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Wise Counsel Interview Transcript: An Interview with Laurence Westreich, MD on Helping Families Help Addicted Members

David Van Nuys, Ph.D.

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Dr. David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by mentalhelp.net, covering topics on mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist, and your host.

On today's show, we will be talking with Laurence M. Westreich M.D. about his book, "Helping the Addict You Love: The New Effective Program for Getting the Addict into Treatment." Dr. Westreich is a board certified psychiatrist who specializes in the treatment of patients dually diagnosed with addiction and mental disorders. He is board certified by the American Board of Psychiatry and Neurology in General Psychiatry and he holds a certificate of added qualifications on Addiction Psychiatry and is certified as an Addiction Specialist by the American Society of Addiction Medicine.

Dr. Westreich is Associate Professor of Clinical Psychiatry at the New York University School of Medicine and serves as the consultant on drugs of abuse to Major League Baseball. Now, here's the interview.

Dr. Laurence Westreich, welcome to the Wise Counsel podcast!

Dr. Laurence Westreich: Well, thank you for having me.

David: Now, before we get into your book, which I must say I'm really impressed by. It's a very practical, down-to-earth book for families who have loved ones who are struggling with addiction. But before we get into your book, let's start out a little broadly. Let's start off with what's your definition of addiction?

Laurence: Well, my definition is when someone has compulsive use of a substance that's causing them problems in their life, like with their physical health or with their job or with education or with their relationships, then I think that's enough of a problem that we should call it an "addiction."

David: OK. We hear of so many celebrities struggling with addiction -- people like Britney Spears, Lindsay Lohan, Keith Urban and the recently deceased Anna Nicole Smith. Is there something about being famous that makes them more likely to have drug problems or are they simply reflective of what's going on in the larger society?

Laurence: Well, I think that's exactly right. They reflect what's happening all around us. I think people who are wealthy or who are celebrities are often protected from the consequences of their actions. For instance, if you've got a bunch of people around you who are your entourage, people unlikely to confront you about your destructive behavior. Or you've got a lot of money, sometimes you can back off the consequences of addictive substance use, the point that you don't get help as quickly as the rest of us would.

David: Right, and of course, the person in the news now is Paris Hilton, and I guess what you've just said applies to her as well.

Laurence: Sure, and I think the main issue is that most people who have addictions are not wealthy or celebrities and most people get good treatment for their addictions, don't go to fancy mint-on-the-pillow treatment facilities. There's plenty of good treatment around for people who have medical insurance or have Medicaid or Medicare.

David: OK. Now, what do you think of the war on drugs?

Laurence: Well, I think if it means spending a lot of money on law enforcement, I think it's mostly a loss. I think that can even be a war on their own citizens. I think we need to focus our efforts and our money on treatment for this problem rather than trying to put every drug user in jail, which is simply silly.

David: Yeah, I have to agree. What's your assessment of how the war on drugs is going?

Laurence: Well, since we spend so much on law enforcement and so little on treatment, I think it's not going very well at all. I think that law enforcement attempts to stop drug use are essentially a waste of time and energy and money.

David: Yeah. What's happening these days with teen addiction?

Laurence: Well, the data show that teenagers are probably plateauing out on the use of drugs like marijuana and alcohol but there's been an increase over the last two or three years in the use of prescription drugs. Those are things that they can get from Mom and Dad's medicine shelves. That's where the concern in the field is right now, with that increase of prescription drug use.

David: My goodness. That seems kind of bizarre, that things would evolve to that place.

Laurence: Yeah, I agree.

David: Well, you've spoken of this a little bit, I wanted to ask you if you're seeing any changes in the pattern of what drugs are being abused now as opposed to in the past.

Laurence: Well, there is a change. Over the last seven or eight years, there's been an increase in the amount of heroin being used by people across the board, with the drug that would have been seen as very deviant by most people 20 years ago that's essentially flooded the market with very potent and inexpensive heroin.

So you're seeing people who long ago would never have used heroin or have had any access to it, use it in the same context they use party drugs. They use marijuana, a little K, a little Ecstasy and then try snorting heroin with it. When they snort the heroin, obviously they don't have to inject it so it doesn't seem as scary. The scary part though is that you can get physically dependent on it very, very quickly, after three or four uses.

David: Oh my goodness! Is heroin somehow perceived as chic now?

Laurence: Yeah, there was a whole movement of heroin chic several years ago and there were, you know, talk about models looking like they were heroin users and that was seen as kind of cool. I think the spate of deaths that have occurred from heroin have cooled that off, but the issue is there's a lot of heroin around, and I see high school students, I see professionals, doctors and lawyers hooked on heroin in a way that we never would have seen 15 years ago. It's something very scary and often hidden because it's seen as much more stigmatized and shameful to be addicted to heroin than having an alcohol problem.

