Friday, June 10, 2016

Jails, Institutions or Death...So What!

(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 of narcotics has always been associated with dangerous neighborhoods however what was considered dangerous decades ago pales in comparison with what is considered dangerous now. An outsider’s biggest concern in the past when entering a bad neighborhood to purchase drugs was getting robbed or beaten when today with the increased prevalence of weapons and gangs, one may be risking his or her life by going into the wrong neighborhood, yet many people do it on a daily basis for their drugs
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.