Recovery is an interesting term in mental health. The idealised version for people with mental illness is to rapidly return to their “normal” level of functioning shortly after entering treatment with their general practitioner, psychologist or psychiatrist. Unfortunately, recovery is not always clear-cut and people often aren’t sure what they will lose along the way.
Peter is a client that often comes to mind.
He is a 39-year-old man who works as an accountant in a small business. He has been married to Amara for 10 years and they have two children, nine-year-old Maya and seven-year-old James. Peter had been referred to my clinic by his GP for assistance with his alcohol and cocaine use, and low mood. This had caused significant marital problems and a recent police charge of driving under the influence and the loss of his licence for three months.
Despite heavy drinking for the past seven years, Peter presented for treatment because he was told by his employer to get on top of his alcohol problem or he would lose his job. Like many men I see in the clinic, Peter had been referred several times before, but only with the risk of losing his employment did he keep his appointment.
Peter starts by saying, “I don’t think I’m that bad. It’s just work and the wife that seem concerned by my drinking.” I assume that Peter is minimising his problems to appear better than he really is. I don’t challenge him directly, but opt to continue the session. I’ve been taught that rapport building is one of the more important parts of the first session. You can’t treat people if they don’t return.
During the assessment, Peter tells me that he is drinking two bottles of wine a night and blames this on financial stressors, arguments with his wife and difficulty connecting with his children. His alcohol intake only became a problem after the birth of his son. At the time, Amara was a stay-at-home mother and he was working overtime to make ends meet. The drinking was the starting point of several arguments with his wife, leading Peter to go out more with his friends, which escalated into weekly cocaine binges.
Peter is now sleeping in the living room and is vague on the reasons for this. I ask him if Amara is considering a separation and he denies this, saying: “I don’t think so. We’ve been married too long.” I make a mental note to consider a family meeting at a later stage of treatment. He concedes that the distance between his children and himself does make him sad and he is constantly apologising for being hungover or forgetting sporting activities.
At the end of the assessment, I recommend a hospital detox as a circuit breaker and a chance to initiate anti-craving treatment for his alcohol dependence. Peter is initially hesitant, but later agrees when I advise him that his employer would look favourably on this course of action, and it allows his wife and children to get to know him sober. He is admitted the next week and his withdrawals are managed with some diazepam and thiamine. Peter agrees to take naltrexone (anti-craving medication) to assist with remaining sober. To my relief, Peter is aiming to be completely abstinent from alcohol in the coming months as he sees controlled drinking as too risky for him.
This detox raises some concern when neither his wife, children or friends visit him during the hospital admission. This is sadly not uncommon, but for a man who is undergoing his first detox there tends to be more fanfare. Peter makes excuses for them which are later put into question when his wife sends me an email stating she has a restraining order against him. She also alludes to domestic violence. Ultimately, Amara says that Peter cannot return to the family home and will instead live with his parents. When this information is presented to Peter, he tells me he was already aware but was hoping this detox would get him back into Amara’s good graces.
In the last week of his detox, I observe that Peter has some signs of depression and I recommend antidepressants which he refuses, saying: “I think that’s too many pills.” We discuss therapy to assist with staying sober and interpersonal issues involving his wife and children. Peter worries that therapy will make his symptoms worse as it involves rehashing old wounds. He agrees to weekly group therapy as the compromise and further outpatient appointments when he is discharged into the care of his parents.
Detox is the first step in a difficult journey towards recovery. The next months are difficult for Peter. While engaged in weekly group therapy, he relapses during the court process of both the restraining order and the divorce. On his third detox admission, Peter decides to trial mirtazapine to assist with his poor sleep, fleeting suicidal thoughts and low mood. Fortunately, he has been able to improve the relationship with his children and they visit him in hospital, chaperoned by his parents. He agrees to begin individual therapy on discharge.
The following months are more positive. Peter can remain sober for longer periods of time and this helps at work and at home. He gains a promotion from work and moves into a small apartment with a spare room for his children to visit. Eventually, the restraining order is dropped and he is able to have a healthier relationship with his ex-wife. Two years have passed and Amara has found a new partner which causes Peter some discomfort, especially when his children comment on how well he treats them. Peter has been less successful romantically and finds dating apps constantly frustrating.
I recently reviewed Peter who has been sober for a year and his depressive symptoms are stable on medication. We talk about the challenges he has overcome in his journey to recovery. Peter tells me how lonely he is and explains that a good number of his friends were that of his ex-wife’s and he has been struggling to build his own support groups. He has his parents, children and a good job but hasn’t nurtured friendships over the years. We make some plans to work towards this in future sessions.
When Peter leaves my clinic, I can’t help but think that he is one of the loneliest people I know.
Recovery is rarely linear or tidy. The rule of thumb is the sooner you enter some form of treatment, the better the outcomes. With Peter’s case, we’ve seen substance abuse, detox, depression, divorce and relapse. But I hope people know that even though recovery can be lengthy and up and down, it’s still a worthwhile pursuit.
• Dr Xavier Mulenga is an addiction psychiatrist based in Sydney.
• Patient examples are not real people and are amalgamations of situations often seen by psychiatrists.
• In Australia, the crisis support service Lifeline is 13 11 14. If you or someone you know is impacted by sexual assault, family or domestic violence, call 1800RESPECT on 1800 737 732 or visit www.1800RESPECT.org.au. In an emergency, call 000. International helplines can be found via www.befrienders.org.