David: Interesting. Now, the subtitle of your book is "The New Effective Program for Getting the Addict into Treatment." That raises the question, what's new about your approach?

Laurence: Well, I have concerns about families who use the "tough love" approach in the intervention approach. The reason being that sometimes, families focus on the "tough" part of it rather than the "love" part. By just waiting till an addict hits bottom, it can be a very disastrous method because sometimes, the "bottom" for an addict is death. I'd never advocate for just pushing the addict out and waiting for them to make the choice to get better. I advocate for raising the bottom.

Rather than doing the tough love approach, I advocate for a series of staged and graded confrontations with the addict that take place over time and that press the addict and push the addict towards treatment rather than a big, final ultimatum that can sometimes be disastrous.

David: Yeah, and one of the things that I really like about your books are these dialogues, these sample dialogues, that you provide plenty of when you talk about the graded confrontations. I think many of us would say, "Well geez, I don't know how to do a graded confrontation. What the heck do you mean by that?" But in your book you really illustrate that by giving these sample dialogues, which really I think give the reader a very concrete idea of appropriate confrontations.

Laurence: Right, thank you for noticing that. Because I think that is the most important piece that families often ask, "What do I say, if he says this?" Or, "What do I say, if he says that?" I've been doing this for a long time, so I have a pretty good idea of what people are going to say in different situations, although everyone is different. But there's some very, very common scenarios that arise, that I can give families advice on how to respond to.

David: Yeah.

Laurence: The response has to be a loving response. It has to be a true response. You have to say what your concerns are. But the idea is not to get into a battle with the addicted person, but to ally with the addicted person and say, "Look, we both think that you have a problem with alcohol. We're all concerned about it. I'm sure you see the problem also. Let's get on this, and try and get some help." Rather than shouting at the addict or expressing your anger with the addicted person.

David: Yes, yes. As I read through the dialogues, in fact they did ring true. They did sound like conversations that I could imagine flowing in just the way that you outlined them. What are the signs that you need to be alert to, if you suspect a loved one may have an addictive problem?

Laurence: I think, look for the obvious things like alcohol on the breath, or the person's got a bloody nose. But then I think we need to look for things; like the person being more tired than usual, having a sudden decrease in their ability to function with their work or with their school, having sudden problems in their relationships, but would still make an exchange.

I think we all need to have a higher level of suspicions about our loved ones' addiction, because addicts naturally hide their behavior. In a scenario I see often is, a high school kid who will come into the office with a full-blown addiction having hidden it from his parents for many years. Certainly we as parents don't want to see an addiction, but also people with addiction problems hide it. So I always advocate that family members in front should be very nosy with people they love and care about, and ask a lot of questions.

David: I can imagine that could generate a lot of resistance, and irritation, annoyance, anger.

Laurence: Yes, I think it does. I think in a way, that's the answer. If I ask a question to someone I care about, and they come back to me angrily and defensively, it makes me think that there probably is something going on, rather than me being mistaken about something that I'm observing of someone I care about.

I think in that circumstance where you're not really able to make any headway, that's the time to ask for some professional help for the addicted person. And that person would go for yourself, to see how you could address the problem as best as possible.

David: Years ago when I was in graduate school, I actually got involved with Synanon...

Laurence: Yes.

David: ...which was an organization at that time. I don't know if they're still around, are they?

Laurence: I think there are vestiges of Synanon around, and certainly some of the ideas from Synanon have been used in other treatment facilities.

David: Yeah. Well, as I say back when I got involved, they invited "squares" to be involved. It was an organization, at least initially, that focused very strongly on working with heroin addicts. It involved confrontation, attack therapy. Part of the party lying, and I'm not sure that's unique to Synanon is that, "OK, your hardcore addicts are liars and thieves, and to be distrusted. You never believe what they say." It sounds like you're not quite to that far of an extreme.

Laurence: Well, I would see it in two ways. I think, that some who has got an addiction problem almost by definition has to lie about it in order to keep it going, right? I mean, it's part of the syndrome that there's lying, and often manipulation that keeps the addiction going. You have to lie to people who care about you. You have to manipulate things, and people, and jobs, in order to get the substance into yourself in as much as possible.

But the wonderful thing about this field and one of the reasons I enjoy working with addicts so much, is if you're able to get the change going, get the person's sobriety, almost always the lying and the manipulation dries up and goes away. You're left with someone who are the way they were before they had the addiction, and that can sometimes happen very, very quickly.

