Addictions and Mental Illness – Continued

By Dr David Laing Dawson

Folk wisdom tells us that with alcoholism and addiction, at several points in the spectrum of these afflictions, there lies choice. Free will is at play. The law generally agrees. Drunkenness is not grounds for “not responsible due to mental illness.” Even science and rehab experience agree. All treatment and rehabilitation programs for addiction and alcoholism are founded on a principle of choice and free will.

No doubt alcoholics and addicts develop a sort of tunnel vision. The big picture is lost to them. The effect they are having on others is lost to them. The ability to plan beyond the next few hours is lost to them. Reality for the addict becomes a set of shadings and lies he tells himself and others.

Scholars and philosophers can debate the myth, reality or limitations of free will, but the concept is in itself a foundation of community, of organized society. To function communally we must assume that individuals generally have free will and are responsible for their actions. We are careful and strict when we allow exceptions to this rule, as we must be. Science and compassion inform these decisions.

Our courts debate these decisions every day. The age at which one can be tried in court as an adult rather than a child has been changing and varies from state to state. At what level of mental development should we assume a mentally handicapped person is fully responsible for his crime? Harvey Weinstein will claim he is a sex addict and couldn’t help himself; the prosecutor will point out he is a serial predator who chose to debase women over and over because he could get away with it.

Within our long history we have only recently absolved people of personal, moral responsibility for falling ill with recognizable physical diseases. Though not totally, for we still expect them to assume some responsibility for working to get better, take their medicines, and do the things that prevent illness in the first place. e.g stop smoking, get vaccinations, use condoms.

It is only more recently, within two hundred years, that we began to include severe mental illnesses in the body of afflictions for which people should not be held morally responsible. Nobody chooses at any point in their lives to become schizophrenic, bipolar, depressed, have regular panic attacks. These are illnesses. Nobody chooses for these illnesses to continue.

Folk wisdom regarding who with mental illness should be absolved of moral and personal responsibility (and therefore not punished if a crime is committed) remains fluid. The question is often decided, in the public’s mind, by our visceral reaction to the crime itself.

But at least without horrendous crimes occurring, folk wisdom generally, today, accepts that severe mental illnesses are indeed illnesses and no personal decision making is involved.

But this is always a tenuous belief.

Which is why it was such a setback for the public’s attitude toward mental illness when our institutions for addictions and for psychiatric illnesses were merged, and many of the philosophies for “treating” addictions slipped over to mental illness. I could argue that this merger has set us back a hundred years and allowed us to believe (or by inaction accept) that many with mental illness choose to live on the street or cycle in and out of our jails. (I put treatment for addictions here in quotation marks because there is no treatment as such. All programs for addictions are forms of organized browbeating to quit, and then to stay abstinent. Whereas we actually have effective medical treatments for severe mental illness.)

I might even argue (with the exception of it providing more resources for addictions) this merging of the services was also a disfavor for society, addicts, and alcoholics. For when we absolve people of responsibility for their behaviour, we give it wings.

Hence the astounding human behaviour we see today in all our communities in which a person is offered in a back alley or a house party a substance that promises to alleviate any suffering (emotional or physical) for a few hours, maybe cause the experience of a little euphoria, but which has a 30% chance of being lethal – and still that substance is greedily taken and snorted or injected.

Conflating mental illness and addictions has caused a paradoxical shift. It has allowed us to absolve addicts of personal responsibility for their addictions and, at least tacitly, blame the mentally ill for their illnesses.

Though I am in favour of suing, for billions of dollars, the pharmaceutical company that lied about and promoted oxycontin/oxycocet/oxycodone  and then pouring that money into “treatment” and prevention of drug addiction.

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3 thoughts on “Addictions and Mental Illness – Continued

  1. Ron, as always brilliant thought-provoking analysis. I have three comments.
    First, I wonder if your loved one struggled with years of addiction and died from an overdose, would you be talking about free choice?
    Second, remember 50-60% of mentally ill people struggle with substance dependence.
    Finally, a bit of history. I’ve been in this business long enough to have seen the shift to the non- medical Recovery Model within the mental illness treatment system. Drug addiction and alcoholism went from the medical/asylum model to a more cognitive/behavior focus in the 1930’s with self-support step groups (AA, etc.). The first Relapse Prevention CBT training programs emerged in the 1960’s. The Recovery Model was adopted by SAMHSA, which also saw success with dual diagnosis clients. Relapse prevention principles were then retooled as illness management. Since peer substance abuse counselors worked well, why not peer support specialists with SMI clients. Thus, mental health providers accepted the Recovery Model enthusiastically and stopped serving those with serious mental illness who did not fit in their clever power-of-positive-thinking recovery culture. Their bias kept them from seeing the difference. Unconscious Obfuscation.

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  2. Another very thoughtful and insightful post, thank you.
    I am very concerned by the latest calls for the legalization of all drugs by Mr. Singh (NDP leader), as well as the legalization of cannabis.
    Canada has since the Mulroney administration and all those that have followed, utterly undone the social medicine and social services safety. Thus, we have no beds or services for the mental illness, addiction or both. The staggering numbers of increases to HIV, Hep C, STD infections related to intravenous drug use and other related behaviors, point clearly to the need of restoring and building the necessary “safety net” before legalizing or accepting national drug usage. Furthermore, police officers and first responders, contrary to PR and biased press reporting, are wholly unfit through training and socialization to properly interact with let alone help people dealing with mental illness or addiction. Our homeless population is skyrocketing in even rural areas of Canada. Emergency rooms refuse to properly serve mentally ill or addicted individuals and rather have them escorted out of the hospital or simply make them wait for 12+ hours before telling them to go to their GP for a referral or go to a private detox facility. If you are mentally ill, addicted, and not wealthy, you are basically abandoned. Emergency room residents and most GPs are frankly not able or interested to do anything more than they are able to find on Google. Furthermore, the majority of psychiatrists in our area and indeed the GTA that are taking new patients are foreign trained and seemingly chose a specialization that is very secure and has little or no oversight. As a result, their lack of patient care or competence is aggravating the problems that the mentally ill and their families must face on a daily basis.
    If Conservative supporters want to cut costs, and Liberals and NDP supporters want to give everyone everything they want without putting in the essential medical, social, or policing support, then all any of them are doing is playing politics.
    We must as a nation, critically analyze both mental health and addiction and what is needed before we become a clone of the disastrous conditions in the United States.
    Sadly, I doubt this will happen, neither PM Trudeau, PM Harper, nor any of the present alternatives, possess the intellectual honesty and integrity that are needed to deal with these very complex issues.

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  3. I think one of the reasons for merging addiction and mental illness is that a lot of addicts are mentally ill and their addiction to drugs is a a form of self medicating. People choose to do drugs but no one chooses to become an addict.

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