Recently I have several patients who have made remarkable progress in a short time. I would call this discontinuous change. That is, there is a prevalent notion that change occurs gradually, step by step. And sometimes that's how it happens. But then there are times when people change in multiple ways, on multiple dimensions, all at once. Change can be continuous or discontinuous. Now, in some ways this distinction requires some kind of arbitrary decision about what those terms mean. Ultimately, it's an issue of measurement. So, "continuous change" occurs at a smaller scale than the current measurement can detect, while "discontinuous change" occurs in a way that is distinct, a detectable change. Or, one could define it quantitatively or qualitatively. For example, "discontinuous change" could be defined as a change of a certain magnitude, or changes of a certain magnitude on multiple levels or in multiple scales.
But clinically, there are times when I'm simply blown away. A patient comes in who is hardly recognizable, and not simply because of cosmetic or clothing or grooming changes, although they may be a part of it. It's more that a different person walks through the door. Someone who thinks, speaks and otherwise behaves in multiple ways they have not previously. This happens with both substance use disorders and with psychiatric disorders. All of a sudden, everything is different. And no one, least of all the person who just transformed, has any idea why this happened now, at this moment in time. These events are not predictable with current knowledge and scientific methods. They may never be. (A part of me hopes and, of course, therefore predicts, that they never will be.) Anyway, in the past several weeks I have been completely blown away by progress in some of my patients.
What causes the change? There may be environmental events that have powerful effects, such as a DUI, hospitalization, serious medical illness, interpersonal experience, and so on. But these are not very reliable predictors and are not always present. I have patients who have had a DUI and then stopped drinking, and I have others where it doesn't seem to make a difference. Most often, my changed patients report to me that they have either "gotten sick and tired of being sick and tired," or "just decided," or "I just woke up and felt different." We don't have insight into how or why we make the most important decisions in our lives. Our reasons, by and large, are constructions designed to continue a cohesive narrative of our lives. We decide and then construct the reasons. Now sometimes it is the other way around. A slow, rational deliberation (System 2 in Daniel Kahneman's scheme) often plays an important role. But more often I think it's the other way around.
Here's my working hypothesis: complex dynamical systems (including us) tend to configure into a number of discrete, finite states, rather than an infinite number of slightly different ones. We tend to flip from one state to another, much like a tornado suddenly forms out of a certain set of optimal circumstances (but not always, and not easily specifically predicted.) And for us, these states include cognitive, affective (emotional), perceptive, behavioral, genomic, metabolomic, organ, organ system, organismal and social components that may all change at once on multiple levels.
And the thing is, there is only one thing happening even though it is happening at multiple levels. This is a hard one, an idea I finally developed when I was at NIH. In complex dynamical systems, an event occurs on many levels at once. Of course, there may be an instigating event, let's say an adverse social interaction that sets off a crusade of processes ending in severe depression and extremely heavy drinking. The response of a particular person (organism) involves all different levels of analysis essentially at once, because there are millions or billions or trillions of extremely rapidly interactive events that make up the whole. Everything happens on all levels at once: from particle physics up to global and beyond. However, we cannot examine the whole, we need to examine a part of it. We may talk to the involved person, ask them about their experience, perhaps ask them to fill out some scales. We may examine their social interactions and networks, or patterns of communication. We might put them in an fMRI or PET scanner to examine brain blood flow and metabolism, we might measure the output of a stress hormone such as cortisol in the blood, and so on. But we delude ourselves if we think that by looking at one level of analysis, we can say much about the system's behavior. It's not simply linear: A causes B which causes C. It requires a different type of mathematical modeling to help predict the behavior of the system as a whole. But this science is new and will take a long time to mature.
What about therapy or treatment? Sometimes, I think that by creating a safe, therapeutic environment and providing straight, often difficult, but always compassionate feedback, I may make a change like that possible. It often feels like a lifeline - I provide a secure support and anchor for taking chances and making changes. Some patients volunteer this information - that having me in their corner allowed them to make changes they were previously afraid to make, or that I provided a direction they had not seen before. Other times, I have no idea. A patient changed suddenly to the better, and I don't feel I had much if anything to do with it. This isn't false modesty; I'm talking about people I may see every 3 months for medication checks, but who suddenly undergo a big positive change. Most of the time, it's pretty hard to tell. Maybe I made a difference, maybe not. But it's enough to keep going, doing my best, trying to help people in any way I can. And I'm grateful for that opportunity. People let me into their lives in the most intimate ways imaginable, trusting me not to betray them, not to hurt them. I feel very privileged and humbled by that trust and I do my best to be deserving of it.
