Achievement And Addiction

A Guide To The Treatment Of Professionals

Edgar P. Nace

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134861774
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Achievement and Addiction strives to answer those difficult questions, and, in so doing, to provide mental health professionals with the expertise necessary successfully to guide this unique population on their journey toward recovery

CHAPTER 1

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The Professional Paradox

It is to no purpose, it is even against one's own interest, to turn away from the consideration of the real nature of the affair because the horror of its elements excites repugnance.

—Clausewitz

Over the past three decades, Americans, with the rest of the Western world, have witnessed the spread of drug abuse. Drug abuse has been superimposed on the preexisting scourge of alcoholism and has been accompanied by the development and increasing use of pharmaceutical products with addictive potential (Mellinger, Baiter, & Uhlenhuth, 1984). A “modern epidemic” (Nicholi, 1983) is now endemic.

As awareness developed and concern grew over the toll taken by substance abuse, extensive efforts were undertaken to characterize those addicted, as well as those who may be subject to addiction (Brooks, Whiteman, Gordon, & Cohen, 1989; Kandel & Logan, 1984). Profiles of drug abusers emerged: They were poorly motivated and were poor academic performers; they had few religious convictions, were rebellious and depressed, had low self-esteem, and were maladjusted (Nicholi, 1983). Alcoholics had been viewed negatively long before characterizations of modern drug users were drawn (Chappel, Jordan, Treadway, & Miller, 1977; Fisher, Mason, Keeley, & Fisher, 1975). Alcoholics commonly have been viewed as morally weak, unmotivated to change, irresponsible, weak-willed, and passive (Morse, Mitchell, & Martin, 1977).

The usual images, stereotypes, and profiles of substance abusers, whether drawn from empirical studies or from clinical frustration, are confronted when alcoholism and drug dependence present in professionals. In that circumstance, glib assumptions about etiology and character are challenged. The professional patient forces us to reexamine our understanding of and attitudes toward addiction. For, now, we face a patient not unlike ourselves in so many ways: background, training, aspirations, fears, and, in many instances, personality structure. The professional—achievement-oriented and typically devoted to his or her vocation—enables us to appreciate in bas relief how the tentacles of addiction choke and potentially destroy character, ambition, accomplishment, reputation, health, family, and future.

It is my hope that this book will help physicians and other professionals recognize the presence of chemical dependence, guide their approach to professionals with substance use disorders, and encourage active involvement in forwarding the process of recovery.

To provide a text on addicted professionals implies that they are different from others with similar problems. Is this true and, if so, to what extent? This text argues that professionals often present “special” problems, which the skilled clinician needs to appreciate.

ATTRIBUTES OF PROFESSIONALS

The term “special” is used in this context conservatively and does not refer to elitism. Special is derived from “species”—a kind or sort. Webster (1980) defines special as “unusual, uncommon; differing from others; designed for a particular purpose.”

How then do the men and women who enter professions fit the above definition? For one, members of professions are well rewarded and compensated by our society in many ways—by esteem, status, privileges, and better than average earnings. The edge of financial peril is commonly dulled for professionals by job security, demand for services, and a “market” that bears lucrative salaries. Respect for their special knowledge and training and a favorable standing in the social order continue to be endowments of public opinion.

Secondly, a high sense of self-efficacy that bolsters their ability to focus and fix on distant goals contributes to the “special” characteristics of professionals. According to Bandura (1986), “perceived self-efficacy underlies the motivated forces which propel goal directed behavior.” Perceived self-efficacy is defined as “judgments of [one's] capabilities to organize and execute courses of action required to obtain designated types of performances” (Bandura, 1986, p. 391). The individual aspiring to a profession is unusually goal-directed; certainly well beyond the average.

Associated with self-efficacy and goal-directed behavior is a third attribute: a capability for endurance. Long, intense academic preparation and additional years of apprentice-like training are required. For those preparing for a profession, goal-directed behavior, endurance, and a focused, sustained level of motivation cut a swath through youthful years where personal experimentation and immediate gratification are more typical.

A fourth attribute is a keen sense of responsibility. Professionals are generally very reliable. They accept the need to be accountable, and they fulfill obligations. In order to be accepted in graduate school, outstanding letters of recommendation are necessary. The academic record reflects intellectual ability, but the letters of recommendation address character. Such letters often describe stability, conscientiousness, and reliability, and frame a portrait of responsibility reassuring to admission committees. Intellectual abilities substantially greater than average would also be expected in professionals because of the competition for admission into professional schools and the rigor of the curriculum.

