(The following is an
excerpt from Taking the Escalator: Express (2016)
The
above perspective is not true with all people who need help with substance use
issues as well as coexisting issues, however there is an ever increasing number
of young people dealing with their substance use who do not fear jails,
institutions or death. Take for instance the threat of jail or prison. Most
people still fear jail and would do whatever is needed in order to stay out of
jail. Nevertheless, there is a growing segment of society that does not fear
jail. For some, jail is seen as a milestone in life like getting your wisdom
teeth or graduating high school. There is a new generation of young people who,
during their childhood and adolescence, have had one or more parents in jail as
well as cousins, siblings, aunts and uncles, etc., that were incarcerated for
various time periods. Many young people will openly tell you that they have a
lot of friends they see in jail when the get incarcerated. I had one person I
worked with tell me that jail wasn’t really that bad to her as she likened it
to a “dysfunctional summer camp”. This fearlessness and lack of concern about
going to prison and jail is not limited just to gang members. Although gang
membership often involves with it an acceptance that jail is to be avoided
however at some point it is imminent, other non-gang involved young people are
also more frequently displaying a lack of fear of incarceration. If you are a
counselor reading this or someone who uses substances yourself then I am sure
you know people to whom this applies. All of this leads to the following
question: How can the threat of jail be used as a motivator for upward change
with someone who is not overly concerned about going to jail? The answer is, it
really can’t.
What
about institutions? Once again, the majority of people, even those who abuse
substances, do not want to go to institutions such as hospitals and psychiatric
facilities. Nevertheless, similar to those who do not fear jail, there is also
an increase in the number of people out there who do not fear psychiatric
institutions as well. Any emergency room employee can speak of the many
“frequent flyers” in the psychiatric department who repeatedly and periodically
return the emergency room for psychiatric screening and admission to the
psychiatric unit. As stated earlier, most people do not want to go to an inpatient
psychiatric unit however there is a vast increase with regard to people who
have accepted the need to go to the hospital when they need to “get away from
it all” for a few days. Not all people go to the psychiatric unit for
illegitimate reasons (although at times people do, such as pretending to be
suicidal just to get admitted for detoxification). Most people who go to
emergency rooms for psychiatric emergencies are truly in crisis. The point is
however, that the number of people who are motivated to stop abusing drugs and
alcohol because of a fear of going into an institution has decreased.
Therefore, as in the case with jails, the following question arises: How can
the threat of institutions be used as a motivator for recovery with someone who
is not concerned about going to an institution? The answer is, it really can’t.
Finally,
let’s consider the fear of death. Once again, fortunately most people do not
want to die and they will do what they need to do in order to avoid endangering
their lives. This is even true with chronic and severe drug users as most do
not want to die despite the risks taken with abuse of substances. However, the
number of substance abusers who are not concerned whether they live or die most
definitely seems to be on the rise. The reason that I am saying “seems to be’
on the rise is because no one really knows for sure if someone fears death or
not often until they are directly faced with it. There are many who say they
don’t fear death but when the threat is real, they change their tune and want
to live. Still, the number of substance users who are willing to take death
defying risks with their lives on a daily basis is assuredly on the rise.
First, consider some of the neighborhoods that many substance users frequent in
order to obtain their drugs. Sale
A
second and even more serious concern when it comes to risk of death is the
potency of drugs in today’s world, particularly with regard to heroin. The AIDS
scare of the 1980’s and 90’s may have subsided in many young people’s minds and
as a result the number of young people again willing to use the needle to
inject heroin and other opiates is overwhelming. Furthermore, the increased
potency of the opiates that people are injecting into their veins today as
opposed to in the past is significant. The risk of overdose is ever-present
with a lot of young people today and as a result those who use IV drugs realize
that each time they use, there is a risk of death. Unfortunately, in my career
as a counselor I have had conversations with young people who openly
acknowledged the following statement: “If I keep on going like this I am going
to die”. Sadly on more than one occasion I have seen those words come true with
young people abusing hard drugs that overdosed. Fortunately there is still hope
that as people can realize that they can have a better life they often can
increase their hope and their desire to live because the desire to live is
ingrained somewhere in the mind of every living thing. Still, when it comes to
fear of death alone as a motivator, for many substance abusing young people and
others sadly, that is not always enough to motivate change initially.