MW
Showing posts with label mind/body integration. Show all posts
Showing posts with label mind/body integration. Show all posts
Tuesday, November 27, 2012
Tuesday, September 25, 2012
How to Save $30,000 and Get Better Results
I have had numerous patients who have been pressured by their families to "go away" to some residential treatment program, usually it seems in another state (than Minnesota). Florida, Arizona and California seem to have a concentration of these, especially "Executive Programs" with gourmet food, precious handling, "equine therapy," "golf therapy," yoga, life coaching, and of course first class accommodations. They run from $20,000 to $70,000 for a month. These are people who have severe, recurrent addictions, usually to alcohol but some are addicted to opioids like heroin. Almost all have been through some sort of rehab multiple times before. Many but not all have money. Often enough, it's a family member who is coughing up the big bucks.
What do they get? One patient relapsed on the plane on the way home. Not a single one had any lasting benefit. Almost all relapsed within weeks, often days after returning home. In other circumstances, patients and families, and in Minnesota, state government, will pay for lengthy stays, 90, 120, 180 days in some "recovery environment." Again, it's plenty costly. But do they get any benefit? The vast majority do not.
It's an uphill battle to try to convince family members that sending their loved one away for some period of time to some "special place" is very unlikely to change their long-term outcomes. People just do not want to believe it. And admittedly, it's a hard pill to swallow. After all, the chemical dependency treatment industry has done a commendable job of spreading the idea that anyone can recover "if they really want to." And of convincing people that they have some unique answer to an ancient problem that defies easy resolution. The really difficult fact is this: all of our treatments (yes, that includes 12 Step treatment programs and AA) have modest effects at best. (The exception to this generalization is for opioid maintenance therapy with Suboxone or methadone for addiction to opioids such as Oxycontin or heroin. Opioid maintenance therapy is extremely effective and more cost-effective than almost any medical intervention other than vaccination.) Too many people do not respond to any available treatment. And they die of their illness. They die of a hereditary, brain-based behavioral disorder that makes them vulnerable to compulsive use of alcohol, opioids, cocaine, meth or cigarettes. It's not that they aren't motivated to change. I have to say, this is one of the cruelest things that rehabs do: people are told they could stop the process if they wanted to. But guess what? Some people can't. No matter how hard they try to "work the program." No matter what they do. Even if they go 90x90, or attend 1000 12-step meetings a year. They are mystified. "Why do I keep doing this? I'm not stupid! I know what will happen, but I do it anyway." This is the mystery of addiction.
In other chronic severe diseases, health care providers constantly experience failure of available treatments, and are able to accept it. People die of heart disease, cancer, diabetes, stroke, multiple sclerosis, dementia. But in the rehab industry, staff members are protected from experiencing treatment failure. First, treatment is time limited. So, instead of having to live with patients who come back with recurrent illness when the treatment doesn't work, staff members don't have to live with (and struggle to help) people who don't respond to treatment. Second, the entire industry (and unfortunately, too many 12-step program members) believe without doubt that "treatment doesn't fail patients, patients fail treatment." Try telling that to someone with metastatic cancer, end-stage liver failure, Parkinson's disease or chronic obstructive liver disease. But because we continue to stigmatize people with addiction, we get by with it, we are told to reject them, to use "tough love," to let them "bottom out." In my experience, in too many people "bottom" is 6 feet under ground. We condemn family members who don't abandon their loved ones as "enablers." What could be more cruel than this?
As a healer, one of the hardest things I do is to stay engaged with someone who dies of addiction. To not reject them. To not condemn them. To understand they are in the grips of something neither they nor I nor anyone else can control or stop, short of imprisoning them (and even then, prisons and mental hospitals are usually full of drugs.) To accept the limitations of our available treatments. To be compassionate even as death approaches. In the last year alone, in my part-time clinical practice, I have lost 6 patients to addiction.
