Many of the stereotypes that we hold as a society are not always accurate. Castigating our friends who are suffering from mental illness with the notion that it is because they are not pious enough only pushes them further away and makes them more vulnerable to the allure of illegal substances. Prior to becoming a psychiatrist, I had a negative attitude towards substance abusers.
Clinical Vignette:
“Khalid (not real name) is a 22 year old male of mixed Lebanese-Pakistani descent of Professional Muslim parents who both met each other while in medical school in the United States. Despite both parents coming from Muslim backgrounds and both being Sayeds, their union was viewed in mixed terms by their respective culturally-sensitive grandparents. Despite this untoward start, both parents tried as hard as possible to provide Khalid and his younger sister as much love as possible. Khalid attended a prestigious private high school, and the family was very involved in the local Muslim community in which Khalid’s father was on the Board of Directors. Khalid considered himself a Muslim, but while in high school he began to question his faith, as he had a difficult time coming to terms with some of the contradictions he observed among the families at the mosque he attended. In addition, Khalid’s peer group at school often engaged in practices that were not consistent with the values that he learned at home and at the Sunday school Madressa he attended and enjoyed. Desperately wanting to fit in the “status quo” and embarrassed by the stereotypes that Muslims face and the general condition of the international Ummah, Khalid began to subconsciously isolate himself from his practicing Muslim friends and began to identify more with his non- religious friends regardless of denomination. Khalid stated that in itself this was not a bad thing, but what compounded Khalid’s struggle was that he always suffered from anxiety attacks and social phobia. These attacks became more prominent while in high school and further led to his isolation. While at a party at the age of 15, Khalid had his first alcoholic drink. At first he was shamed by this action when he thought of the reaction that his parents and elders would have, but he blocked these feelings out. He continued to “hang out” with this crowd, and the drinking increased, eventually leading to marijuana and cocaine use. Despite this growing problem, Khalid still maintained stellar grades and was able to secure admission to a very prestigious university on the opposite coast of where he lived. In fact, he swore that his usage helped him, because it allowed him to focus longer and helped with his anxiety. While at university and thousands of miles away from his family and support system, Khalid’s addiction went unabated. The stress of university and dream of becoming a physician in order to please his parents became too powerful for him to overcome. He completely abandoned his spirituality, and he became dependent on drugs. At this point, the drugs were no longer helpful but rather his new “religion”. After getting expelled from school, suffering from failing health, getting arrested, and suffering from polysubstance dependence, Khalid at the age of twenty two feels that he has hit rock bottom and wants to salvage his life before he dies. He is asking for help.”
Discussion:
The above fictional vignette illustrates a problem that is evident within our Ummah. Personally, treating patients with substance abuse disorders is one of the most challenging problems that I encounter in my practice. Unfortunately, relapse is a part of the cure, and such patients – in spite of going to numerous rehabs and having many arrest – will have many “slip ups” prior to stopping completely (if there are lucky to survive). The sad reality is that no one intends to become a “junky”, and often times the substance abuser is the last person to realize the extent of their problems. (The Holy Qur’an, Surat An- Naas, verse 1-4: “Say: I seek refuge in the Lord of mankind, the King of mankind, the God of mankind, From the evil of the sneaking whisperer.”)
I have often found that people who fall into the web of substance abuse were led to this by a multitude of factors. In this case, one thing that comes to mind is that prior to engaging in illegal substances, Khalid had a psychiatric disorder, i.e. anxiety and social phobia. Adolescences is a very difficult time, and suffering from a mental disorder can compound the struggles that adolescents already face. It is imperative to have a community that is sophisticated enough to recognize some of the sequels of mental illness and refer these adolescents to the proper professionals before actions are taken into their own hands by self-medicating with illegal drugs. The reality is that people who suffer from bipolar disorder, schizophrenia, anxiety disorders, personality disorders, and other mental illness have an increased risk of eventually developing substance abuse. In addition, suffering from the aforementioned disorders is not a sign of poor faith but rather documented biological and chemical problems within the brain. Insha’Allah, as science becomes more advanced, this reality will be more evident to the masses.