Finally, I believe that those who choose a professional career have a strong desire to help their fellow humans. The origins of this desire may be complex and multidetermined, while the aim, professional success, may sometimes be misguided. The same complexity of motivation may apply to the other attributes referred to above, such as goal-directed behavior, endurance, and responsibility. Nevertheless, my impression is that most men and women in the professions want to do good, want to help clients/patients, work hard, and conscientiously strive to fulfill both societal and self-expectations.

There are, of course, many other factors that direct one toward or deter one from a professional career, and these factors have no relationship to ability or character. The values of one's parents, money, availability of scholarships, exposure to appropriate and effective role models, peer examples, and good health are but a few determinants that can propel one toward a successful career or deny one such opportunity.

The external rewards of pay and recognition for professionals have been briefly mentioned. The rewards of success, esteem, power, and financial gain account, in part, for the goal-directed, achievement-oriented behavior of those who enter the professions. Professional life, however, is enriched by “rewards” less obvious; that is, by rewards that are part of the preparation for and practice of a profession. If the rewards of professional standing were bounded only by purchasing power or public image, the substance of a professional's accomplishments would be little different from those of a lottery winner, rock star, or other form of celebrity. The external compensation is important, but there are rewards, less acquisitive in nature, that stamp profes-sional life. Compared to these, remuneration and status are weak competitors.

INTRINSIC REWARDS OF PROFESSIONAL LIFE

Preparation for a professional career can be likened to a drama. Who can fail to recall the protagonists in one's own drama? Each stage of a career calls forth a cast that provides the tempo, mood, and action for the “scenes” that follow. An intrinsic reward is this legacy of relationships through which a professional identity is ultimately formed. These relationships have involved teachers, mentors, and role models, and are characteristically intense and ambivalent. That the feelings about those who taught and directed our professional development would be strong and often conflicted follows from the demands put on students, the rigors of training, and the subsequent sacrifices and deprivations. The years of training extend the dependent status of the trainee, and a prolonged adolescence results.

Out of this difficult journey the student emerges with a mosaic of affect and recollection. Gratitude, humiliation, awe, contempt, and devotion are but some of the emotional elements through which personal and professional identities fuse. No matter what the complexity of emotion may be for any one physician, attorney, or other professional, each has been the beneficiary of a legacy of accomplishment passed on. Those who preceded us, through their scholarship or practice, have transmitted by social process an identity with their profession that is, perhaps, as unique as the biologic transmission of the genetic code.

The professional identity emerges almost imperceptibly as role development proceeds. The third-year medical student is awkward and self-conscious with patient contact. “Do I have a right to ask these questions; to touch his or her body” are unvoiced questions as the student confronts self-doubt as to whether or not he or she is a legitimate member of the medical profession. In contrast, a senior resident has no doubt whatsoever, and expects role confirmation and role support from staff, patients, and families.

A second intrinsic reward is that of service. As with one's relationship to mentors, the concept of service deepens the sense of professional identity and belonging. Here, also, relationships are the vehicle by which the legacy of dedication to the welfare of others is transmitted. The concept of service and welfare of others is contained in the following definition of a profession: “... a socially sanctioned activity whose primary objective is the well-being of others above the professional's gains” (Racy, 1990).

Involvement in the lives of clients or patients over years and decades, or briefly during crises, exposes the professional man or woman to the vulnerable and the tragic, as well as to the sublime facets of others’ lives. This is a privilege the weight of which each individual suitable for the professions will appreciate. Cynicism, fatigue, and apathy are often ameliorated by a remembrance from a patient, an unexpected thank you, a recommendation. I believe this to be true even in a climate where practice is often defensive and the spectre of litigation omnipresent. Satisfaction in professional work is significantly related to sharing one's wisdom with clients, patients, peers, and students; to the sense of accomplishment from assisting in the resolution of complex problems; and to the stimulation and esteem gained through meeting diverse challenges.

A third intrinsic reward is that of having chosen one's vocation. The satisfaction of having reached a goal, of having followed one's calling, is largely an intangible asset, sometimes forgotten as the demands of increasing responsibility and high performance are encountered. Most professionals will find, however, these demands preferable to the tedium, monotony, and anonymity that characterize many less deliberately selected occupations.

PROFESSIONAL SUCCESS VERSUS SUBSTANCE ABUSE

In the context of native ability, personal achievement, and substantial financial and social rewards, how are we to understand the emergence of a process that erases achievement, provokes punishment, and potentially compromises skills and abilities? This is the paradox of professional addiction. Shouldn’t professionals, with their education and advantageous position in our society, know better than to get themselves into such difficulty? Indeed, this criticism is familiar to the chemically dependent professional; he or she expects to be subjected to greater stigma for a substance use disorder because of the higher expectations others put upon professionals. Professionals have a highly developed sense of self-efficacy, and individuals who perceive themselves as highly efficacious attribute personal failure to lack of effort, while individuals with a low sense of self-efficacy attribute failure to deficient ability (Bandura, 1986). Thus, professionals are particularly likely to go through a process of self-castigation, believing they should have “known better” or “seen it earlier,” and they may assume that their own self-directed efforts will be sufficient to correct a growing dependence on substances. Paradoxically, their achievements, self-expectations, and sense of self-efficacy can delay the acceptance of the need for help. The professional's strength becomes a weakness, at least initially, often because of this inability to ask for help.