It's not actually different than dying of diabetic renal failure, or of multiple sclerosis, or cancer. We can accept those illnesses as "not the person's fault." But when it's a brain-based disease, we cannot fathom that a brain can become dysregulated to the degree that someone loses control of their behavior to such an extent that they die from it. It's too frightening. We can't stand the thought that we aren't in full control of our lives. That we can't control our own behavior completely.
And yet, we all know better. We all have areas of problem, non-optimal behavior. We smoke. We drink too much. We don't exercise enough. We can't get our behavior right with our spouse or partner or children. We lose it. We shop too much. We can't handle money. We eat too much. We don't take good care of ourselves when we have a chronic illness. We lose our tempers. We work too hard, or not hard enough. We ignore important things. We procrastinate.
Yet we cling to the illusion of control. Of self-determination. We control our fates. Why can't "they"?
Just to be clear, I am not advocating that people with brain-based behavioral disorders not be held responsible for their behavior. For example, I am not advocating that people who commit crimes while intoxicated should be found innocent because of their addiction. As we move further into understanding the brain mechanisms underlying destructive and/or illegal behavior, this question looms large. But I have concluded that even though brain dysregulation might underlie much of this type of behavior, society only works if we hold people responsible for their behavior in spite of that fact. Individual responsibility for behavior is a social and political necessity that cannot be sorted out by science. In this blog, I am addressing how to provide health care for people with addiction and nothing else.
It's terrifying to think of having a behavior so out of control that it kills us. Anorexia nervosa. Depression. Bipolar disorder. Schizophrenia. Addictions. Antisocial and borderline personality disorders. All have substantial mortality rates. People with serious mental illness die 25 years early on average! Is it because people don't care if they die? I know that's not true, I've worked with too many of them. No, it's because the brain is a flesh-and-blood organ that can get sick, dysregulated, in specific ways that the individual cannot have insight into and cannot control. And it kills them. We have to come to grips with this grim reality if we have any hope of overcoming these dread diseases.
One thing I do know is this: some short-term high-end expensive rehab program is not going to change anything. The best hope is long-term care management with an experienced and qualified clinician or team of clinicians. That's what we do for diabetes, heart disease, cancer, stroke, arthritis. That's the best we can do for people with severe addictions. And it is a heck of a lot cheaper besides. Give me $30,000; I'll see you daily for a year! Geez, with 8 patients, I could make $240,000 a year!
I can obtain better results at a fraction of the price than any high-end time-limited treatment program. I guarantee it! And yet, I have to accept that despite all of my best efforts, and theirs, and their families', some of my patients will not respond. And some will die as a result. And they deserve our compassion, not condemnation.
What do you think? Please spread this around, comment on it, argue, agree or do something else. These are incredibly important questions.
MW
What do they get? One patient relapsed on the plane on the way home. Not a single one had any lasting benefit. Almost all relapsed within weeks, often days after returning home. In other circumstances, patients and families, and in Minnesota, state government, will pay for lengthy stays, 90, 120, 180 days in some "recovery environment." Again, it's plenty costly. But do they get any benefit? The vast majority do not.
It's an uphill battle to try to convince family members that sending their loved one away for some period of time to some "special place" is very unlikely to change their long-term outcomes. People just do not want to believe it. And admittedly, it's a hard pill to swallow. After all, the chemical dependency treatment industry has done a commendable job of spreading the idea that anyone can recover "if they really want to." And of convincing people that they have some unique answer to an ancient problem that defies easy resolution. The really difficult fact is this: all of our treatments (yes, that includes 12 Step treatment programs and AA) have modest effects at best. (The exception to this generalization is for opioid maintenance therapy with Suboxone or methadone for addiction to opioids such as Oxycontin or heroin. Opioid maintenance therapy is extremely effective and more cost-effective than almost any medical intervention other than vaccination.) Too many people do not respond to any available treatment. And they die of their illness. They die of a hereditary, brain-based behavioral disorder that makes them vulnerable to compulsive use of alcohol, opioids, cocaine, meth or cigarettes. It's not that they aren't motivated to change. I have to say, this is one of the cruelest things that rehabs do: people are told they could stop the process if they wanted to. But guess what? Some people can't. No matter how hard they try to "work the program." No matter what they do. Even if they go 90x90, or attend 1000 12-step meetings a year. They are mystified. "Why do I keep doing this? I'm not stupid! I know what will happen, but I do it anyway." This is the mystery of addiction.
