Resetting the Bar

I’m not a fan of competition. It brings out the worst in people, while trying to bring out the best. So of course I have difficulty understanding athletes using steroids or doping just to win a contest. These drugs have possible health consequences after all. For the athlete, I’m sure they believe it’s about achievement and maximized potential, but it’s driven by trying to be better than the other guy. The bar is set by another person.

With that drive they are willing to do “whatever it takes.” Train more. Work harder. We as spectators encourage it and set up an environment that doesn’t reward holding back. Those that hold back anything that might enhance their performance don’t last too long in competitive sports. Once someone else becomes the standard to be matched or exceeded, they determine the bar for “normal.” Anything less is unacceptable.

In society we have a name for functioning below the level of “normal.” We call it impairment. As a psychiatrist I am supposed to intervene when someone has a mental impairment. Physicians usually define normal as the range of functioning of the average person in society. Not having enough energy to get regular activities done is an impairment. As society pushes people to pursue one’s “full potential,” expectations shift up for “normal.” People view normal by unnaturally high standards, and feel disappointment if they don’t meet it. Performance enhancement becomes common, normal, and expected.

When I was twenty-two years old, I did my job with five hours sleep and little to eat. That was normal then. Now in my thirties I need three cups of coffee to get the same amount of work done if I’m sleep deprived. I view it as necessary and justified since the work needs to get done. It’s normal. In medicine we’ve trained ourselves to maximize functioning without sleep, because it’s expected of us.

While it’s possible that my medical training has skewed my view of athletes, college students don’t seem to find performance-enhancing drugs in athletes acceptable either. Last year, in a study in the journal Psychology of Addictive Behaviors, authors Dodge et al., found that college students viewed such athletes as “cheaters.” These same college students, though, believed it was all right to abuse stimulant medications (not prescribed) to do better academically. They did not consider that misuse of stimulants to be cheating. The more they themselves had abused stimulants, the more judgmental they felt about athletes. Stimulant abuse is rampant in colleges, with students attempting to enhance their academic performance. If their classmates are using them and scoring better on tests, the bar is raised, and a new “normal” is set.

I routinely have patients who come to me asking if they have ADHD. More of the time they insist that they have it. They insist because they’re sure they have attention problems. Or because they tried their friend’s Adderall and were “able to focus so much better.” In their minds, improvement on a drug must indicate a diagnosis and thus an explanation for the difficulties. I even have parents of patients who presume that the lack of A’s must indicate ADHD and insist on my prescribing stimulants. Two hundred years ago people weren’t expected to sit in a chair for eight hours a day. Today we have a diagnostic construct of ADHD. Now this isn’t to say to that ADHD doesn’t exist, as we have all seen children who really struggle with this condition.  But perhaps thinking about our expectations reveals the slippery slope that leads to overdiagnosis.

As we’ve stumbled upon many ways to “enhance” functioning, to maximize what we can do with our bodies and minds, the bar shifted on normal. We expect people to perform at that new level. If they can’t, it must indicate a deficit. Such a progression leads to less and less tolerance for any impairment, distress, or problem. In the end, this is really about performance at all costs, masked in the pretense of “treatment.” In 2008 a group of eminent scientists published a commentary in the journal Nature, calling for regulation to allow “cognitive enhancers,” namely open use of stimulants to improve brain function in the average person. Implicit in their argument is a goal to “call a spade a spade.” In that argument, people use drugs to do better at tasks, so let’s call it what it is. I reserve an opinion on the matter.

It’s easy to have perspective on something we ourselves are not doing. Once we have incorporated it into our routine, we develop rationale to justify it. I can understand how the college student thinks “athletes shouldn’t use drugs to win at sports, but keep your hands off my Adderall.” Personally I believe students shouldn’t use ADHD drugs they aren’t prescribed to do better on tests. It’s wrong for them to misuse drugs just to be able to take tests.

Just don’t take away my coffee. I need my coffee.


Hitting Rock Bottom

I’ve been thinking on this a lot lately, as the issue has arisen in various clinical situations.

We do many things as caregivers (clinicians, providers, physicians, friends and family members) in an effort to help another person. Sometime it seems that if only this person could get a little help, they’d do so much better. And that is absolutely true, some of the time.

On the other hand I’m meeting many people who actively sabotage their own improvement. Maybe they do this by burning bridges with family or friends. Maybe they do this via drugs or alcohol. As this happens there are inevitable consequences — loss of job, friends, health, or housing. Watching this transpire in someone we care about can be incredibly difficult. We’re pulled as we watch the tragedy, to want to intervene. It is in the nature of our role as “givers” to intervene. As if more help in all circumstances will solve the problem of someone who actively sabotages themselves.  For the simplicity of this post, I’ll illustrate these issues using drugs.  It doesn’t have to be drugs, though.  The concern is applicable with any self-destructive behavior.

Imagine having a seventeen year-old daughter. She has started drinking. I’m not talking about a beer here and there. I mean stumbling drunk on a daily basis. She gets expelled from school. As a dutiful parent, I’m sure you’d try to support her. Maybe you would try to limit her contact to friends that are a “bad influcnce.” You might stick her into rehab or send her to boarding school if you can afford it.

