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Psychiatry and Society
by Keith Russell Ablow, M.D.
April 1996

A Necessary Evil

My patient was a haggard man, near 50, who had used heroin for decades. His lucrative business career was a distant memory. Home was a single room. He was referred to me for treatment after his 19th hospital admission for detoxification.

"Should I have any hope you'll be able to stay off drugs?" I asked him skeptically.

"I'm through with it," he deadpanned.

"Why?" I persisted. "What's changed?"

"My father dropped dead," he answered immediately. "The bastard beat the hell out of me when I was a kid. I needed the junk while he was on the planet. Nothing else worked to keep my anger under control, keep me from killing him or killing myself. Not Prozac or anxiety pills or therapy. Nothing but heroin helped me. Now that he's gone I don't need that anymore, either."

"Heroin nearly destroyed you," I said. "You're saying it was necessary?"

"A necessary evil," he responded.

I suspected my patient of self-deception. He was fooling himself, I theorized, into thinking he had chosen his addiction, refusing to acknowledge that he had lost control of his life. I worried he still lacked the psychological strength to maintain his sobriety.

As months went by without his picking up drugs, however, I began to wonder whether he might have been telling me the truth: Only heroin had been an effective enough balm for him to bear his pain while his abusive father was alive. Now, with his father dead, he could manage his anger more easily.

Should every addict stop using drugs or are there some few individuals who would actually be worse off--whether suicidal, homicidal, more profoundly depressed or, even, psychotic--without access to their mind-altering substances?

Certainly, a more desirable way to cope with psychiatric symptoms is through therapy, spirituality, prescribed medication or some combination of the three. Working with an empathic professional, for example, can identify the true sources of one's distress and relieve the compulsion to "drown one's sorrows." Antidepressants and nonaddictive antianxiety agents can speed the healing process.

Not everyone, however, can be reached by psychotherapy or 12-step groups, or sufficiently helped by psychiatric medications. When people revert to alcohol or illicit drugs, are they sometimes making rational decisions to medicate themselves? Absent these substances, might they succumb to more serious psychiatric disorders?

Perhaps the reason it sometimes takes patients dozens of detoxes to actually achieve sobriety is that a drug-free life is, until that point, simply unbearable to them. And if the stress they face without their drugs of choice is that severe, might it also, even on occasion, be ill-advised to go without them?

A teenager I treated a few years ago admitted she smoked marijuana daily to cope with her parents' violent confrontations with one another and their emotional cruelty toward her. I advised her at that time that her drug use might leave her vulnerable to psychiatric illness, including paranoia.

"If I don't use it, I'm vulnerable to burning down my house," she half-joked. "I have one more year in that hell hole, then I'm out and off to school. I'm staying high until then, period."

When patients like this teenager refuse to attempt sobriety, there is no way to enforce it. And even if we could make her face her family life substance-free, no one can say with complete certainty whether abstinence would enhance her long-term stability or diminish it.

My instincts and training tell me that almost everyone stands a better chance of achieving or maintaining mental health without extensive use of alcohol or drugs. But my feelings about the matter are not facts. In siding automatically and uniformly with a drug-free lifestyle for every patient, psychiatry is advancing popular social doctrine without a proven scientific rationale.

American medicine counsels that all alcoholics should stop drinking and that all addicts should get off illicit drugs, at any cost. American law seeks to punish those addicts who choose otherwise. We assume that those who don't give up their dependencies are harming themselves. In some severe cases, however, we should admit that we don't really know.

Keith Russell Ablow, M.D., born in Marblehead, Massachusetts in 1961, is a psychiatrist, author and journalist. Dr. Ablow graduated from Brown University, the Johns Hopkins School of Medicine and the Tufts/New England Medical Center with a Residency in Psychiatry.