64,000 and counting


The numbers are in for 2016, and they are not good. According to the National Center for Health Statistics, Centers for Disease Control and Prevention, drug-related overdoses in the United States reached their highest level. What’s more, the rate of drug overdose deaths for people under the age of 50 is occurring at a faster rate than HIV at its peak. Given the rise of fentanyluse and easy access to heroin, the number of deaths from opioids is likely to climb for this year. The New York Times published a revised breakdown of data related to the opioid epidemic. Equally as troubling with the numbers is the news that prescription opioid-related deaths have leveled off, while cocaine and methamphetamine have reared their ugly heads as contributing factors in the surge of fatalities.

So far, the recommendations made by the newly formed Commission on Combating Drug  Addiction and the Opioid Crisis appear to be unoriginal and vague. The effort to have real mental health parity in the treatment of mental health and substance abuse disorders has been echoed for decades to no avail. While the commission encourages easier access to opioid replacements (“MAT”) such as subutex  , there is a greater need to understand and analyze the reason drug use is on the rise across various socio-economic, cultural and racial groups. The epidemic has not and is not affecting just white suburbanites, inner city minorities and Appalachia. In fact, the three states that saw the highest increase in opioid-related deaths were Delaware, Florida and Maryland.

State legislators have begun to implement prescription drug monitoring programs to detect the rate patients have been prescribed pain medication. However, this system regulates the patient, not the doctor. It is widely known that doctors (see pill mill crisis of 2011) routinely overprescribe, but 300 million prescriptions for pain medication were written in 2015. The commission does discuss the need for more screening tools to assess addiction and pain, but tools already exist.

One place to look for a new solution is the state of Ohio, where new rules for prescribing opioids caps doctors at dispensing a maximum of 7-day prescriptions for adults in chronic pain. Additionally, the state will require diagnostic codes on all prescriptions for pain medications beginning in December.

As I have written about in the past, practioners on all levels who work in medicine, psychology, addiction and the like, must look at the rise of addiction from a multi-disciplinarinary approach. The guidelines and suggestions handed out by the commission focus primarily on reactive measures. Those on the front line of treating the epidemic must return to analyzing family structure, mental health pathology, performance in school and other societal factors that are being sidelined as explanations for the explosion in opioid-related disorders and subsequent fatalities.


Dismissing Freud 2.0


It happens every few years: historians, psychologists, journalists and investigators find “new” material to dismiss and discredit the work of Sigmund Freud. Since his passing in 1939, the man, who is often mythologized, has undergone numerous character assassinations. Many have said his work is both unscientific and offensive, while others have labeled him a racist and a sexist. Most recently, his work and its lack of empirical research, has been cause (somewhat fairly) for concern about the effectiveness of psychoanalysis. In his new book, the British author and critic Frederick Crews continues his take down of the late Freud. The book, “The Making of an Illusion,”  focuses on Freud’s shortcomings as a man and a professional, and rails against a form of treatment that created a “cult of personality” in the late 19th and early 20th centuries.

Freud’s most notable dissenters have spent years rejecting his theories on penis envy, the Oedipus Complex and the core concept of the sexual drive inherent in all humans. His experimentation with cocaine has poured into mainstream culture. But the main problem with dismissing Freud outright is the lack of understanding of the value of psychoanalysis. At its core, psychoanalysis is a talking cure (coined by Josef Breur in 1895). Patients are able to therapeutically process emotion, content, disturbances and conflicts. The contemporary relational psychoanalyst Susie Orbach said “Psychoanalysis is the study of human subjectivity. It is a clinical practice. It theorises the vicissitudes of human attachment, of the psychological development of mind and body that occur within a relational, cultural field.” She is correct. Furthermore, psychoanalysis proper is rarely practiced today because of the “need” for brief, concrete and managed mental health treatment.