Clashing with this belief in the efficacy of self-direction are the complex variables that compose the etiology of substance use disorders. These include a genetic vulnerability to alcoholism or drug dependence; the high degree of stress common to professional life; the availability of drugs, especially in the medical field; and certain personality vulnerabilities, such as self-efficacy, that may propel a person to achievement on the one hand, yet eventually, may undermine the individual's functioning, when taken to extremes.

A military analogy reflects the addictive process: As an advancing line of troops spearheads an attack, military commanders are aware of the potential for a segment of this advancing line to undermine the overall effort. This segment is referred to as a “reverse salient.” The reverse salient exposes the vulnerability of the operation and is the point that collapses and reverses the fortunes of the mission. Certainly, the addictive process is the professional's “reverse salient.” What ac-counts for the presence of this vulnerability varies from individual to individual and can be considered a blend of the etiologic variables already mentioned. The chapters that follow explore this paradox and offer clinical guidelines for the diagnosis and treatment of addicted pro-fessionals.

Many occupations are considered professions. The professions chosen for this discussion are medicine, law, nursing, pharmacy, and business. The selection of these particular professions is based on the availability of studies on these groups and the author's clinical experience with members of these professions. It is likely that the basic factors leading to addiction are similar across most professions.

This book does not serve as a textbook on addiction. Several excellent general textbooks are available (See Frances & Miller, 1991; Lowinson, Ruiz, & Mulman, 1992; Miller, 1991).

This text describes the clinical expression of addiction in a selected sample of the population. The etiologic factors believed to cause an addiction are reviewed, as well as the neurochemical mechanisms of the major drugs of abuse. The processes of intervention, diagnosis, and evaluation, and guidelines for matching the patient to level of treatment are described. Of special importance are the case histories, which are written by a member of each of the professions specifically for this volume. The candid contributions of these professionals enrich and bolster the educational value of this text. I am deeply grateful to them for their willingness to help. I have not altered their presentations except to assure confidentiality.

Specific therapeutic approaches are reviewed in the context of their application to professional patients and not as a review of such therapies themselves. The uses of psychotherapy, medication, and monitoring are discussed. The chapter on 12-step programs emphasizes the importance of Alcoholics Anonymous in the recovery of the professional patient.

Finally, the terms addiction, substance abuse, and chemical dependence are used interchangeably. For the purposes of this text, I find it useful to think of substance abuse in a generic sense, without emphasizing specific drugs. The next chapter describes why the numerous drugs that produce an addiction can be viewed generically.

CHAPTER 2

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The Generic Concept of Chemical Dependence

The drugs of abuse possess a remarkable variety of properties. Tolerance, withdrawal patterns, effects on neurotransmitters, and sites of action in the brain vary across the broad categories of stimulants, hallucinogens, opiates, and central nervous system depressants. Yet, from this pharmacologic diversity there arises a set of phenomena common to the experience of chemical dependence and independent of the specific drugs involved. These phenomena enable us to clinically conceptualize substance use disorders from a generic point of view. The adjective generic is defined as “relating to or descriptive of an entire group or class” (American Heritage, 1987).

The features of drug dependence that transcend the specific drugs use...

Table of contents

• Cover
• Half Title
• Full Title
• Copyright
• Dedication
• Contents
• List of Tables and Figures
• Foreword
• Acknowledgments
• Chapter 1. The Professional Paradox
• Chapter 2. The Generic Concept of Chemical Dependence
• Chapter 3. Etiologic Variables of Addiction
• Chapter 4. Initial Steps: Intervention and Diagnosis/Evaluation
• Chapter 5. Medical Students and Residents
• Chapter 6. Physicians
• Chapter 7. Nurses
• Chapter 8. Pharmacists
• Chapter 9. Attorneys
• Chapter 10. Executives
• Chapter 11. The Recovery Process
• Chapter 12. Matching the Patient to Level of Care
• Chapter 13. Specific Treatments
• Chapter 14. Twelve-Step Programs
• Appendix A. Guidelines for Taking a Substance Abuse History
• Appendix B. Adult Recovery Services Chemical Dependency Schedule
• Appendix C. Withdrawal Signs, Symptoms, Techniques
• Appendix D. Impaired Health Professional's Treatment Contract
• References
• Name Index
• Subject Index