Wednesday, November 16, 2011

The Clinician's Illusion: A Prescription for Relapse

Addiction is a disease of relapse, and it is our way or the highway, and the highway here is jails, institutions or death. This is one of the most commonly heard declarations in the field of addiction treatment. If you look up substance dependence recovery rates with and without treatment, you will come across a very interesting fact. 75% of people who have overcome addiction or alcoholism have done it without resorting to medical treatment (for addiction) or attending self help anonymous groups. It is a known fact that the client population in treatment centers is largely a revolving one, thereby strengthening the belief that addiction is a disease of relapse. I have always worried about the fact that a group of people who self-declare themselves to be physically, mentally, emotionally and spiritually unwell can pronounce that the only alternative to “their way” is jails, institutions or death for the addict. Let us look a little closer at this belief that addiction is a disease of relapse, where it comes from, and what it does to the addict seeking recovery from proponents of this belief.
There are two reasons, in my opinion, that this belief flourishes. The first is the fact that those in the helping profession find meaning in their lives from being needed by those in search of help. Transference and counter-transference in the psychotherapeutic process are ideas that have been beaten to death, but what a lot of people do not pay attention to is the fact that a large number of people in the helping profession are people who are “recovering” from their own devils, and more often than not, the “helping” is a component of their recovery program, as it is in most self help anonymous groups. In addition, there is a catch-22 situation in this belief. If addicts were to not relapse, then the addiction equals relapse model would not hold true, and that would bring into question the entire belief system about addiction being a manifestation of a spiritual bankruptcy, reinforced by an obsessive-compulsive acting out. Therefore, unconsciously, every recovering person in the helping, while “praying” for the wellbeing of fellow addicts would be unconsciously praying also that all that is written in the holy books of recovery be proven untrue, which is something that even artificial intelligence routines would find challenging.

The second reason for this is that of the clinician’s illusion, a statistical bias error that was identified by researchers back in the 80’s. This stemmed from the fact that researchers and clinicians seemed to have differing perspectives on health and disease statistics. This came from the fact that the population sample that these two groups were exposed to or working with were different. The clinician saw more of people who were witnessing health and disease events, while researchers worked with samples of general population. This error of bias was termed the clinician’s illusion. Let us take a look at how this translates when you place it in the setting of addiction and recovery.

The addict typically finds himself or herself a peer group where drug use or drinking is the norm, along with other associated behavior and personality traits. So in his sample population, people struggling with addiction is the norm. Typically, those who break the habit dissociate with the using or drinking population, so he does not get to see a lot of people who have broken the habit. He also gets to see a lot of the “jails, institutions, and death” outcomes. If in this scenario, he interfaces with an anonymous self help group, and puts an end to his addictive behavior, there is an immediate and understandable reinforcement of the belief that the addiction was “treated” by the self help program. Therefore, what they say must be true, this is the way, there is no other way, and along with it, addiction is a disease of relapse. With time, he goes on to stay clean and sober, and starts propagating the same belief to newcomers. This is not through any ill-intentioned thinking. It is the same thinking that keeps most people trapped in the cycle of recovery and relapse, the only fault being not knowing any better. The gurus of anonymous self help groups typically endorse this view because in their worldview (based on the limited world sample), they have not seen things happening differently.

This same illusion passes on to professionals in the addiction treatment field. The top priority for an addiction counselor is the chronic relapse patient. The relapse population not only keeps showing up more frequently at the clinics, deaddiction units, and rehab centers, but also present the greatest challenge. That which occupies the greatest part of your attention typically creates the strongest beliefs. So the addiction professional, by virtue of his attention being hogged by repeat clients, unconsciously reinforces the belief that addicts are prone to, if not bound to, relapse. You will find an excellent article on the clinician’s illusion at the cleanslate website.

I have personally been involved with a number of treatment agencies, and the percentage of returning inpatients is usually more than half the population, with some agencies having as much as 70% of their clientele being repeat admissions. In many instances, these treatment agencies are poorly disguised employment generation programs for the unemployable, and it is in their interest that this belief be proven true. I have witnessed counselor interactions where the client has been told that he needs to undergo a relapse in order to get well! While I totally understand the need to keep businesses running, to want to do it at the cost of having addicts relapse seems to be as serious an offence as drug peddling.

What does this do to the addict seeking recovery through systems that propagate this belief? In a sense, this is one of the most tragic aspect of the helping profession in addiction, that it creates a self defeating belief system that ends up condemning those in need of recovery to act out the script of the “addiction is a disease of relapse” theory. A very common input to people who are first time clients, or coming to self help groups for the first time is that you will not figure things out till you relapse after you have been on the program, that you will not value what is being offered to you till you go out there and suffer some more. Another common attitude is one of smug superiority that is handed down by the old-boys-club to newcomers who have not had the misfortune (self help groups subtly project it as good fortune) of experiencing a relapse.

There are two important disclaimers that I, as a person in recovery, need to make before I sign out. The first is that I have received great benefit from people in self help groups and in the addiction treatment field, without which I would not be alive to write these lines. These people have not only saved my life, but also enriched it beyond belief. The greatest gifts that I have received though has been the encouragement to question and disagree with what was put out by the high priests of the system, in spite of some of them being chief priests themselves. However, I have been fortunate in finding the exceptions in this community. I cannot say the same for the general population of self help anonymous groups or for addiction treatment professionals. The other disclaimer is that while death is a certainty for all human beings, even the careful ones, regardless of addict or not, I have experienced institutions that were as good as jails due to my addiction. So in a sense, my personal experience may appear at variance with what I am attempting to say in this post.

Two perspectives that will help understand this illusion in a more positive manner. The first is that a very large percentage of people who do get well after encountering medical addiction treatment or self help groups do not “keep coming back” to participate in meetings and ongoing followup. Most of these people go on to enjoy lifelong freedom from addiction. The second is that most people who do achieve freedom from addiction or alcoholism do it without encountering either medical treatment or self help groups. Even conservative estimates show that most of them do go on to lead meaningful and productive lives free from addiction.

If you find yourself in a chronic relapsing pattern, you need to assess what is causing it. You will want to identify the pattern, see what your triggers are and develop practical and failproof responses to each of them. You may want to take the help of an addiction professional for this purpose, or you may just want to tap into your inner wisdom or your concept of a god. Given the choices, I know what I would choose.

If you are an addict or if one of your loved one is dealing with addiction, be certain that it is possible to find freedom from addiction, and that the addict is not condemned to relapse unless he or she chooses to. Active addiction may limit the choices available to the addict, but once the pattern has been broken, it is not necessary to believe that one has a disease that obliges him to live out the horrors of addiction over and over again.


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