Swept up in the Freudian revisionism is a more common problem, which is the dismissal of the magnitude his ideas have had on the field of psychology for 100 years. Freud’s groundbreaking understanding of transference and countertransference, along with his working model of the mind, are still understood and used today. Psychiatric assessments refer to “attitude toward writer,” which can be linked to a patient’s transferential projection onto the therapist. Because of Freud, we now understand the omnipotence of defense mechanisms and the unconscious motives of our drives.

Freud normalized sexuality for men and women. The ability to relate sexuality to early childhood experiences is a sensitive issue, but one that needs exploration in the therapeutic setting. Today, we have a greater appreciation for attachment theory, psychosocial development and the ego because of Sigmund Freud. The problem with the argument that Freud’s work was not empirical rests on the idea that therapy is strictly a science. Cognitive behavioral approaches, along with other standardized modalities are ubiquitous, but their long-term efficacy remains unknown. Behavioral interventions negate defense mechanisms, unconscious conflicts, inhibition, drive and attachment.

The mind is still a largely unknown construct. Psychoanalysis has allowed therapists, physicians and lay people to inch closer to understanding its processes. Replacing this with psychopharmacology and shallow methodologies of treatment that rely on labels and symptoms fails to grasp the rewards of the subjective therapeutic experience.


Homeless and stuck


Barcelona_Homeless_by_Nicolas_R  When we talk about psychoanalytic theory, especially developmental theory, it is often assumed that it is not practical or relatable to every day life. How many people say that one is stuck in the oedipal or the anal stage of development? My guess is nobody, analysts included. But the more one works in the field of psychology, counseling and psychotherapy, it becomes clear that people are in fact “stuck” at times in various developmental phases. Dependent people often represent oral phase characteristics, while those struggling to connect with a boyfriend or girlfriend might be caught in Erikson’s intimacy vs. isolation.

One group of individuals who, generally speaking, become stuck is homeless men in recovery from drugs and alcohol. As I have observed, many homeless individuals (I can only speak about men) yearn for independence, but are often unable to fully break away from their past, from the government and from their own self-imposed barriers (many times, this is resistance). What comes to mind is Mahler’s separation-individuation phase, in which the child tests his or her environment on the quest for autonomy, and periodically touches base with the mother for confirmation of safety and security. What happens many times with the homeless population is an outright desire to be free from shelters, free from mandated treatment and free from curfews. However, many do try to strike out on their own, but do not have the tools nor the ego strength needed to truly be independent.

The lack of independence goes far beyond life skills and coping strategies. The inability to become independent is the result of a long-term process of years of enmeshed relationships, poor or non-existent attachments to a care giver and  dependence on others, mainly the government and substance abuse programs who have provided cover and a safety net. The abuse of  supplemental security income (SSI) and social security disability (SSD) payment provide a reprieve from work and an unintended consequence of denial of autonomy. While the monthly income is little, there still becomes a sense of being taken care of. This attitude is harmful to a group of individuals  need help becoming independent. In addition, some patients in recovery also develop an attitude of entitlement.  Patients often expect me to provide tasks for them at the snap of a finger. When I try to explain my role as a therapist, I am quickly silenced and cast in a light of an oppressor or disciplinarian. In reality, I am encouraging patients to fill out their own paperwork, visit the library and begin to make decisions on their own.

Those of us who provide psychological services to an undeserved and often times misunderstood group of individuals need to understand the significance and symbolic representation of government-assisted programs. While they provide concrete relief for many, they restrict psychological individuation. Reenactments of dependence create transferential relationships of being misunderstood, abandoned and reprimanded. We often fail to understand our patients’ need for proper boundaries and facilitation of taking one’s own life into his hands.

Treatment centers for substance abusers can provide too much comfort, in that patients are at times encouraged to forgo a balanced approach to recovery that focuses on work, therapy and skills-building in favor of mastering one’s own sobriety. A more integrated approach needs to occur.

I am not advocating for the shutdown of government-assisted programs. I am simply shining a light on their impact on a vulnerable population that is often overlooked by policy-makers and providers.