By Caroline Ridout Stewart, MA, MSW, LCSW

homeless man on bench with bottle of liquor

This business of being a psychotherapist and the mother of an adult son with a co occurring disorder is not easy. My patients and I are slogging through cement all in an effort to move forward and to keep ourselves and our children alive. It is not easy because of a paucity of funds for clinically-informed treatment. It is not easy because of mass confusion and disagreement over the roots of the problem.

It is not easy because of HIPAA walls against family and clinical collaboration. It’s not easy because of non-availability of housing for those suffering from addictive illness. And, finally, it is not easy because of the bizarre Ayn Randian belief that human autonomy trumps the most elementary of basic human needs such as food, housing and health.

With regards to the paucity of funding for clinically-informed treatment, San Diego is a wasteland. Wealthy people, and I mean VERY wealthy individuals, can pay for more clinically-informed programs that now allow MAT (Medication Assisted Treatment such as Suboxone or Methadone) but the vast majority of programs for the middle class and blue collar contingent require the client to be “clean” and free of any mind-altering substances. Betty Ford now welcomes the use of MAT but your son or mine would be kicked to the curb were these treatments to be used. Some of these treatment programs even disallow their clients from using prescription antidepressant medication. This two-tier system allows for a higher level of clinical care informed by compassion for those with indiscriminate funds while promoting religious faith and will power for those less financially endowed. Sadly, along with faith, a misstep in such programs invites contempt and eviction. There is, I am told, some good news on the horizon for all California communities. Programs historically funded by MediCal will be mandated to permit MAT this coming July 1st. Let’s keep our fingers crossed.

The smoke literally comes through my ears on this next barrier to health for those with addictive illness. The opposing philosophical forces cannot, will not, get their acts together regarding the etiology of addictive illness. Some of you might have read my open letter to Gabor Mate (In the Realm of Hungry Ghosts) in the past. My letter thanked Dr. Mate for his general harm reductionist stance towards his clients yet expressed frustration with his reductionist view that “all addictive illness is trauma-informed.” Sadly, this view is now infusing every corner of treatment both in clinical and non-clinical settings. After thirty-five years working as a mental health clinician, I smell a rat. Trauma-informed therapy is a form of treatment modality once again blaming mothers or others for early emotional injury. First of all, there is no one explanation for addictive illness. It is a highly complex dance between brain biology, genetics, environmental influences (including trauma for some), social and cultural influences and nutrition. Over-focusing on trauma too often serves as a  combustive agent for blame and divisiveness. Not a day goes by that I do not receive some anguished call from a parent whose child desperately needs their shepherding, financial and problem-solving support yet who are being “fired” by their loved one because of a belief that the co-occurring disorder is entirely the outcome of adverse childhood events. Why the American love affair with rehashed Freudian arguments keeps emerging is beyond me.

Related to the too frequent painful estrangement between one suffering from addictive illness and his or her family is the barrier created by HIPAA mandates. The Health Insurance Portability and Accountability Act was, initially, designed to promote an integrated, holistic health record which, in turn, was hoped to promote more generic good health. In theory, this is a viable and worthy cause. Sadly, HIPAA puts gasoline on the fire of poor health, especially with regards to psychiatric and addictive illness, as authentically, caring and concerned parental shepherds are locked out of the process at every level. My son suffers from a severe learning disability that undermines his efforts to achieve long term recovery. While currently incarcerated, he is mandated to hand-write long personal letters to various treatment programs requesting entry into their program upon discharge from jail. Should our son be released to the streets with zero assistance or bridging support, he is at very high risk of re-using and, sadly, of returning to a life of homelessness and ultimate overdose. Alas, our son’s dysgraphia (profound difficulty with handwriting) and lack of computer knowledge places this mandate at risk of not being met without parental support. That being said, our son has historically blocked our parental engagement in any or all of his mental health or addiction treatment refusing to sign the essential ROI or Release of Information. Again, parents call me daily to literally weep over this gross thwarting of their strong desire to have a collaborative relationship with their child’s treatment providers.

Following a 911-PERT call two years ago, my husband and I were required by the police to file a restraining order against our son in lieu of the police jailing him for elder abuse. He had been living with us, going daily to a local Methadone clinic and was in an anxious, druginduced, agitated state the night that this happened. He subsequently was forced into homelessness which lasted 18 months until he was re-jailed for a dog bite during the theft of food from Vons. This 18 month period of homelessness brought our entire family to our knees. Our son became increasingly confused, emaciated, filthy and disorganized. We would drive by him on the street as we drove to work. One afternoon, I was having lunch in a side-walk café close to our home, and my son walked by and greeted me. He was dying…. He was dying of poor health, poor hygiene, aimlessness, anomie and despair and, yes, of addictive illness. The current societal answer to chronic addictive illness is shame and blame-informed homelessness. Might our son have avoided a very expensive year in jail and the loss of his family, had the PERT team assisted him that very night into treatment with subsequent housing and ongoing care? Housing First must be our cry!

In conclusion, what is truly destroying all of us is the ill-informed, antisocial view that individual human drive and goal-directedness, are all that is required for human happiness and success (Ayn Rand: Atlas Shrugged). Designing interventions for those suffering with addictive illness on the basis of the Randian belief in the so-called “self-actualized” man is a pathway to failure. Human beings are hard-wired primates who need social supports, mirroring and shepherding. Economic and social philosophies that purport to understand the roots of human suffering as based upon poor choices and laziness and which block necessary collaboration between the client, the providers and family must be seen as anathema to a harm reductionist belief system.

Caroline Ridout Stewart recently retired from the UCSD Department of Psychiatry where she was a Clinical Instructor and Psychotherapist for over twenty years specializing in the treatment of anxiety and addictive illness. Caroline continues to be a harm reduction provider in her private practice where she enjoys working with those struggling with opioid misuse. She is the mother of a son who suffers from a co-occurring disorder and leads the local NAMI Co-Occurring Support Group for Family Members whose children suffer from both mental and addictive illness. Caroline has been the President of the board of A New PATH (Parents for Addiction Treatment and Healing) for 17 years promoting community Naloxone distribution. She is an artist and essayist.