So you've put the finger on what the joy in this job is, helping someone get back to a real life with their loved ones and with their work, and moving on in a way that they themselves didn't imagine they could move on to.

David: Well, that's very interesting to hear you say. I somehow never expected you or anybody working in this field to talk about the joy of it. That's an interesting dimension, and I'm sure it makes you good at what you're doing.

Laurence: Yes. I think people who do this kind of work and probably any kind of work in technology, if you don't have a real calling to do it, it can turn out to be drudgery. But, I think working with addicts is something that really moves me.

David: Yeah. In the field of psychology and probably psychiatry generally, I think that the whole issue of addiction has a dark cloud over it, and has the reputation of oh, well, these people never yield to psychotherapy; you're going to be batting your head against a wall.

Laurence: Right. Yes, it definitely has that reputation. I think that's changing though. I think it's changing because we have much better treatments than existed before for treating addiction. I think that if you use the right kind of therapy and have a reasonable set of expectations for what you're doing, you can be very effective and you can enjoy the work, and find it's a tremendously gratifying -- get great results.

David: Well, that's good news. We'll talk about some of those specific interventions a bit down the line here. In your book you discuss "Identifying the Three Cs of Addiction." What are the "Three Cs"?

Laurence: The "Three Cs of Addiction" are compulsive use of the substance, continued use of the substance -- despite knowledge of adverse consequences, and loss of control over use of the substance. That pretty much describes what someone who's got this addiction problem has.

The person will intend to drink one or two beers on a Saturday night, but end up drinking 12; will drink huge amounts, and look like they don't even care that they are drinking huge amounts. They will continue to drink, even when they know it's harmful to themselves.

Rarely is an addiction a problem of intelligence. Addicted people know that they shouldn't use cocaine or know that they shouldn't use heroin. But they can't stop doing it, and that's what makes families so angry. But that's the problem, that's a definition of the problem. A person is well aware they shouldn't do it, they can't stop.

David: Yeah. Let's talk a little bit about etiology. You talk about, "How and why a loved one becomes an addict." What are your thoughts on that?

Laurence: Well, there are a variety of different ways people can get to the final result of being addicted. I certainly really believe there's a biological component, some people have a genetic vulnerability to it. If your mother or father had an addiction, you're more likely to have it yourself.

I think there are underlying psychiatric conditions, which people can sometimes self-medicate, to get started with the substance, and they get caught with the substance.

I think there are personality structures that are somewhat more vulnerable to addiction. I think at the end of the day, though, every individual has their own reasons for getting through an addictive behavior style. I think that, that in many ways is the work of physiotherapy to figure out. Doing work with the family immediately, is to get them to treatment immediately to stop the fire. Put the fire out, and then figure out what caused it.

David: We talked a little bit about the need to be secretive, and about lying. What are some of the other, what we might call defense mechanisms that addicts tend to use to defend their addiction?

Laurence: Well, a very common one is denial. I really differentiate that from lying. I think when people lie about something, they know they're lying and they're trying to fool somebody. But the psychological mechanism of denial is when you lie to yourself, and you really believe it.

That you may believe you have no problem with the alcohol. You may be able to tell other people that, in a way that surprises and shocks other people. Probably if you took a lie detector test, it would come up and you're not lying, because you don't think you are. So that's denial, and again that's very scary for family's to see. Because so often, it's so contrary to what their senses tell them about the addicted person.

I think family members have to become a bit of a therapist when that happens, and not try to talk logic to the person, but try to go around. Ask the person, "So if you don't think there's a problem now, when would there be a problem? How would you define a problem with your alcohol use?" Try to get started that way with a person who's in denial.

David: OK, OK. Well, let's see if we can get a little bit more deeply into your particular approach. You recommend a combination of creative engagement, and constructive coercion.

Laurence: Right.

David: What do you mean by these two terms, and how does one combine them?

Laurence: Right. Well the creative engagement is with trying very specific treatment about, is I go through them in the book in a way that engages the addicted person. Because the way you think or I think might be the best way, might not be the way that the addict's willing to accept.

So I've sat with addicted people and their families as they've done outpatient treatment, when I desperately think they need to go to impatient treatment. But I'm aware that I can't really force another human being to do anything, so you stay engaged with the person. Push them towards what you think is right, and whether it's outpatient treatment, or detox, or medications, or psychotherapy, stay in there with the person and keep pressuring them towards getting the right kind of care, and towards getting the care that's available.

The only issue though, is that if the addicted person is hurting you in someway, you can't allow that to happen. You can't allow the addicted person to hurt you certainly physically, but obviously emotionally or financially also. So, you have to protect yourself in the same time that you're pushing the addict towards a treatment that's best for him.

