Tuesday, September 16, 2008

Accountable To Whom?

In psychiatry, we talk a lot about the treatment of mental illness. Sometimes we talk about the treatment of disordered behavior, but often that discussion falls into the realm of other specialists such as psychologists, social workers, or lay support people (is that what I should call them?)-- members of self-help groups, personal coaches, and others.

Just to be clear, I'm talking about addictions and motivated behaviors-- people who can't stop doing what they're doing and seem to be driven by something other than logic. So the alcoholic who keeps drinking despite horrible repercussions, the smoker, the drug addict who keeps using when he's lost so much, the over-eating overweight person who grabs the next chocolate cupcake, the bulimic, the gambler, the internet sex addict, the pedophile, oh, name your "addiction." Illness or choice? The owners of such problems struggle, and often unsuccessfully.

This is what's frustrating about treating disordered behavior: we're not very good at it. It's really hard to get people to "Just say No." Actually, almost no one just says no. Sometimes people seem to have their own epiphanies-- something clicks-- and they change. Sometimes they "hit bottom" and they turn around. Some people just live in their ditches.

So how hard is it to change behavior? I think it depends on the person and on the addiction. Many people stop smoking-- for some it's harder than for others. The stats are that something like 95% of people regain lost weight within 2 years. I don't quite believe that, seems like I know people who've lost weight and kept it off, though not most. In the course of taking many psychiatric histories, I've heard of many people who've gained better control over a variety of behaviors. The most desperate often seek help, sometimes more than once, sometimes in a variety of places.

Here's my caveat:
I'm not very good at getting people to change behaviors they don't want to change. I've made some observations, I've tried to change some of my own behaviors (-have you seen the chocolate?), I've watched lots of people struggle with big things and small things.

Support helps. A lot. And accountability helps--perhaps it's essential. 90 meetings in 90 days, the mantra of starting in a 12-step program. And having a sponsor, or a therapist, or a coach--someone to be accountable to, helps. Are there things about a sponsor or therapist or doctor that increase the success of the person trying to change? I believe at some level, the "coach" (I just need a term here, let's go for this one) has to be someone the patient respects. It helps if the coach is not judgmental, is optimistic, encouraging, and believes in the patient's ability to meet their goal. It helps if the patient wants to please the coach, but isn't so worried about a negative reaction that he (the patient) lies and says he's meeting goals when he isn't. If the coach is a forbidding character, the patient may simply never return. Frequency of accountability helps: whether by checking in or by face-to-face. Having reasonable goals helps.

Oh, I'm rambling. You tell me what helps a patient change...


Anonymous said...

I would agree with everything you included in the last paragraph. I would add that a belief in a higher power is an important part of recovery for many people (I understand it's not for everybody).

On a side note, do psychiatrists equate pedophilia with other addictions? I always considered pedophiles as being more in the serial killer category.

Aqua said...

I believe your last paragraph is a perfect description of what helps. I know for me, having a pdoc I see regularily, who trusts me, believes in me, is non-judgemental, open to my making mistakes, (so I am open about my mistakes) and sometimes, just knowing someone is rooting for me and at my side while I am trying to change is what help me change.

Anonymous said...

I think you might be missing the point because you are looking at it from the perspective of being a psychiatrist/"coach". The issue is MOTIVATION. My thought is that another person or a group can provide a lift and an assist, but for change to occur the "addict" has to "own" the problem and accept that only the addict him/herself has the power to effect change. Pleasing someone else is more short term. I think when a person has taken responsibility and found a powerful internal motivator, then change will occur with or without a coach and without it, there will be no change. I think sometimes people seek a "coach" because they feel powerless and they hope that the coach will be able to do it for them. That's unlikely to happen. A lot of changes require suffering and it takes guts and determination which only come from within.

Novalis said...

You're right that a coach (who may be a supportive therapist under another guise) certainly can help, functioning as a quasi-parental figure who both validates a person's weakness and yet embodies society's standards of behavior.

Weakness of will is a great (and ancient) philosophical problem. I'm no psychoanalyst, but I think it may be more helpfully viewed as a conflicted or ambivalent will rather than a weak one per se. If someone "can't" stop drinking or overeating, there must be some competing need or desire that overrides the will to stop. Once the NEED to stop reaches a crucial threshold, the WILL will suddenly be there (of course, some people seem to have other needs that will always outweigh the need to stop).

Battle Weary said...

This makes me think of a joke/riddle I heard several years ago...

How many psychiatrists/psychologists does it take to change a light bulb?

Only one...but the light bulb has to WANT to change.

I think that says it all!

Anonymous said...

Hmmmm. I can only think of 3 major changes I've made in my life: quitting drugs, drinking and smoking.

