Tag Archives: Addictions

The Word ‘Issue’ Has Become an Issue.

stone of madness

By Dr David Laing Dawson

There it was again. The local paper reporting on homelessness, reporting on the results of a survey of over 400 homeless people in our city. All very nicely written and laid out. The number of homeless people who have been the victims of violence; the number who struggle with addictions. And the over 80% who suffer from “mental health issues.”

Dictionary definitions of the word ‘issue’ include:

“An important topic or problem for debate or discussion” – the operative portion of that definition being “for debate or discussion.”

Now I understand that how we describe or name something may shift and change over time, often for good reason, often not. We no longer use the word ‘retarded’ to describe someone who has less than average intellectual capacity. It is a word that accrued a lot of baggage through the years, and became a schoolyard epithet, implying, at least in the vernacular of teenagers, something like “willful stupidity”, or “in bad taste.”

But euphemisms often creep into our vocabulary to hide the truth, or to reduce the sting of truth. Sometimes the euphemisms are simply more polite (‘disability’ may become ‘special needs’); sometimes they are obfuscations with only a limited reference to the original activity, problem, or thing (‘illness’ becomes ‘issue’), and sometimes they are softer vague words chosen to hide the reality of the action or intention of our governments, bureaucrats, and military, and sometimes they are even, a la George Orwell, antonyms of the word that would actually reveal the truth.

I don’t know how the word ‘issue’ became the mot du jour, sometimes even added as a totally unnecessary noun. As in ‘he has addiction issues’ instead of ‘he is addicted’. I suspect it is related to the actual meaning of ‘issue’, (a topic open to debate), and by calling mental illness an issue we are placating the deniers of mental illness and we are reducing it to an abstraction, a topic for discussion and debate, rather than a reality in our midst, and often the actual cause of homelessness.

Even if, reasonably, we want to reserve the words ‘disease, illness, and disorder’ for only severe forms of this reality, this plight, we still have other words to chose from that do not imply a debatable abstract: ‘problem, difficulty, trouble, worry’. We might even say “mental health concerns, including mental illness”.

But let’s stop with the “issue” when we are naming or describing a painful reality.

How Did We Get Here? Further Reflections on Recovery in Mental Illness

David Laing DawsonBy Dr David Laing Dawson

When trying to understand society’s, or a country’s, concepts, thoughts, approaches to, treatment of, mental illness, we can look at medical and scientific progress: This is the “march of progress” approach to understanding history – our advances in diagnosing and treating mental illness over the past hundred years. But history also tells us that attitudes toward mental illness have always been influenced by the economics of the time (only when we can feed our own children do we have the capacity to worry about our strangely behaved neighbour), our preoccupations of the time (being at war leaves few resources for the mentally ill), and, finally, the folk wisdom of the era.

Folk wisdom – the thoughts, rationales, explanations, assignments of responsibility and blame that linger in our consciousness long after being modified or disproved by science. Our brains are programmed to look for causation, a way of understanding an event, and, wherever possible, to ascribe blame. We also quite naturally and quickly look for a cause, a thing to blame, that we ourselves can avoid.

It is reported that a man younger than myself dies suddenly. I can’t help it. I search the report for cause, and relax when I find that he was a heavy smoker, which I am not. A woman is assaulted after midnight in a sketchy part of town. We know it’s wrong, but our brains immediately ask, “What was she doing there?” The child is behaving badly. We immediately think, “He could use some better parenting.”

It is always surprising to hear nurses blame the full moon for a perceived increase in the number of patients flooding the emergency room, though this “lunacy” has been thoroughly debunked by science. And otherwise intelligent people continue to ascribe perceived behavior to an astrological sign, or numerous other semi-mystical notions of alignment, karma, vapors, chakras, auras, and miasma.

Most of all it is comforting to think that if we behave well, and morally, and kindly, pray before bedtime, and avoid certain pleasurable but dangerous substances, we can also avoid dis-ease, illness, and a fall from grace.

We know that alcoholism and addiction include an action taken, engaged in, by the sufferer, engaged in willfully, of free will, and that recovery from addiction will entail a mind set, a decision, a commitment, a major effort on the part of the sufferer. So with alcohol and addiction programs this process is supported, encouraged, often through peer support, non-judgmental encouragement, soul searching, an acknowledgement of weakness, a trust in a “higher power”, and even, in some programs, forms of confession and penance. When we talk of treatment for alcoholism and addictions we are really using the word “treatment” to mean a complex sophisticated form of persuasion. We don’t really have a treatment for those two problems beyond persuasion and support.

In the post WW II era, our mental hospitals became “psychiatric hospitals”, and, a few years later, at least one ward in most general hospitals became a psychiatric ward, or colloquially, a “psyche ward”. This naming was important. It acknowledged a medical specialty, and a group of diseases treated by that specialty, much like an orthopedic department, a gynecology wing, a surgery ward. In fact the federal funding in Canada to support general hospital psychiatry wards (via federal provincial transfer payments) was a considered effort to acknowledge mental illness as illness, deserving of the same attitudes, funding, and professional support as “physical” illnesses.

Through the 1970’s and 80’s it appeared to be working. Programs were developed, new more effective medications were developed, attitudes were changing, physical facilities were improved, and maybe, we thought, this de-institutionalization will work.

