AddictionDoctor.Org

Imagine you walked into your doctor’s office for your annual check-up. Afterwards he asks you into his office to talk about the results (I know the idea of a doctor sitting down to talk to you is weird, but bear with me). He points out that your blood pressure is not in control. “Have you been taking your medicine, watching what you eat?” “Well, no,” you say. He looks at you with a condescending look and says, “Well, I guess your just not ready. Don’t bother me again until you are,” and fires you from his practice.

If that happened to me I’d feel a range of feelings: shame, rage, hurt, fear. All of which would decrease my dopamine receptor levels in my reward center and make it much less likely that I’ll actually feel any motivation to change and do what the doctor wants. In the addiction treatment world, I hear this kind of attitude all the time, and when I do, the practitioners of this schema inevitably say it works. If you only remember your successes, and forget the people who never come back, I’m sure it looks like a good plan. When I ask people who treat patients this way for written retention figures for their practice or program, I get blank stares.

There’s a fantasy that seems to infect addiction treaters; it’s called “The Bottom.” If everyone had a Bottom we could safely let go of them and let them keep falling until they hit it, and, then, they’d come back to us in a more reasonable teachable way. I think the origin of this fantasy is the experience of getting into recovery. So many of us got into the addiction treatment world through our own recovery that we think everyone has the experience we did. Well, the members of the addiction treatment community who got sober are a self selected group that had Bottoms. To assume everyone has one because you had one is like assuming everyone is as tall as you are. It makes no sense on the face of it.

And what if not everyone has a Bottom? If we let them drop assuming they’ll bounce, and there’s no Bottom, they’ll just die of this disease. Since most people with this disease die of it and very few get into and stay in treatment, I’m betting there’s more evidence against the fantasy of The Bottom than for it.

So when we’re faced with a patient who doesn’t want the treatment we offer, or doesn’t want to adhere to the treatment plan, or thinks there’s another way then what we say, we have two choices. One, my way or the highway; and two, okay let’s try it your way, but remember I have another one if this one doesn’t work. It’s pretty obvious to me that if we meet the patient where he is and pick number two we’ll be able to be of more help. However there are some barriers to picking number two, and they’re systemic in addiction treatment.

One is the limited training most people have who treat addiction. This society confuses drug use, drug abuse, and addiction on a daily basis. Because we focus on the drugs, we focus training on stopping the drugs. A great deal of my psychiatry residency was focused on dealing with resistance on the part of patients. Unfortunately it’s not a subject that gets a great deal of interest in the addiction field.

Another problem is the structure of the “programs” that treat addiction. If you’re a hammer, you only look for nails. If someone doesn’t want to be a nail, you’ll try to hammer him anyway. And when it doesn’t work; he just wasn’t ready to be a nail. If all you offer is inpatient treatment or IOP or residential 28 days then you can’t meet the patient where he is unless he’s where you are already. The goal should be to be a tool box, not a tool.

Many people call addiction a chronic disease, but until we in the addiction treatment field start treating our patients as if they are ill, instead of not ready, we’ll never be accepted by society or mainstream medicine as people who treat an illness. When we do start treating them as patients with an illness, I think they won’t feel so much shame, rage, hurt, and fear. Their dopamine tone will actually go up, and they’ll have more motivation to follow our advice. So the best reason to meet people where they are is because it works better.