In all three cases, you could say the reason for quitting fell into the "epiphany" category, but was followed by a prolonged period of ambivalence and procrastination before I actually did anything about it.

In two cases, when I quit drinking and using drugs, I encountered active resistance from the people around me (who were also drinking and doing drugs). My solution was to change environments (moved, went back to college) where no one knew my history. I neither asked for nor received direct help, but being around people with the same abstinent habits was incredibly useful.

Quiting smoking was actually harder than either illegal drugs or drinking. But fortunately, I had married by then and my DH was incredibly supportive. The patch helped, too.

What motivated me was imagining the future with and without those addictions. "Without" presented a much more hopeful and desirable picture.

Anonymous said...

I am overweight. Several months ago my left knee started hurting very badly. I went to the doc who prescribed an NSAID, but after the pain continued, referred me to an ortho.

Ortho said it was my weight. He injected cortisone into my knee and that helped the pain so much.

I had already been doing leg exercises my regular doc told me to do, so I kept on. I also joined a gym and swam, which was another recommendation.

Then I joined Weight Watchers. I found the point system so overwhelming I didn't even try. I bought healthier things at the store and tried to avoid sweets, but it seems like the more I think about my weight, the more I want to eat.

I remember that I was motivated. I picked myself up and went to a water aerobics class that was fun. I quit going to Weight Watchers and never even looked at their "e-tools" or much of the literature because I felt so overwhelmed.

I feel hopeless. Hopeless and depressed.

I don't know how to generate a flame of hope. When I manage to, it doesn't last long.

This is a tremendous source of despair for me.

I say you need HOPE first. HOPE is the catalyst for motivation, motivation for action, and action for change.

The old men I see, do nothing for me. The meds make me sluggish and lazier (lithium, klonopin, paroxetine,xanax). I think they may keep me from killing myself, but I am not quite alive either.


Anonymous said...

Nice post, nice comments.

I thought about this issue when i asked my clinical psychologist for help with my insomnia. She handed over a self-help kit and said offhand 'My heart sinks when people ask me for help with 2 things: losing weight, and sleeping - they seem to think i have the silver bullet and I don't.'

This stuck in my head because I have lost weight (and kept it off for 4 years now), and in the end I sorted out the insomnia myself (with the self-help kit & a little 'coaching' as you aptly put it).

It made me think that the key is motivation - you really have to want to make the change, and there is no silver bullet.

And I'm with anonymous - equating paedophilia with non-criminal behaviours that primarily (with extreme exceptions) only hurt the self such as overeating, alcoholism, smoking and sex addiction, is not quite right!

Paedophilia and drug abuse are both crimes and one would argue that drug abuse is wrongly classified as such because primarily it hurts the user, and the social impact stems from its illegality (whereas the social impact of paedophilia is the result of the act itself, including imagery and propogation via the internet etc).

People overcome them all with motivation & rehabilitative support - not just a big stick. Some people just don't really want to change I think.

Anonymous said...

Motivation and Hope are both key to changing-- no one can foist motivation upon someone, but in a treatment setting, I'll assume that the act of seeking help implies at least some motivation. Coaches/therapists/helpers don't typically pull people out of their holes, patients come seeking.

Novalis, I'm not sure I buy the theory of competing needs. It sounds happily analytical, but I don't think psychoanalysis has proven to be an effective treatment for over-eating, smoking, etc.

Psychiatrist DON'T equate overeating, or smoking, with pedophilia. I think the issue is here is that these are impulses that people have trouble controlling. No one grows up hoping to be attracted to children with a goal to be a child molester-- just as no one Hopes to be a alcoholic....these are all struggles and with our limited treatments, accountability helps in all of them.
People who abuse children are criminals and should be imprisoned for their harmful behaviors. It doesn't mean we can't offer help to those who request it Before they act on heinous urges, or that I can't feel sorry for people who are victimized or victimize others because of urges that most people are fortunate enough not to ever experience.

Anonymous said...

the things that help a patient change are exactly the same as what would help a person who was not a patient but wanted to change, change.

Anonymous said...

It's getting the "whatever" bit to click, but not just changing to a different form of destructive behavior. That seems to be the tricky bit. I think wanting to change helps, perhaps not wanting to abandon the safety of the disorder, but wanting more from life than to be controlled by a habit. I think it's finding self belief, and working on self esteem which is the key. Once I started to see myself in a better light, I realised not only did i want more from my life, but I actually could want more, because maybe i deserved it. Thats what i'm working on. it seems to be doing something! Support helps because along with change there is much pain. Mostly from all the years and the many friendships lost along the way. i just try and focus on the new ones that i am creating.
Hope that wasn't too pink and fluffy....