When I was an active addict, my interactions with medical professionals harmed rather than helped me. Sadly, I’m far from alone.
The year before I got sober, I was in group therapy, snorting dangerous amounts of cocaine, suicidally depressed and seemingly without the ability to connect these facts. The therapy was only making me feel worse, so the solution, I decided, was anti-depressants. I asked my group therapist to recommend a psychiatrist, and she sent me to a guy with a fancy Beverly Hills office, a Southern accent and a pinkie ring.
For some reason, when I walked into his office and he asked me if I did any drugs, I decided to be honest and told him that I was regularly doing cocaine. Maybe I was sick of lying. Maybe I had faith that there was another way and believed he could help. Maybe I was just tired or coming down.
“While most medical professionals are great on the science, they’re not so great on the art of establishing a therapeutic alliance with the patient,” says Dr. Paul Hokemeyer.
“What?” he asked, clearly horrified; I made an instant decision never to be honest with a doctor again. “Does Arlene know?” he asked of my group leader. I shook my head. “Well then, you have to tell her,” he commanded. “Tell her or I will.”
I was terrified. I didn’t know the rules. The Internet existed but I was too wired and paranoid all the time to try to find out if his threat was legal or appropriate, and I felt judged and cornered and terrorized.
Until, that is, I saw an easy solution. The following week, during group, I made this confession: “I was doing a lot of coke for a while. But I’ve stopped.” They nodded. I think one of them picked at a hangnail. Group moved on; it was someone else’s turn to share. I called my coke dealer on the drive home.
While my situation was somewhat unusual, addicts receiving damaging responses from the medical profession—above and beyond the frequent failures to diagnose addiction—is sadly all too common.
I continued to see my pinkie-ring psychiatrist for the next year or so, because he told me I had to if he was to keep prescribing me Paxil and Ambien—drugs I was convinced I needed. I thought he was a terrible psychiatrist and a worse person, and found the $250 half-hour sessions a serious financial strain. But he was a professional, and I was desperate and afraid.
Then one day he calmly explained that he couldn’t continue to see me, and I “must know why.” I theorized it had to do with my constantly telling him I’d gone out of town again and—would you believe it—had left my bottle of Ambien in Houston or Vegas (in reality I was barely leaving my apartment and taking roughly 10 times the amount he’d prescribed me). But I was too ashamed to say anything, so I only nodded.
He told me to find a new shrink, and that he wouldn’t give me any more Paxil; then he handed me a prescription for six months’ worth of Ambien. At no point did he mention AA, rehab, or even the words “addict” or “addiction.” I left his office hysterically crying, scrip in hand, feeling like he hoped I would kill myself.
Here’s what I’ll say in his defense: Active addicts tend to be nightmarish patients. They often refuse to look at reality, lie whenever they can and would happily steal any doctor’s prescription pad if they didn’t think they’d get busted. I was all of those things and worse.
But does that excuse what he did? I didn’t think so. A year or so later, once I’d been to rehab and sobered up, I received a bill from his office and a note which claimed I’d never paid for my last visit. I sent him a reply detailing what I’ve just told you—adding that if he tried to contact me in future, I’d report him to the American Medical Association. I never heard from him again.
All that said, I have plenty of friends whose doctors have spoken to them directly and appropriately about their addictions, and it didn’t make a difference until they were ready to change. Tiffany, an LA-dwelling actress I went to high school with, told me that her general practitioner diagnosed her as a bipolar addict years before she got sober, adding that she couldn’t drink because “bipolar addicts don’t live long.” Her liver enzymes had shot through the roof, and she respected her doctor. But she hadn’t surrendered, so she did what anyone in the grips of alcoholism would: Quit long enough for her enzymes to normalize, got re-tested to get that doctor off her case and then went back to drinking.
After that, Tiffany’s luck with doctors ran out.
She was referred to an addiction specialist who said that he couldn’t treat her because she was dual-diagnosis (even though roughly 50% of people with severe mental disorders are also substance abusers). Later, once she was in treatment, the rehab brought her to see a different doctor—another addiction specialist. He took one look at her and asked, “Why do you drink the way you do? You’re so pretty and have such a nice body.” When she told him how much she drank, he shot back, “A couple of bottles a night? I drink that much and I’m not an alcoholic.” He also didn’t do a medical detox on her, which means that she spent weeks pacing (a common sign of alcohol withdrawal) up to 20 hours a day.
Let’s be clear: There aren’t only horror stories. David, a 62-year old resident of Coconut Grove, Florida who’s been sober for 16 years, recalls just how direct yet gentle his doctor was with him back when he was a practicing alcoholic. “I went in for sleep apnea and he asked me, ‘Why do you have liquor on your breath?’” David remembers. “And I could see in his eyes this idea that here he was trying to save my life and how difficult it was that I seemed to be working in the opposite direction.” Within two months of that conversation, David got sober.
“The patient should be directly confronted and told outright, ‘You can’t use. You have to follow these specific guidelines for this to work,” says Dr. John Sharp.
And my friend Zan worked with a “completely brilliant” female doctor when she was going through detox. “She said to me, ‘You’re never going to get sober until you can let go of the need to be the most interesting person in the room,’” Zan remembers. “And that one concept is what got me through my first year—understanding that I didn’t have to be fabulous, that I could just be boring.”
So why do some doctors help and others hinder? “Addiction treatment is both a science and an art,” says Dr. Paul Hokemeyer, a marriage and family therapist in New York. “While most professionals, and medical doctors in particular, are great on the science, they’re not so great on the art of establishing a therapeutic alliance with the patient. The most difficult part is sticking in there while the patient pushes back against them. And this push-back is especially difficult for ego-driven and narcissistic clinicians, who are the first ones to throw in the towel and blame the patient for their disease.”
Medical schools have also been notoriously lax in educating their students about addiction. Nora Volkow, the neuroscientist in charge of the National Institute on Drug Abuse has called this oversight both “a gap in our training program” and “a very serious problem.” While steps are being taken now to correct this—10 medical schools introduced the first accredited residency programs in addiction medicine last year—that doesn’t do much to educate the doctors out there in the trenches with active addicts right now.
And even when they are trained, doctors aren’t always employing methods that work with addicts. “Psychiatrists are taught to interpret acting out rather than to confront it,” says Dr. John Sharp, an addiction psychiatrist on board at Harvard Medical School. “If a patient is trying to get sober but is still using, that patient’s actions shouldn’t merely be reflected back or interpreted à la ‘I wonder what this means that you are saying one thing and doing another.’ Rather the patient should be directly confronted and told outright, ‘You can’t use. You have to follow these specific guidelines for this to work; now let’s talk about why following these guidelines is difficult.’”
Sharp believes that doctors who want to work with addicts are best trained by working with experienced and effective addiction doctors and literally watching what those people do. “I was a nervous intern one day out of medical school when I landed at San Francisco General Hospital to work in the Forensic Psychiatry ward with inmates,” Sharp recalls. “The doctor who ran the ward was fabulous: he was able to walk into an addicted patient’s room and handle whatever was going on quickly and easily. And that’s where I learned the most.”
Of course, not every internist or psychiatrist who works with addicts is going to do that. For now, perhaps the best we can do is open up the dialogue about what really goes on in consultation rooms and therapists’ offices and hope that doctors, just like addicts, can learn from being confronted with the truth.