Episode 22 – Involuntary Commitment
Dr. Ashish Bhatt ❘
Involuntary or civil commitment can be used when patients present as a danger to themselves or others. Dr. Bhatt, MD explains what this means.
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Hayley: Hi everyone. This is Hayley and you’re listening to Straight Talk With The Doc: a podcast on addiction, mental health, and treatment. We look into topics on all things addiction and recovery related and get some expert insight from our medical director Dr. Bhatt. We are also joined today by our content director Jeff. How are the two of you doing today?
Dr. Bhatt: Doing well, Hayley, how are you guys?
Jeff: I’m doing good. It’s a really nice day.
Hayley: Good, I’m glad to hear it. If you or anyone you know has ever struggled with substance abuse, you probably know all about the high possibility of relapse. According to a study from the journal of the American Medical Association, between 40 and 60 percent of people who’ve gone to treatment relapse within the first year. For a lot of people relapse is just a part of the process of recovery, but I’m sure that doesn’t make it any less frustrating. Dr. Bhatt, from your experience of working in addiction medicine, why is relapse so common that first year?
Dr. Bhatt: Addiction such a behaviorally, psychologically, and physically mediated illness that once somebody leaves treatment or enters early recovery the variables and the context in which the addiction existed often hasn’t been tested yet. And these have been influences, triggers, to why someone used in the first place. When addiction doesn’t exist in a vacuum, it exists in relationship with many other things in one’s life and it’s important that those things get tested in a gradual manner. Being that addiction is such a powerful thing and it is something that affects so many domains of someone’s life. It takes practice. It takes reconditioning, learning new habits, being around new persons, places, things, and situations, and then unfortunately that takes time to master. And those influences are there when somebody reenters society and reenters their life. Being that those risk factors have such a tremendous influence on somebody, we often will see this illness re-emerge. And unfortunately, when it comes to addiction you talk about 40 to 60 percent, those numbers actually vary even more than that. Those depending on the substance of abuse, the time into recovery, the co-occurring issues somebody might have, we have seen numbers as high as 90 percent. Because by definition, addiction is a disease of chronicity and incorporates, unfortunately, relapse. That doesn’t necessarily mean it has to have relapse and people have to start using again, but the nature of the disease is that difficult that we do see people use again.
Hayley: I know it depends on the individual and their history, but how many relapses would be considered normal? Is it one, five, ten? Is there a normal?
Dr. Bhatt: I would probably stay away from using the word normal or abnormal. We have seen the studies. We’ve seen the research. We see the fact that people who suffer with addiction have high rates of using again, but we see the similar rates in other chronic diseases where the disease symptomatology reoccurs and relapses. I wouldn’t identify a number that can somewhat bias an individual. It can somewhat look as a predestination. We have individuals that relapse multiple times and we have people that enter sobriety, achieve recovery, and don’t use any substances again for the rest of their lives. I would not identify a number to the relapse for any individual.
Hayley: Is it more likely to happen within a certain time frame from leaving rehab? Is it more likely within 2 days, 2 weeks, or can it be much longer than that?
Dr. Bhatt: I think if you talk to many people in the recovery community, relapse can occur at any time. Often times, any habit, any practice, anything that we do- the longer you do something, the more you solidify it. When you achieve recovering, we hope that you gain mastery as you go along. The earlier time when you are first embarking on your recovery journey, that’s often a vulnerable time because you haven’t had an opportunity yet to manipulate all of the variables that you will come across in your life. Most people would say the early time in recovery is often a difficult one, but I don’t want to minimize the fact that when it comes to staying vigilant. That has to last a lifetime.
Hayley: I’d like to talk about the factors that influence rates of relapse, including certain substances. Do certain substances have higher relapse rates than others?