Many of the stereotypes that we hold as a society are not always accurate. Castigating our friends who are suffering from mental illness with the notion that it is because they are not pious enough only pushes them further away and makes them more vulnerable to the allure of illegal substances. Prior to becoming a psychiatrist, I had a negative attitude towards substance abusers. I remember as a family doctor working in the ER all the Fitna that alcoholics and other abusers would bring. I started to see substance abuse as a sickness that can be cured after working with substance abusers and listening to their stories and sharing with their successes. I realized that things are not always so cut and dry, and many of those who were addicted had genetic predispositions. Their illness could have been prevented if they had chosen or been afforded treatment prior to the addiction becoming out of control. I also realized that if a person still has breath, sobriety is possible!
In retrospect, my initial apprehension towards those who are addicted to illegal drugs could be attributed to society’s general discomfort with the stigma of mental illness. The prejudice that those who suffer from mental illness face reminds me of the prejudice that people use to have about cancer, a prejudice that is born out of fear. A person can run away from mental illness, but mental illness will not run away from you. So it is better in the long run to confront this problem from the onset, before it becomes too big. Also, try not to have an arrogant attitude when it comes to substance abusers. For example, just because something is legal does not mean that it is not harmful and addictive. People can be addicted to caffeine, cigarettes, and food! So many of us are walking around with addictions and do not even realize the fact!
Another important aspect of this fictional vignette is the importance of internalizing spirituality. Allah says in Surat al-Ankaboot, verse 2 “Do (people) think that they will be left alone on saying, We believe, and not be tried?” To be tested is the reality of life, and sometimes we may not even be aware of when we are being tested. Hence, having a strong spiritual core will help during times of vulnerability. But, it helps to have a community that will enable one to develop this spiritual core. In the book Child and Adolescent Psychiatry – The Essentials by Dr. Keith Cheng, the protective factors against substance use disorder are described as
- Strong family attachments.
- Clear parental rules about behavior within the family and in the community.
- Active parental involvement in the lives of their children.
- Active parental monitoring of behavior.
- Academic success.
- Internalization of societal norms against drug use.
Whereas the essential risk factors for substance use disorders according to Dr. Cheng are
- Chaotic home environment.
- Parental substance abuse.
- Parental mental illness.
- Ineffective parenting.
- Lack of parental involvement.
- Failing school performance.
- Poor social coping skills.
- Association with conduct-disordered peers.
- Perceived parental/peer/community approval of drug use.
The best way to avoid substance abuse is abstinence, plain and simple. Many people who are addicted to crack cocaine report that it just took one time to develop a lifetime of pain and suffering for themselves and their loved ones. In our society, many people will try to minimize marijuana use, but I have treated people who became psychotic after smoking a single blunt. Many times marijuana is mixed with other drugs such as PCP, and the user can never be sure what is in the joint. The most effective form of rehabilitation from substance abuse is AA (Alcoholic Anonymous), which in itself is a very spiritual form of treatment. In AA, participants are told to believe in a higher power, and each person is assigned to a member who has been sober for a significant portion of time. This person serves as a mentor for the recovering addict. I truly appreciate AA and other similar groups (like Narcotics Anonymous and Cocaine Anonymous), because they offer 24 hour, 7 day a week support for the recovering addict.
In addition to AA, other forms of treatment for the recovering addict would be CBT (cognitive behavioral therapy) and Motivational Enhancement. CBT works under the premise that we have automatic thoughts that are self defeating. The person in CBT treatment will learn skills to dispute these thoughts. Of course, after addressing the substance abuse problem, then one can begin to treat the underlying psychiatric problem that led to the abuser’s vulnerability. In addition, there is a whole host of modalities that can be used to treat the recovering addict.
Remember, substance abuse is a major problem that adversely affects our society, and it will take a community to end this scourge.
The author is an attending psychiatrist and a clinical instructor in psychiatry at Harvard Medical School.