In other chronic severe diseases, health care providers constantly experience failure of available treatments, and are able to accept it. People die of heart disease, cancer, diabetes, stroke, multiple sclerosis, dementia. But in the rehab industry, staff members are protected from experiencing treatment failure. First, treatment is time limited. So, instead of having to live with patients who come back with recurrent illness when the treatment doesn't work, staff members don't have to live with (and struggle to help) people who don't respond to treatment. Second, the entire industry (and unfortunately, too many 12-step program members) believe without doubt that "treatment doesn't fail patients, patients fail treatment." Try telling that to someone with metastatic cancer, end-stage liver failure, Parkinson's disease or chronic obstructive liver disease. But because we continue to stigmatize people with addiction, we get by with it, we are told to reject them, to use "tough love," to let them "bottom out." In my experience, in too many people "bottom" is 6 feet under ground. We condemn family members who don't abandon their loved ones as "enablers." What could be more cruel than this?
As a healer, one of the hardest things I do is to stay engaged with someone who dies of addiction. To not reject them. To not condemn them. To understand they are in the grips of something neither they nor I nor anyone else can control or stop, short of imprisoning them (and even then, prisons and mental hospitals are usually full of drugs.) To accept the limitations of our available treatments. To be compassionate even as death approaches. In the last year alone, in my part-time clinical practice, I have lost 6 patients to addiction.
It's not actually different than dying of diabetic renal failure, or of multiple sclerosis, or cancer. We can accept those illnesses as "not the person's fault." But when it's a brain-based disease, we cannot fathom that a brain can become dysregulated to the degree that someone loses control of their behavior to such an extent that they die from it. It's too frightening. We can't stand the thought that we aren't in full control of our lives. That we can't control our own behavior completely.
And yet, we all know better. We all have areas of problem, non-optimal behavior. We smoke. We drink too much. We don't exercise enough. We can't get our behavior right with our spouse or partner or children. We lose it. We shop too much. We can't handle money. We eat too much. We don't take good care of ourselves when we have a chronic illness. We lose our tempers. We work too hard, or not hard enough. We ignore important things. We procrastinate.
Yet we cling to the illusion of control. Of self-determination. We control our fates. Why can't "they"?
Just to be clear, I am not advocating that people with brain-based behavioral disorders not be held responsible for their behavior. For example, I am not advocating that people who commit crimes while intoxicated should be found innocent because of their addiction. As we move further into understanding the brain mechanisms underlying destructive and/or illegal behavior, this question looms large. But I have concluded that even though brain dysregulation might underlie much of this type of behavior, society only works if we hold people responsible for their behavior in spite of that fact. Individual responsibility for behavior is a social and political necessity that cannot be sorted out by science. In this blog, I am addressing how to provide health care for people with addiction and nothing else.
It's terrifying to think of having a behavior so out of control that it kills us. Anorexia nervosa. Depression. Bipolar disorder. Schizophrenia. Addictions. Antisocial and borderline personality disorders. All have substantial mortality rates. People with serious mental illness die 25 years early on average! Is it because people don't care if they die? I know that's not true, I've worked with too many of them. No, it's because the brain is a flesh-and-blood organ that can get sick, dysregulated, in specific ways that the individual cannot have insight into and cannot control. And it kills them. We have to come to grips with this grim reality if we have any hope of overcoming these dread diseases.
One thing I do know is this: some short-term high-end expensive rehab program is not going to change anything. The best hope is long-term care management with an experienced and qualified clinician or team of clinicians. That's what we do for diabetes, heart disease, cancer, stroke, arthritis. That's the best we can do for people with severe addictions. And it is a heck of a lot cheaper besides. Give me $30,000; I'll see you daily for a year! Geez, with 8 patients, I could make $240,000 a year!
I can obtain better results at a fraction of the price than any high-end time-limited treatment program. I guarantee it! And yet, I have to accept that despite all of my best efforts, and theirs, and their families', some of my patients will not respond. And some will die as a result. And they deserve our compassion, not condemnation.
What do you think? Please spread this around, comment on it, argue, agree or do something else. These are incredibly important questions.
MW
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