David: OK. So, let's say that you've got a loved one who is actually ready to get therapy. How do you find out who the best therapist is, and how would you evaluate them? How do you figure out who you should avoid?

Laurence: Right. I think that the first piece is to get some people who work with addiction in your community. You can ask a local doctor, I also recommend people go to an open AA meeting. Because at an open AA meeting there will be people around who are in recovery, who are able to direct you towards good treatment. You can call the American Academy of Addiction Psychiatry. There are several government websites. There's SAMSHA website that has conations on it, and that's a way to generate a list of names for yourself.

Once you've got one or two people to talk to, what I recommend that you do is look for people who are trained in treating addiction, and have experience with treating addiction, and that you or your loved one are comfortable with. It's probably less important what credential they have, whether they're a psychologist, or a social worker, or a psychologist, than that they're trained and experienced in working with addiction.

I think usually in talking with someone for 10-15 minutes, you can get the sense at whether they're going to be sympathetic to your loved one, or if they seem punitive or angry about someone who has got an addiction problem. I think it's tremendously important to be empathic, and to engage with the addicted person. So look for someone who is trained, who's got experience, and who's empathic with you and your loved one.

David: So in terms of who you should avoid then, would that be somebody who is not empathic? Are there any other signs of...?

Laurence: Right. I think that someone without substantial experience in addiction is likely going to be unable to treat the addicted person. I'm not in favor of people without a credential and without licensing from the state, just because it's a mixed bag. You often get people in that circumstance who are counselors, and who have had their own addiction, which has been treated. But they only know one way to do it, and that's the way that they got treated. I think that's always a mistake in psychiatry in general to only have one modality to use.

So if someone tells you that everyone they treat gets better with "X," I'd be a little suspicious about that. You want someone who can use all different types of methods, or if he can't or she can't, is able to refer you to some other different method--which I think that will tell you what a good clinician is.

David: OK. In a similar vein, what should listeners look for in a treatment facility?

Laurence: If someone is going inpatient, it's probably a sign that they have some serious problem, like withdrawal from a substance, or they have an ongoing psychiatric problem that's serious, or they're suicidal. In those circumstances they should go inpatient, and then you want to look for the inpatient facility being able to treat that specific problem.

For instance if you're loved one is in alcohol withdrawal, you want to make sure that they have medical care immediately. If they don't have a physician there, they should have a nurse who can do the assessment, and if not treat it right there, get that person to a freestanding hospital immediately.

If it's a psychiatric problem, again you should make sure that they have the ability to treat depression, bipolar disorders, schizophrenia, with whatever is necessary, whether it's medications, or psychotherapy, or whatever is going to be needed for that person.

Again, don't hesitate to ask questions. I think a 10-15 minute conversation will give you a good idea of what the tone of that treatment facility is going to be.

David: Now in your book, you do cover a whole range of treatment options. Can you step us through them, or at least some of them?

Laurence: Sure. The major delineation is between outpatient treatment, and inpatient treatment. Outpatient you're outside of a facility, inpatient you sleep there overnight. I always recommend people start with outpatient--that is you go to the treatment facility during the day, and then you come home at night. Because that way, you're able to work with the stresses that might push you towards using in a normal way when you get home at night.

So in the outpatient world, therapy or treatment can range all the way from psychotherapy with someone who you will talk to once or twice a week, all the way up to programs that last all day long. It depends on the severity of the addiction what would be best for you.

I usually don't recommend psychotherapy alone. I mean I do psychotherapy, I think it's wonderful. But for treating addiction, the psychotherapy should always be combined with other modalities--most likely AA, which is a paralytic group, which is not treatment itself, but can be tremendously helpful.

There are actually medications, which are helpful for treating addiction at this point. There are group therapy's that are led by a trained facilitator that are tremendously helpful with addiction. The reason I recommend group therapy's as well as AA is that it's always helpful to hear about other people's experiences with drugs and alcohol.

The 12 Steps of AA, I think, are very wise psychologically. But most the people that I work with get the most benefit from hearing other people's experiences. So those are the types of things you can do outside of a hospital. Inside a hospital, if you need that, there's detoxification, if you are in withdraw from a substance. Alcohol is very, very dangerous and should be treated very aggressively.

There is intensive therapy on how to deal with the cues to use. Of course we all have cues that make us do particular things. If you addicted to something, some of the cues can be overwhelming. So a therapist in an inpatient facility will help you deal with those cues when you walk out of the door of the hospital.