Mind you, addictions got short shrift from the mental health system in those years (though the hospitals were psychiatric hospitals, the overall system of care was still called “the mental health system”). Generally addicts and alcoholics were told that they would have to get those problems attended to before we could help them with their mental illnesses. They had to first attend detoxification programs and then alcohol and addiction programs, which often had little patience for either mental illness or psychiatric treatment.

So detox centers, alcohol and addiction treatment programs developed apart from and separate from psychiatric wards and hospitals. And from these centers the “recovery model” developed. The word alone is nothing but positive, but it contains all the implications and expectations and attitudes outlined four paragraphs above. It implies that full recovery is possible, if you put in the effort. Peer support, will power, the power of positive thinking, goal setting, avoiding negative thinking, take life a day at a time, take responsibility for yourself……..

And, absolutely, for addictions and alcoholism, recovery can be defined as a life free of alcohol and drugs, and it is certainly achievable.

And through all this, our folk wisdom, that wisdom that often governs legislation and attitude, maintained a conviction that, ultimately, alcoholism and addictions are the sufferer’s responsibility. If he does not get well, or clean and sober, he is culpable, or at least, ultimately, to some degree, the architect of his own fate. And folk wisdom was shifting to believe that this is not true for schizophrenia, manic-depressive illness, depression or anxiety disorder. These are illnesses requiring treatment. They are usually chronic illnesses. Full and complete recovery is rare, though medications can alleviate symptoms and prevent relapse. There is nothing the sufferer can do on his own to prevent or stop these illnesses. And for these illnesses we do have actual treatment.

And then…. actually I’m not sure how this happened…. but somehow the bureaucrats and perhaps a few idealists, managed to bring these two systems under one much more economical roof. Three words were lost in this recent transition: “psychiatric”, “illness”, and “hospital”.

And suddenly we now have a multitude of “Centers for Addiction and Mental Health”.

And while this undoubtedly saves money, and perhaps serves better those who suffer both addictions and mental illness, it has had, in my opinion, some very negative unintended consequences.

  1. The recovery model, well suited to addictions, has been foisted upon those suffering from mental illness.
  2. The stigma of mental illness has been entrenched by the use of the paradoxical euphemism “mental health”.
  3. We have inadvertently allowed the folk wisdom of acknowledging personal responsibility for addictions (blame) to rub off on those suffering from diseases of the brain, those suffering from schizophrenia and manic-depressive illness.
  4. And ultimately it has allowed us well-meaning citizens to feel comfortable that now, not in 1950 or 1960 or 1970, but now, in 2014, our jails and prisons are filled with the seriously mentally ill.

The Disease and Medical Models as they Pertain to Illness and Addictions

David Laing DawsonBy Dr David Laing Dawson

The “disease model”, the modern concept of disease, developed alongside enlightenment and the science revolution through the 19th century. One of its components is the absolution from moral responsibility. This means, for example, that one is not held morally responsible for developing the affliction of lung cancer, notwithstanding the fact that twenty years of smoking may be an etiological factor. Similarly we do not hold people morally responsible for developing the disease schizophrenia. It is an affliction unwished for, unwanted, and it has nothing to do with the moral character of the sufferer. And once the disease begins, it is not within the power of the sufferer to stop the disease.

The “medical model” is short-hand for a definable relationship between a doctor and a patient. The responsibilities and privileges of each participant in this relationship are both traditional and defined in codes of ethics. One aspect of this relationship is responsibility. The patient’s responsibility is to do his or her best to get well and follow the prescriptions and proscriptions of the doctor. The doctor’s responsibility is to do his or her utmost to treat the patient’s illness and alleviate suffering. This model, this way of understanding the relationship between healer and sufferer, is age old, and predates science.

Can we apply these two models to addictions, the same way we can and should apply them to cancer and schizophrenia?

There is little argument about the second, the medical model. In its assignment of primary responsibility to the physician (as described above), the medical model always fails when it comes to addictions. When the doctor assumes the same level of responsibility for his or her patient’s alcoholism or heroin addiction as he or she does with pneumonia, cancer, and schizophrenia, trouble ensues. Usually, in fact, we physicians find ourselves contributing to a poly substance addiction. In fact, one can safely say that a major component of any addiction is the sufferer’s failure to assume personal responsibility for his own behavior. An understanding of this is built into the tenets of AA, and most addiction treatment programs. It is, ultimately, unlike with schizophrenia and cancer, the sufferer’s responsibility to stop reaching for that bottle or pipe.

Addicts suffer and we need to help and develop programs for them. But a full frontal medical model does no good.

What about the disease model? A cancer or schizophrenia sufferer cannot stop his illness by simply doing something or simply not doing something. An addict or alcoholic can, though to do so he or she may need extraordinary courage and a willingness to tolerate a lengthy period of physical and mental pain. We should help him find this courage and we should ameliorate his suffering and we should always consider reduction of harm (e.g. safe injection sites). But we cannot and should not assume responsibility for the actual act of his drinking, smoking, swallowing, or injecting.

Inebriation, intoxication, alcoholism, and addiction, do not qualify, under our law, our science or our folk wisdom, for “not criminally responsible due to mental illness.”