Sunday, June 26, 2016

Don't Let the Boogieman Be Your Boss

The regulating bodies for the mental health/chemical dependency field place a huge burden on the professionals in the field and that is never more apparent than when a client dies. You will lose clients. If you stay in the field for any length of time some will die. Some will die of health problems, some from violence, some will take their own lives, some will fall victim to very bad luck, and some will die of unintentional overdose. When this happens one or all of the regulation bodies will descend upon your organization and comb through your treatment notes. They may ask you uncomfortable questions, they may seem like the inquisition. You may feel unduly blamed, you may be unduly blamed and more than likely you will to some degree blame yourself. One of the worst things that can come from this is the professionals involved leave the experience thinking they can never let this happen again.

The worst policy and professional decisions are the ones motivated by fear. They usually take one of two forms, discharging a client who is deemed "too risky" to keep in your program because gods forbid they die on your watch, or putting so many unrealistic requirements on the client that they disengage or are driven away from treatment. While the death of a client under your care will require that you prove you did everything possible to keep the client alive, the death of a client shortly after discharge only requires you tried some type of intervention before the discharge. Threatening the client with discharge if they don't do A, B, and C counts as an intervention, no matter how unrealistic A, B, and C may be counts as an intervention and the regulating bodies will check that you documented the threat and leave confident you did everything you could.

So we can sleep at nigh we tell ourselves the clients brought this on themselves, that the clients failed we did not fail them. We tell ourselves we did it for the client's own good. When that fails us we resort to the Nuremberg defense, we say we didn't have a choice because if we had not discharged, if we don't continue to discharge similar clients, they will take away our licenses. The problems with this are legion so I'll just mention a few.

1) "They" the regulating bodies are not after our licenses. Not only have I never seen a counselors license revoked for continuing to treat a client who is struggling, I have never even heard of it happening. The counselors I've heard who lost their licenses (I don't know any personally) lost them for gross incompetence or unethical behavior like entering into a sexual relationship with a client. The regulating bodies need people doing our jobs so they can keep their jobs. The boogieman isn't real.

2) Even if you are answerable to a regulating body that will revoke a counselor's license for a sound clinical decision, our job is to help people to recover from substance use problems, it is not to protect our license. Usually doing the first doesn't exclude the second but to do this job right may sometimes requires a little courage.

Fear based decisions are almost never good clinical decisions if you let the boogieman be your boss you will hurt the people who need you the most.

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Wednesday, June 22, 2016

Scary Stories and Demon Drugs

Scary Stories and Demon Drugs
The views expressed here are my own and may not be shared by any organization I am affiliated with, but they probably should be.

Scary stories drive large portions of the world economy and it's not hard to see why. People don't sit through the evening news (is there still such a thing) let alone stay glued to a 24 hour news cycle to hear good news. They don't need mindless sitcoms to escape when they are happy.  While depression may drive a few people to the mall the real money is in fear. The same goes for politics. People don't rush to the polls because everything is alright, they vote because everything is going to Hell and the other guy or gal will only make it worse. Unfocused fear is as useless as joy to the entrepreneur so every good fear monger has to point the finger, a good target is usually found in criminals, minorities, communists, other countries, big pharma, or "incompetent" teachers, judges, and in this case doctors. But nothing makes a better target than a Demon Drug. Teachers and doctors have organizations to speak for them, big pharmaceuticals have billion dollar marketing campaigns, but a   Demon Drug, especially an illegal drug, can't speak out for itself and it makes a frightening antagonist for both the 24 hour news cycle and for a luxury rehab who will gladly help save you and your loved one from this monster, but not for free. 

The current Demon Drug is heroin but I'm old enough to remember when marijuana made the list. Heroin seemed like old news during the methamphetamine scare in the 1990s and early 2000s. The stories are always similar. The drug is incredibly addictive so much so a single use might ruin your life, it's deadly in the short term but if you manage to survive long term use will ruin both your physical and mental health, but most importantly it's coming to your neighborhood, it's coming for your children. Woven into the narrative is the idea that though things may be bad, we may even be on the brink of societal collapse, things would be much worse if the drug were legal. Law enforcement standing behind tables covered in the Demon Drug De Jour or hauling haggard looking drug dealers away in cuffs are cast as the only thing saving us from the brink. It's a thrilling story, but it's fiction, and we are suffering the consequences of 100 years of fiction driven policy.

 Any study of illegal drugs and drug users will always have a big margin of error, but the data that exists indicates between 1 and 2 people out of 10 who try heroin will have a problem with it. If you include legal opiates the number is much lower.  Oddly enough the number is about the same for meth and crack cocaine. Only 3% of all the people who have ever used meth or heroin have used it in the last 30 days. If the substance is as addictive as we are led to believe shouldn't the numbers be much higher? I've seen some make the argument "even if these numbers are true, we shouldn't make these drugs legal. If 10% of the people who try the drug become addicted to it, making it legal will cause more people to try it and that will make more addicts!" This is usually followed by some math assuming a 20% addiction rate followed by more scary numbers, but rarely do these story tellers realize that there is another Demon Drug that was legalized and there is no call from from the media, politicians, law enforcement, or judges from any part of the political spectrum to outlaw the drug again.

If any drug deserves to be demonized it's Alcohol. Alcohol related deaths dwarf those of any illegal drug. Long term alcohol use can be tied to early dementia and other mental and physical illness even when used in moderation. People using alcohol often become violent and foolhardy putting themselves and others at risk. There is no medical benefits from alcohol that can't be achieved through safer methods while heroin and methamphetamine both have legitimate therapeutic uses. But heroin, meth, cocaine, and if you're old enough marijuana are bad, alcohol is not.

But didn't heroin cause the current heroin epidemic? Doesn't that prove how much more dangerous it is? The answer is NO. The truth is we are not experiencing a heroin epidemic, we are experiencing an addiction epidemic. Yes heroin deaths are up but so are deaths from alcohol, the reason nobody is panicking is that alcohol deaths are always very high and the current uptick doesn't look so dramatic. Legalizing heroin would actually make it possible to reduce the overdose deaths. The truth is heroin addicts aren't dying from the drug they are dying from the drug war and the real horror story is the way we treat them. 

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