Dr. Bhatt: The physically dependency causing drugs are often more difficult to stay in remission longer. These individuals who end up having pretty significant painful withdrawal tend to have a more difficult time staying abstinent. These are often the opiate drugs, alcohol, sedatives, they cause pretty significant physical withdrawal symptoms, and thus makes it harder to stay away from. But then also, you asked other variables. We look at the context in which addiction exists and that is the environment, the person, places, things and situations. And if somebody who has been using around certain people, are back around those people becomes very difficult to stay abstinent. People, places, and things and situations all connect these triggers to using again. It’s important that this is incorporated in someone’s recovery plan in what context they use and try and anticipate those when trying to maintain long-term sobriety.
Hayley: Does also having a mental health disorder impact someone’s risk of relapse?
Dr. Bhatt: Well having a mental health disorder in itself is a risk factor for developing addiction, so, for sure. Your state of mind plays a huge part in why somebody uses a substance in the first place- being happy, being sad, being stressed. And if your mental health is something that was fragile or something that was the reason that you were using to escape from any psychological pain or distress, if that decompensates, if those symptoms reemerge, then definitely. That can be a huge risk factor for somebody pursuing substances again. When we look at developing a treatment plan, we encourage people to ensure that if there is an underlying mental health condition, that it be addressed through proper medication, therapies, support groups, anything that can help you feel better psychologically, so drug seeking behavior is less attractive. That’s definitely encouraged and should be incorporated.
Hayley: You mentioned triggers- people, places, things. But in your experience, can you give some examples of what are some of the most common triggers that cause people to relapse?
Dr. Bhatt: It’s funny. I could probably ask one hundred different people and they’d give me a hundred different scenarios. But those classes that you just mentioned, that we talked about. Of course, most people identify drug use with some sort of emotion. Emotion is a huge thing. If you get angry, if you get sad, if you feel depressed, well often those things were what psychologically we identified as a reason to use, or we habituated, accustomed, whatever word we want to use. They went hand in hand with substance use. When we first enter recovery or early sobriety, it’s important that the individual have learned during their treatment process, those relationships. I often suggest, it’s important, I kind of say identify A, B, C, and D to certain things in your life. For example, A could be recognizing who are those persons and places and things and situations that have been associated with B? B being thoughts. What are those thoughts that are related to those persons, places, things, and situations? And those thoughts being B, often leads to C. C being emotions- feelings. What are those feelings that are ultimately segueing to D? D being the actual drug using behavior. And the reason we highlight or encourage people to really dissect this is because this is happening in seconds or minutes in real life when we start using or resume using drugs, or use drugs in the first place. While in treatment, it’s important that we take the time to dissect that dynamic, that relationship. Because any one of those four main things, or three main things that lead to D, have an influence on that. And they don’t necessarily have to come in that order. If I talk to anybody who suffers with addictions, they’ll tell me well sometimes I got mad and it made me think badly about my family. And then when I felt badly about my family, I felt guilty. It’s a cycle. There’s a relationship, there’s an influence that one bares on another. The bottom line is there are so many different factors that are associated with it. You have to put that in context and dissect them. Because for each individual, like I said at the beginning, they all could come up with their own unique examples of why they use. And it’s important that we do our best to identify them. So we can anticipate them and incorporate healthy alternative behaviors, coping mechanisms, aside from the drug use to help deal with those A, B, and C’s once we’re not using illicit substances.
Hayley: For those who might be listening who may just be starting their journey towards recovery, are they more likely to relapse if they try to get sober on their own versus going to treatment and getting professional help?
Dr. Bhatt: We spoke about in previous episodes that addiction is not a disease that just affects one person. It affects the person using and then everybody and everything in that person’s life. And it’s important that that be addressed in its entirety. Many people who do try to stop who often are not successful is because the only thing that they can possibly influence is themselves. But when there’s so many other things going on around them, it becomes very, very hard, especially when we’re under the influence of a mind-altering substance. Professional help is sought out to help provide that framework, help enter an environment that is free of those external variables that are often associated or influenced on substance use, and give that person a roadmap, so to speak, to help get back on track. The short answer is treatment is there and it exists and shows really good outcomes when somebody utilizes it and puts their best effort into it. It’s very hard to get an answer as to: well, what’s the numbers? Or what’s the ratio? Or how well do people who don’t seek treatment? Well we don’t know. It’s hard because that data isn’t necessarily being aggregated and available to everybody. The way to look at is that seeking is there for individuals that have tried and failed to get sober on their own. Or they see that their life is spiraling so quickly out of control that any further delay could cost them their life. Treatment is there. It should be utilized and it should be used as a tool to help address not just the individual but help as a roadmap to address other aspects in somebody’s life.
