40 hours a week with no health benefits and who still need food stamps to make ends meet going to find money for psychotherapy?

That being said, the substance abuse treatment population at least has someplace to go with AA and a few government or charity sponsored treatment options (such as the religion-based Salvation Army, Jewish Family Services, or the Arab Community Center for Economic and Social Services). But while there may be group home “storage facilities” for the chronically mentally ill, there are fewer options for functional people with serious affective disorders. The idea of releasing people with major depressive illness from the hospital after a ten day stay concerns me greatly. I had one patient commit suicide after two hospitals released him subsequent to his having maxed out the days for which his insurance company would pay.

Interestingly, it is the hospitals and healthcare professionals who wind up paying off on the malpractice suits when health insurance companies terminate therapy, which is making the treatment of these conditions less economically feasible all the time. I’ve received letters from insurance companies (when I took insurance) saying, “We’re done paying for treatment. We think the client/patient should be cured after these [usually miniscule amount of] sessions. But if he isn’t well you shouldn’t release him from treatment. If you do and anything bad happens, you’re responsible, not us.” They control the funding, but abdicate any responsibility for the consequences of pulling the plug. Consequently, they get richer, while the poor and middle class get a decreasing quality of service.

The days of talk therapy of any kind may be numbered (except for the rich), as both doctors and patients tend to seek medical solutions to their problems rather than genuine psychological well-being. And in fairness there are many effective medications on the market that are part of the solution. However, many drugs, especially prescription opiates and benzodiazepines are clearly being overprescribed. According to the Center for Disease Control, more people now die from legal prescription opiate overdose than from the heroin and cocaine combined.[iii] Moreover, these drugs are often prescribed for addicts/alcoholics without regard for their past histories, which is both unnecessary and highly irresponsible.

A couple of years ago, one of my clients told me he had a hernia operation, which was done very well and healed quickly. However, despite his history of alcohol and drug abuse, the first thing he was offered when he came out of the anesthetic was morphine. He was not in pain, but he was cold and shaking enough to make the bed rattle. “I’m cold,” he told the nurse, and they brought him some warm blankets. He was not in any pain, but he asked the nurse for some Motrin to control swelling. He slept for a while, then walked around and, feeling OK, asked if he could leave. They offered him Vicodin to go. He declined. This was not a case of a patient seeking out medication, but having it shoved at him, despite his history.

In the early days of AA the old-timers would caution newcomers not to take anything addictive. Clients reported being told by old-timers that many doctors treat alcoholism as a “benzodiazepine deficiency.” This teaching has given way to the caution to, “Be careful what you take and only take it according to prescription.” Even so, when I send someone to the Secretary of State for a driver’s license hearing, I know hearing officers look askance at alcoholics or addicts who are using an addictive substance by prescription. Special forms have to be filled out by the physician, assuring the SOS (called a DI4P) that the patient needs to be on these substances, does not abuse them, and that they will not interfere with his ability to drive a car. Even so, one client who was on prescription marijuana was told by the hearing officer to “get another opinion” about the need to be on prescription cannabis.

[i] There are AA meetings that are open to the public (open meetings), and closed discussion meetings (closed meetings), which are intended for those who identify themselves as alcoholic and have a desire to stop drinking.

 [ii] …Healthcare professionals have higher rates of abuse with benzodiazepines and opiates. Specialties such as anesthesia, emergency medicine, and psychiatry have higher rates of drug abuse… http://www.ncbi.nlm.nih.gov/pubmed/17242598

 [iii] “Opioid analgesics were involved in 30% of drug overdose deaths where a drug was specified in 1999, compared to nearly 60% in 2010. Opioid-related overdose deaths now outnumber overdose deaths involving all illicit drugs such as heroin and cocaine combined…”

http://www.cdc.gov/HomeandRecreationalSafety/pdf/HHS_Prescription_Drug_Abuse_Report_09.2013.pdf

 ––––––––––

Michael G. Brock, MA, LLP, LMSW, is a forensic mental health professional in private practice at Counseling and Evaluation Services in Wyandotte, Michigan. He has worked in the mental health field since 1974, and has been in full-time private practice since 1985. The majority of his practice in recent years relates to driver license restoration and substance abuse evaluation. He may be contacted at Michael G. Brock, Counseling and Evaluation Services, 2514 Biddle, Wyandotte, 48192; 313-802-0863, fax/phone 734-692-1082; e-mail, michaelgbrock@ comcast.net; website, michaelgbrock.com.