There are endless barriers to addiction treatment — financial, legal, medical, psychological, and social obstacles — that can stand in the way of a particular patient as they try to find the treatments that works best to improve their life and control their disease. I’m of the belief that just about any of these problems can be overcome with widespread addiction education and care from a competent, compassionate physician. But I see one particular obstacle crop up again and again during treatment; a patient mindset, that many patients don’t even notice in themselves, that prevents them from taking full advantage of their care. It seems to me like a failure of imagination when it comes to life without drugs.
Due to the nature of the disease of addiction, early detection is very uncommon. Most people don’t seek any kind of treatment for addiction until it’s become well advanced and started to have serious destructive effects in their lives and their relationships with others. This means that nearly all patients have been living with their disease for years — often for decades — and it’s become the center of all their routines and the fixture of every day. Their friends are often people they can do substances with, the places they go after work to relax depend on where they get their substances, their time with their family depends on how much of their drug of choice they’ve managed to get that day. Addiction consumes their life. After years and years of this, I find that some patients cannot even imagine what their lives might be like once their addiction is no longer in control. Losing it may produce a strange kind of grief, as they adjust to the absence of something that has been with them every moment of every day and provided a driving purpose to all their actions. The sense of loss can be unexpected and terrifying.
That sense of loss, however, is a necessary side of effect of treatment. The goal of treatment is not to “cure” underlying imbalances in brain chemistry, which isn’t possible yet, but to take addiction out of the position of control over the brain. Therapy, especially maintenance therapy, is meant to return control of the patient’s life to the patient, rather than leaving it to the disease. For some patients, this means that they are forced to make decisions about their own lives that they haven’t had to make for many years. Who do they like to spend time with, now that their need to get and use substances isn’t picking their friends for them? What will they do with the time they used to spend buying and consuming substances, getting drunk or high, and going through all the behavioral rituals and symptoms of their illness? What will their relationships with their family be like now that the person they are isn’t dominated by substances? Not only do some patients not know the answers to these questions, they can sometimes be afraid of finding out. The stress of essentially having to reinvent their lives can come as a shock during a time that’s already turbulent due to the start of treatment.
This is a patient population that I do think could benefit from counseling as a part of their treatment, but not the kind of ‘counseling’ often required by non-medical practices. This is, in fact, one of the aspects in which I think we can learn something from halfway houses and 12-step providers. Instead of focusing on past issues that might have caused the addiction problem in the first place, I think long-term addiction patients could benefit from counseling designed to help them confront the drastic changes that come from simply removing the addiction at the center of their life. I have known many long-term addiction patients who responded well to medical treatment, but were unable to cope with the new and unimagined stresses of sober life, and relapsed as a result.
To be very clear, there are also many, many patients who don’t require this kind of intervention — patients who sought treatment for their addiction earlier, or who are just better equipped to deal with the adjustment in their life that comes along with successful treatment. Any counseling of this kind should be strictly optional, and the decision to undertake it should be made between each individual patient and their physician. But it would be a valuable resource in a field where specialized patient problems are really just beginning to be recognized.