Hayley: Does relapse mean that treatment didn’t work?
Dr. Bhatt: It depends on who you’re talking to or how you look at it. I think historically when something, a disease or illness or symptom has been put into remission, in addition we say we’re in recovery. When the symptoms reoccur, we have relapsed. And that doesn’t mean the treatment failed, that just means that the disease can come back. But, the treatment could’ve initially put that addiction into remission. And put that addiction into what we call recovery where the active symptoms of usage no longer are present. That would be successful. But being that the nature of the disease of addiction is something that is chronic and relapse can occur, it doesn’t necessarily have a reflection of it being a poor treatment outcome versus it unfortunately being part of a chronic illness that needs to be maintained. And for many individuals, it is something that occurs on multiple- I don’t want to say on multiple levels, but it is maybe because they didn’t have an opportunity to address all of the issues that maybe were prior to treatment were not incorporated or thought about as being something that was part of why the used it in the first place. Many times people who do relapse, they end up saying, “Oh wait a minute. This is something that I didn’t recognize or didn’t see, or I didn’t know was a big part of why I used in the first place”. It’s a learning process being that there’s so many things that incorporate or are involved in why somebody uses. And it’s not necessarily a reflection of treatment failure, versus us just needing to master the multiple variables that are unfortunately involved in our lives. I wouldn’t look at it as a failure if somebody relapses, more of just a need to revisit, look at, and refine so we can get back on track.
Hayley: While we’re on the topic of treatment, does the length of stay in treatment have an impact on someone’s chances of relapse? Say comparing 30 days, 60 days, 90 days?
Dr. Bhatt: Well if we look at a habit, if we look at a behavior, the longer we do something, good or bad, often influences our ability to continue doing it. When somebody’s using drugs, is suffering with addiction, it often needs more time to unlearn, decondition, and remodel those behaviors. And I hate to compare this to homework or that we’ve done throughout our lives and learn in school. But the more we practice something the better we get at it. Similarly, when you go to treatment, it’s not just a surgery. Treatment incorporates multiple different things biologically, psychologically, socially. And that’s where we have an opportunity to actually practice living a life of sobriety. Why we have multiple levels of care in treatment setting when we’re treating addiction is because they all have a distinct purpose. For example, when we enter treatment and we go to detoxification. If we go to detoxify ourselves, this is the medical treatment to help us get through our withdrawal process with the least amount of discomfort while being supervised by medical professionals. That’s just one step. But then there’s the psychological or the social components of understanding why we used and how we used and with whom we used. And these are things that are addressed in different levels of care. The bottom line is these can only be accomplished if you stay in treatment and go through these steps. If people were able to do this on their own, most of the time they would’ve stopped on their own. The purpose of being in treatment and getting through these steps, and it usually takes time to do so, because they need to be in place in order to gain that mastery, in order to learn a new way of living substance free, and that takes time. The longer you do it, the longer you’re in treatment, the outcome often is better.
Hayley: I’d like to talk about a topic that might be a little hard to discuss. But is it considered relapse if you use a different drug than what you initially went to treatment for?
Dr. Bhatt: That can often be a philosophical question. Mainly, probably with what culture and what country you live in. In the United States we look at addiction being a very chronic, comprehensive disease that has to do with motivational hierarchy, cognitive distortions, alterations and neurochemistry, and associations between memory and emotions and multiple different facets of a human being’s mind, brain, body, and spirit. When the pursuit of a drug is often due to seeking an alternate emotion or feeling, we kind of pull those altogether. When somebody might be using alcohol to achieve an alternative state of mind, and then stops and we define them as having an alcohol use disorder. I don’t think most people who treat addiction will support that using marijuana, although that was not their drug of choice, is something that they should go ahead and do. Because this person has already struggled with difficulty with something that alters so substantially the way we feel and is associated with their motivations, their memory. It all works around a pleasure and reward circuitry in a similar way that many illicit substances do. Even though these drugs and alcohol may not all have the same pathway, ultimately, they’re often used for the same purpose, the same intention. And that’s why I think there’s a general consensus that if somebody’s addicted to one substance, it’s probably not a good idea to go out and use another one. Because the intention will ultimately unmask itself of using it in a maladaptive way. So yeah, using another substance is considered a relapse, or not a good judgement call. And it’s definitely not advised.