Consider
the following example which encompasses these issues of changing attitudes
about jails, institutions and death:
Mark
–
Mark
is a 22 year old IV heroin abuser. He has an exceptionally high IQ and was
raised in an intact middle class family in a nice house in the suburbs. Mark
first went to treatment at age 15 due to a daily marijuana habit which
concerned his parents who themselves were opposed to substance abuse of any
kind. Mark was a counselor’s nightmare as he was able to justify his daily
marijuana use effectively because he was doing well in school despite being
stoned daily and he had no legal problems. Mark ended up doing just enough to
complete outpatient treatment as a teenager however due to boredom with
marijuana alone he soon moved on to both selling and using opiate pain
medication nasally (Oxycodone). Mark was still able to function well in school
and socially until he was placed by his parents at their own expense in a
long-term residential facility for teens with emotional and behavioral problems
due to his ongoing defiance of basic rules and curfews both at home and at
school. Mark continued to be defiant in his first residential placement and he
ended up going to two separate placements for close to a year between them. On
Mark’s 18 birthday he left his last residential placement against clinical
advice and returned home. Mark’s parents let him come home with the promise he
would stay drug free and go to college since he was always a good student
academically.
Mark
came home and kept his word about college as he enrolled, attended and did
extremely well in all of his classes due to his high intelligence level. Mark’s
parents were pleased. However, for a long time period Mark’s parents had no
idea that Mark was again dealing Oxycodone that he obtained by going to see
multiple doctors along with his girlfriend to obtain prescriptions for the
drug. Mark soon became his own best customer and he again developed a daily
opiate pain medication habit which progressed to him sniffing 10-15 pills a
day. Mark was able to hide his drug problem for about 6 months before his
parents started getting suspicious of him especially with regard to how much
sleeping he was doing and how lethargic he looked at times. After about 9
months Mark got arrested for selling marijuana to a teenager and he was placed
on probation. Mark entered outpatient therapy to try to look good for probation
and to keep his parents off of his back however he continued dealing and using
Oxycodone. He was able to avoid consequences for a while because of skillful
efforts to beat his drug tests and fool both his parents and probation officer.
Finally,
Mark’s wheeling and dealing and clever efforts to avoid consequences caught up
with him, but it took over a year after his first arrest. After a series of
other arrests and probation violations, as well as Mark’s parents finally
getting tough with him and throwing him out of the house, he ended up hiding
out for about a month as a fugitive from justice. During that period, due to a
lack of financial resources and homelessness, Mark switched to intravenous
heroin use as he was living in one of the most dangerous sections of the state,
shooting IV heroin living with other homeless people. Eventually the police
found Mark and all of his charges and probation violations got him placed in
prison for a three year sentence. Mark took advantage of an early release drug
parole program after 9 months which allowed him to get out of prison and move
back home with his parents, provided he enter treatment, adhere to a strict
curfew, work a full time job, and submit to random urine testing by his parole
officer any time day or night
Due
to limited funding, Mark’s parole officer only required him to attend
outpatient treatment despite his actual clinical requirement for much more so
there was no leverage for Mark’s counselor to get Mark to do anything more
other than have him just come in once per week. What do you think Mark’s
reaction was to “Jails, Institutions or Death” as a motivator for staying
sober? Mark, who was quite familiar with 12 Step philosophy from being mandated
to 12 Step meetings for years (but never finding any value in attending),
clearly told his counselor he wants to live, and he wants to stay out of jail
and institutions. However, Mark who had faced jails institutions and death face
to face also openly told his counselor that he would go back to jail if he had
too, he would risk death from overdose from IV heroin use if he decided to, and
he would pretend to be suicidal and voluntarily go into the psychiatric ward if
he needed too in order to avoid something worse. Mark already had faced jails,
institutions and death without fear so using these fears in Mark’s case had
limited impact as a motivator.
If
you are a counselor reading this it is likely you have met your share of
“Mark’s” yourself who do not fear jails institutions or death as deterrents for
their behavior. Or, perhaps you know a “Mark” in your personal life or maybe
even Mark’s attitude may have been yours at one time in your life. Working with
someone like Mark, there needs to be a different approach than the traditional
substance abuse approaches which an important aspect behind the development of
the Escalator.
