I’ve accepted an invitation to give a talk on May 10th 2013 on coping with being a professional in recovery.
I am posting my notes here in the hope that they may be useful to people one day.
Coping being a professional in recovery
Complicated area – personal thoughts – “no right answer!”
A. Being in recovery is a way of enjoying what life has to offer, not being dominated by your ‘drug of choice’.
There’s a temptation to think of some addictions as ‘morally superior’ to others: e.g. ‘alcoholism is not as bad as heroin addiction’. This is not all true – they are all equally destructive.
Common question on Twitter: “How do I know if I am an alcoholic?”
in a reply not giving any medical advice, “Because you can never stop at one drink.” (either end up in a police cell or in Medical Admissions.
Never ‘too late’ to enter recovery – even if you think your life cannot get any more disastrous. It can get more disastrous, surprisingly.
B. The legal doctrine of proportionality
Not personal – can seem that way.
GMC have a statutory duty for patient safety – their application of the law has to obey the legal doctrine of proportionality (necessary/legitimate aim) vs the ‘needs’ of the individual. This is undoubtedly a tricky balance to decide upon.
C. The media
Feb 2012, Daily Mail: Special Investigation: Why ARE so many doctors addicted to drink or drugs?
Can be a reactionary issue like foreign doctors/immigration etc.
“Disturbing new research reveals that one in six doctors has been hooked on alcohol or drugs. How has this happened – and what are the implications? According to shocking new figures, up to one in six doctors will have been addicted to drink or drugs – or both – at some stage in their medical career, raising the horrifying prospect that these highly-paid carers may have your life in their trembling hands.”
November 2012, Independent: The doctor battling drink and depression will see you now …
“Thousands of doctors are continuing to treat patients while hiding their own problems with drink, drugs and depression because of a “culture of invincibility” among health professionals. Each year hundreds of medics are treated for addiction and mental health issues, according to official statistics. But researchers investigating the issue say that this masks a much bigger problem, with thousands of doctors concealing their symptoms.1,384 doctors who had been assessed for underlying health concerns over the past five years. Of these, 98 per cent were diagnosed with alcohol, substance misuse or mental health issues.”
D. Some immediate thoughts
- Insidious progression between problem drinker and ‘serious alcoholic’.
- Patient safety – extremely important, but also important for regulators to resist any urge to find scapegoats.
- Poor performance management of trainees ?needs supervisors to be alert to and sensitive to problems (health, pt. safety, training record, needs of hospital).
- A referral to a regulatory body should not be a ‘substitute’ for sorting out performance issues for health locally.
- Need to build a culture of trust.
- A referral to a regulatory body can be used by all staff involved for the purposes of ‘covering their backs’, but not actually dealing with the problem as it arose.
- Tendency to airbrush
- Prone to overintellectualise – attributes of an alcoholic: telling lies, conceal the truth. Mitchell and Hirschman (2006) : “Forty-one of those patients (87%) kept the drinking hidden from treatment staff.” This project examined the frequency of within treatment drinking and surreptitious drinking among patients who attended a brief substance abuse treatment program that mandated within treatment abstinence.
E. Playing the blame game
Regulators hate it if the patient blames everyone except him or herself.
However this should not ignore widespread issues of culture which need a mature sensitive debate (can healthcare staff ‘whistleblow’ constructively on other staff in the pursuit of patient safety?)
Learning from mistakes – rehabilitation v retributive justice. “Zero fault” approach
Problems with the ‘blame game’ – denial and lack of insight by the patient himself or herself Duffy (1995)
If you have a drinking problem, you may deny it by:
- Drastically underestimating how much you drink
- Downplaying the negative consequences of your drinking
- Complaining that family and friends are exaggerating the problem
- Blaming your drinking or drinking-related problems on others and lack of insight
F. The “steps”
Step 1: WE ADMITTED WE WERE POWERLESS OVER ALCOHOL – THAT OUR LIVES HAD BECOME UNMANAGEABLE. (Step One consists of two distinct parts: (1) the admission that we have a mental obsession to drink alcohol and this allergy of the body will lead us to the brink of death or insanity, and (2) the admission that our lives have been, are now, and will remain unmanageable by us alone.)
The “steps” in full:
- We admitted we were powerless over alcohol – that our lives had become unmanageable.
- Came to believe that a power greater than ourselves could restore us to sanity.
- Made a decision to turn our will and our lives over to the care of God as we understood Him.
- Made a searching and fearless moral inventory of ourselves.
- Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
- Were entirely ready to have God remove all these defects of character.
- Humbly asked Him to remove our shortcomings.
- Made a list of all persons we had harmed, and became willing to make amends to them all.
- Made direct amends to such people wherever possible, except when to do so would injure them or others.
- Continued to take personal inventory, and when we were wrong, promptly admitted it.
- Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
- Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.
G. How do you know if you have a drinking problem?
You may have a drinking problem if:
- Feel guilty or ashamed about your drinking.
- Lie to others or hide your drinking habits.
- Have friends or family members who are worried about your drinking.
- Need to drink in order to relax or feel better.
- “Black out” or forget what you did while you were drinking.
- Regularly drink more than you intended to.
- Start drinking before you go out socially
- Drink on your own in bars
- Go to off-licences or supermarkets to buy cheap alcohol
- Don’t care if you’re ‘performance’ is substandard at work.
Common ‘issues’:
- Repeatedly neglecting your responsibilities at home or work, because of your drinking. ?house untidy, deferring ‘activities of daily living’ e.g. culture, shopping
- Using alcohol in situations where it’s physically dangerous, such as drinking and driving, or drinking the day before a heavy workload
- Experiencing repeated legal problems on account of your drinking. ?how many Doctors facing suspension voluntarily offer their PNC or CRB ?should Doctors be asked to submit this information as part of the revalidation process in future (note comments about outreach)?