Hayley: Okay, it really does have to do with the intent. It’s not like using a prescription drug as you are supposed to be using it; it’s an intent to use a mind-altering substance.
Dr. Bhatt: And I think that’s like a segue here. We know that people are abusing prescription substances on the street; we know that. But then we know that there are people who are not using prescription medications for other purposes other than to treat what it was supposed to treat: their pain. I do believe the intention has a huge part of the definition of it, of addiction. And when we’re talking about somebody using one substance versus another, if the purpose is to get high, and the purpose is to alter one’s sense, and it relates to negative consequences, and it relates to hijacking of the brain, and there is an addiction that develops once the definition plays out. But I do believe intention has a lot to do with this and needs to really be considered when we’re talking about it. And of course taking a prescribed medication as indicated while under the supervision of a physician and not being abused in a way that it was not intended, does not meet that definition.
Hayley: I know after completing treatment, maybe someone’s struggling, the addicted mind is going to try to justify using that substance again. How can somebody prepare for these thoughts that are probably eventually going to happen? Is there anything they can do ahead of time to be ready to handle that when it happens?
Dr. Bhatt: Yeah, when I spoke about earlier, or maybe previously in another segment, that it’s important for us to in our mind, mentally almost roleplay and deconstruct the scenarios that we used in the first place. This often can be played out in cognitive behavioral therapy. And it really is about associating the variables that lead up to somebody using. Identifying those persons, places, things, and situations that have led to certain thoughts that often illicit certain emotions that lead to those behaviors. Because if you can somehow deconstruct that, you can hopefully head it off at the past when it’s happening in real life. And that can’t happen unless you’ve had an opportunity to explore it and slow that whole thing down. Because in real life, when you get into an argument with your loved one, you are angry with them and then you walk out that door and you get in your car. And then the liquor store is there, and you stop. That’s happening very quickly with a lot of flood of emotions, and often needed to be in retrospect. If you look back upon it and say, “Wait a minute, all these things have a link”. That this person and this situation led to this and that, and so, you need to look through that process. And that’s where treatment and therapy helps us deconstruct that chronology that leads up to substance use. A way that we can be successful is identifying those relationships and hopefully avoiding those triggers. Identifying what they are and find alternative courses for us to take when those situations arise. And that takes practice. And that happens as we go through treatment processes once we’ve met certain objectives and goals. That treatment often allows us an opportunity, depending on the level of care we’re at, to play this out under more supervised and structured environment. And I think that’s where people who look at addiction treatment need to see this whole construct. That there was a design. There is thought. There was intent that has been put into place for us to follow in order to try and have the most success once we leave treatment to stay abstinent from drugs. It’s truly about gaining as much mastery of the big picture, so we can anticipate those things that make us or lead us to wander and use drugs or alcohol. And try and create a better case scenario when we’re faced with those things in the future.
Hayley: I’d like to reiterate what you said earlier at the beginning of this episode, that relapse doesn’t mean that you failed in your recovery. The way that you react to that relapse can be an accomplishment and something to be proud of. You can find all sorts of resources on treatment and recovery at addictioncenter.com, as well as our other podcast episodes also on Spotify and Apple Podcasts. Thank you to everyone who has listened to another episode of Straight Talk With The Doc.
Dr. Ashish Bhatt
Dr. Ashish Bhatt, MD, MRO is an accomplished physician, addiction medicine specialist, and psychiatrist with over 20 years of medical and administrative leadership.