Probably the most important piece, interestingly, of inpatient care is the liaison when you go back home, because in inpatient facilities almost always there's no drugs or alcohol obviously, but also it's usually a restful place; there's no particular stresses either. But when you go home at the end of 14 days, or at the end of the 28 days, of course everything is exactly the way you left it. So the inpatient facility must make a good liaison and get you into outpatient care and give you strategies to have in place when you get home.

So those are the two, the breakdown, between inpatient and outpatient.

David: OK and you mentioned medication.

Laurence: Yes.

David: What is the role of medication?

Laurence: Well, medication for treating addiction is, at this point an adjunct. It's helpful, but I wouldn't say any medication is curative for addiction. The reason being, you asked and I agreed earlier, that addiction is often related to biological changes in the body, but it's not the only thing. It's certainly related to the persons psycho-social functioning also and to how he or she grew up.

So the medications can help with addictions but they're not curative. There's one for alcohol that can cut down craving. There's one that can make you sick if you drink alcohol. If you choose to take it, it can be helpful. There are ones for heroin that will block the effects of heroin on the body and that includes Oxycontin, that includes Delodin and Vicodin. So that's a pill you could take every morning, and if you use an OPR like Oxycontin, you will have no effect. There are the substitutes for Opioid like Methadone and Suboxone which are available also. The medications for treating cocaine are really more in the developmental stage so far, and I don't think they have much clinical value at this point. I hope they will sometime.

David: Sometimes I think people worry that use of a medication, that the person will just become addicted to a different substance.

Laurence: Right, and that kind of concern, if it comes up with the family I'm working with or with the addicted person, I think is actually a good one, because I think we do want to be very careful with any substance you take into you body and look at the benefits of that substance and look at the risk of it. I think that goes for psychiatric medications, I think it goes for heroin, and I think it goes for alcohol.

So when an addict says that to me, I'm actually very happy about it because that's the way of thinking I'm trying to promote with that person, that we should think very carefully about whatever substance you put into your body.

The fact is, all the medications that I've told you about, except for Methadone and Suboxone, do not cause addiction in the sense that it suddenly gets tolerant or has withdrawal, or has any kind of negative physiologic effects from it. The ones that I mentioned, Suboxone and Methadone theoretically can in people, and those need to be used very, very carefully.

David: OK, let me take a little bit of a side step here. I'm wondering what your take is on such things as Internet addiction, video game addiction, BlackBerry addiction, I guess, love and sex addiction, and so on. Are these stretching the term addiction too far?

Laurence: Well, they are stretching the term. But I think the behaviors are very similar to people using these dangerous substances. In fact, the people that do the research on this say that when someone's got a gambling addiction and they're gambling, their brainwaves look about the same on a cat scan as they do when they are using cocaine. The same part of the brain lights up.

So I think there is certainly a connection there. But it is not something that comes to clinical attention as commonly as addiction to drugs and alcohol. But I think it is probably the same phenomenon.

David: Interesting, interesting. Well as we begin to wind down, I wonder if there is anything that you haven't had a chance to say, or any last advice that you would like to give to listeners who in fact may be struggling with the issue of a loved one or someone that they know who has issues with addiction.

Laurence: I think the most important thing in working with an addict is to never lose hope, and I think that goes for the addict himself or herself, and it goes for their family members. So, I haven't had the experience I had in the field over the years, I learned never to lose hope and never to stop trying with an addicted person. If there's one message I could give people, that's what I would give them. Do not lose hope.

David: OK. Well, Dr. Laurence Westreich, I want to thank you so much for being my guest today on Wise Counsel.

Laurence: Thank you very much for having me. Thank you for your good questions.

[music]

David: I hope you both enjoyed and learned from this interview with my guest Laurence Westreich, MD. If you have a close friend, a family member, of a co-worker who's struggling with addiction, I think you'll find his book to be very practical, down to earth, and effective. The book is published by Simon & Schuster and is also available as an online ebook. As you heard in the interview, one of the things that impressed me most is Dr. Westreich's joy and optimism in the face of dealing with addiction, which for so long has been under the dark cloud of hopelessness.

You've been listening to Wise Counsel, a podcast interview series sponsored by mentalhelp.net. If you found today's show interesting, we encourage you to visit mentalhelp.net where you can add a comment or question to this show's web page, view other shows in the series, or simply page through the site which is full of interesting mental health and wellness content. Access the show's page and show archive information, via the podcast box on the mentalhelp.net

If you like Wise Counsel, you might also like Shrink Rap Radio, my other podcast interview series, which is available at www.shrinkrapradio.com, and rap is spelled r-a-p. Until next time, this is Dr. David Van Nuys and you've been listening to Wise Counsel.