Flash forward three years. Your daughter is now twenty. She didn’t go to college. She didn’t finish high school or get a GED. She has never worked a job. All your other interventions didn’t work. The more she rebelled, the more you tried to discipline her, with the hope that she would somehow obey or internalize your values. Instead she just rebelled more, and fought against every rule you laid down.

She comes into your home to eat, or sometimes to sleep and shower. She then goes back out to drink, “party,” and even dabble in some heroin. This is real, even though it seems like a nightmare. You as a parent are torn up watching your little girl go down a path you would never want for her. The options at this point don’t seem appealing.

As a parent you could decide that your daughter needs to “learn a lesson,” or “grow up and start fending for herself.” So maybe you kick her out. She couch surfs with her drug buddies for a while. But she doesn’t have any money. You cut her off because you know she’ll spend any money you give her on drugs and alcohol. That would be enabling her. By cutting her off, you hope she’ll learn her lesson. You hope she’ll hit rock bottom. That she’ll come back ready to grow up and accept an adult role in the world. But she doesn’t.

Instead she stays away. She’s mad at you. She feels rejected by you when you cut her off. She doesn’t recognize the “tough love” approach to this. Even though maybe you were right. By giving her someplace to stay for years, she was shielded from the real consequences of her actions. In a way you had been enabling her use. Now, though, since she doesn’t have money, she has to find other ways to pay for her alcohol and drugs (she’s now using heroin routinely and trying out cocaine periodically). So she starts prostituting herself.

Whoa. Too far?  I’ve seen it a lot.

So you ask yourself – Since she hasn’t hit rock bottom yet, where is that bottom for her, where she reaches the point that she won’t let herself get worse? When will she go so far that I have to intervene because I can’t stand to watch the suffering anymore? Where is my rock bottom?

For some parents in this situation, as well as doctors, therapists, nurses, teachers, etc., there is no end point. Once they cut the cord and decide to stop enabling the pattern, they emotionally disconnect themselves from the outcome. They pray. They hope the person will wake up and come to their senses.

I believe that usually the cord isn’t usually cut completely. People don’t stop caring. Instead the child (or husband/wife/sister/brother/patient) pleads harder, or debases themselves enough to get some help again. They’re desperate. And they learn that if they lose themselves more, someone else will step in to take care of them. And so the pattern continues, except really becoming a pattern of exhausting the compassion of the caregiver. Every time the caregiver has tried to stop, their heartstrings are tugged on until they give in a little. It’s an exhausting process on everyone.

I’d like to think that behaviorism has the answers, and that if this intermittent reinforcement could stop then the person would come to their senses. Sometimes that must be true. Sometimes the caregiver isn’t even aware how they’re reinforcing or enabling.

My recent dilemma comes out of the alternative path, when the person doesn’t end their downward cycle. We wait for the person to hit bottom and snap out of it. We hope it’ll happen, and we feel powerless to “force” the person to change. But in that process, what if hitting bottom means death? Can we accept that? Should we accept that? In a harm reduction model, this seems like a failure. Yet the alternative of enabling didn’t seem acceptable either. Do we rationalize this away as “they did this to themselves?” Should we be contented that this is just what happens with some in their self-destruction.  I believe these rationalizations just make us feel better about not having better tools, about our feelings of failure.

Regardless of whether its acceptable, failure should be considered as the possible outcome of setting a limit. Things may get worse. If we as caregivers cease helping the person, bad things might occur. These might even be horrible things we haven’t imagined yet. If we are shocked at each drop in functioning, though, we may be more tempted to intervene. I am not sure that always helps.

I hate being caught in the process of enabling. It makes me feel like I am being manipulated. From the other side, from the person not even conscious of what they’re doing, I can also appreciate that “benign neglect” can just look like neglect. And for those who have emotionally disconnected as caregivers, it can really take the shape of apathy. Sometimes people are just misunderstood, and it is the feeling alone that can drive them to do their self-destructive behavior. Recognizing that, we’re caught in a bind. Trying to intervene in response to “acting out” reinforces, yet withdrawing resources can potentially lead to more self-destructive behavior as well.  This might not be death, and in fact isn’t in many circumstances.  But it is possible.

I understand all of the rationale behind each side. I can even understand the parent who might say “I’d rather have them alive and using drugs in my home, than outside and dead.” Who would want to give up on those they care about?  Death doesn’t seem like an acceptable outcome. Continuing to enable a process of dysfunction in the name of good intentions doesn’t seem acceptable, either.

There needs to be better ways at intervening, and there very well might be. Resources can and should be provided, but in response to positive behaviors, rather than self-destructive behaviors or even requests for support. Other therapeutic approaches should be considered. Waiting or “benign neglect” puts the responsibility on the rest of the world to induce change in the person, while we wait to accept them back. There needs to be a better way.  We have to start by understanding the worst possible outcome, but not accepting that as inevitable.


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