- Continuing to drink even though your alcohol use is causing problems in your relationships.
- Drinking as a way to relax or de-stress/coping with ‘success’. Many drinking problems start when people use alcohol to self-soothe and relieve stress. Getting drunk after every stressful day, for example, or reaching for a bottle every time you have an argument with your boss.
H. Why are “professionals” particularly vulnerable?
Gossop et al. (2000): “There are several reasons why doctors and other health care professionals may be at risk of drug and alcohol misuse. The long years of medical training are characterized by intense competition, excessive workload and fear of failure, and few occupations face the intense stresses experienced in the daily practice of medicine”.
Personal experience from recovery meetings: city lawyers, traders, hospital managers, journalists
I. “Presenteeism” – seeking help is seen as getting a criminal record?
Dr Max Henderson, from King’s College London’s Institute of Psychiatry, believes that these numbers represent the tip of the iceberg because “doctors are often deterred from admitting that they are sick and need time off by feelings of shame.
A recent study led by Dr Henderson showed that medics who do fall ill fear being perceived as “weak” or “a failure” by colleagues. “There is a feeling among doctors, that illness shouldn’t happen to them – that they should somehow be invincible,” said Dr Henderson.
“Doctors are particularly vulnerable to ‘presenteeism’ and we know they are reluctant to use mainstream healthcare services and will sit on their symptoms and not share them with anyone. So they may treat themselves or they try to get their friends to treat them through what are known as ‘corridor consultations’.”
J. The difference between recovery and abstinence / white knuckling
For most serious alcoholics, it is easier to abstain altogether, rather than to engage in controlled, responsible, non-intoxicated drinking.
The idea of controlled drinking (or controlled drug use) is the one hope almost every addict brings to his or her initial encounter with treatment. As one AA veteran put it: “If it were possible for a majority of alcoholics to revert to controlled drinking, every alcoholic in AA would have found out about it a long time ago.”
The ‘dry drunk’ phenomenon: This describes a phenomenon in which a person stops drinking and using, but does not make any other significant changes in his life. They are known as “dry drunks” because even though they are sober, their behavior mirrors that of someone who is drinking.
Specialist advice for disulfiram and acamprosate, e.g.
K. Features of alcohol dependence
Alcoholism is the most severe form of problem drinking. Alcoholism involves all the symptoms of alcohol abuse, but it also involves another element: physical dependence on alcohol. If you rely on alcohol to function or feel physically compelled to drink, you’re an alcoholic.
Tolerance: The 1st major warning sign of alcoholism
Do you have to drink a lot more than you used to in order to get buzzed or to feel relaxed? Can you drink more than other people without getting drunk? These are signs of tolerance, which can be an early warning sign of alcoholism. Tolerance means that, over time, you need more and more alcohol to feel the same effects.
Withdrawal: The 2nd major warning sign of alcoholism
Do you need a drink to steady the shakes in the morning? Drinking to relieve or avoid withdrawal symptoms is a sign of alcoholism and a huge red flag. When you drink heavily, your body gets used to the alcohol and experiences withdrawal symptoms if it’s taken away.
These may include:
- Anxiety or jumpiness
- Shakiness or trembling
- Sweating
- Nausea and vomiting
- Insomnia
- Depression
- Irritability
- Fatigue
- Alcohol withdrawal fits
- Loss of appetite
- Headache
Waking up in the morning – needing to go to a pub
L. Two myths of ‘alcoholism’
a. I’m not an alcoholic because I have a job and I’m doing okay.
You don’t have to be homeless and drinking out of a brown paper bag to be an alcoholic. Many alcoholics are able to hold down jobs, get through school, and provide for their families. Some are even able to excel.
The myth about “the high functioning addict”.
b. Drinking is not a “real” addiction like drug abuse.
Alcohol is a drug, and alcoholism is every bit as damaging as drug addiction. Alcohol addiction causes changes in the body and brain, and long-term alcohol abuse can have devastating effects on your health, your career, and your relationships. Alcoholics go through physical withdrawal when they stop drinking, just like drug users do when they quit.
M. Recovery is an ongoing process
Recovery is a bumpy road, requiring time and patience.
The GMC fitness to practise procedures are reported by many, anecdotally, to be time consuming, but they also involve a huge commitment from GMC staff, panel members and specialist advisors. The problem comes to ensure that the mental health of people under investigation does not deteriorate in the lengthy process.
Stress can make addictive symptoms worse, but if right regulatory process can help encourage people in recovery.
Regulators should avoid giving any impression of criminalising people for illness, or humiliating people unnecessarily in the course of their proceedings. There should be a real effort to preserve the dignity of ill people, as Doctors can be patients too. This requires a commitment of being proportionate in a definite drive for destigmatisation, whilst preserving the duty of public safety in the utmost. This requires a shift in mindset of a view where some people cannot be treated for mental illness such as addiction.
N. Support networks
Tendency to ‘get the certificate’ than to understand the process of recovery.
1. Practitioners Health Programme
Dr Clare Gerada, Chair of the RCGP and PHP’s medical director, said: “We are seeing more sick doctors, more GPs in particular, more shame, more presenteeism, as doctors are worried about their futures. ”
2. British Doctors and Dentists Group – all ages, diverse backgrounds
The British Doctors and Dentists Group was formed originally for doctors who were attempting to recover from alcohol dependency and other substance abuse over 30 years ago. The late Dr Max Glatt encouraged some of the early members to form a group which met for mutual support on a monthly basis.
3. After Care
4. Psychiatrist/GP (nb GMC Good Medical Practice)
5. Friends/family/peers
6. ?Regulatory bodies
7. AA or similar entities.
END