Common Obstacles for Entering Treatment
A substance addiction affects its victims on every conceivable level, from the depths of their psyche to the world around them. Treating the addiction requires wholesale changes to the patient’s lifestyle, and some of those changes are difficult to implement. The most common obstacles for entering treatment can span from the psychological damage carried out by the addiction to the socioeconomic and environmental factors that contributed to the addiction taking hold in the first place.
Why Some Refuse Treatment
An addiction purports to fill a hole in a person’s life, whether that hole is a need for excitement, emotional comfort, pain alleviation, peer acceptance, or anything else for which the patient’s unconscious mind wants.
Because an addiction takes hold at such a deep level, it dodges every attempt to pry it out. The various ways it twists and turns explains why some patients are so resistant to the idea of seeking treatment. Some patients might even deny that they have a problem at all.
The basic concept of denial is the refusal to admit the reality of a situation. In terms of psychology, denial is a defense mechanism: patients subconsciously reject facts from the awareness they have about themselves (or the world around them), because those facts make them intrinsically uncomfortable. To accept the reality of those facts would mean to accept very critical truths about their sense of identity, what they think of themselves, and the image they want to project to those around them. If the truth hits too close to home, the mind finds different ways of covering itself.
While a certain amount of denial can be beneficial (for example, to deal with everyday aggravations), The New York Times explains that the penchant for always looking the other way can be potentially destructive. If denial is a spectrum, a lot of people find themselves on the benign end, the one that allows them to be social and amicable even when things disturb them. On the other hand, people dealing with a substance abuse problem find themselves on the unhealthy end of the spectrum, the one that willfully blinds them to problems and situations that threaten their well-being.
What makes denial a pitfall for the addicted patient is that it does not work as a long term strategy. It may help assuage some of the guilt of stealing money to buy drugs, or it can temporarily put a concerned family off the scent, but “reality always wins,” warns Psychology Today. Once the denial breaks down, when the patient can no longer refuse to acknowledge that they have a problem, the finger of blame always points outwards. They may blame their spouse for not supporting them enough, their job for stressing them out too much, their friends for not looking out for them, or any target they can find to escape the hurdle of submitting to treatment and acknowledging that the problem starts and stops with them.
Denial and Deception
There is an important distinction to make between denial and lying. While some patients actively and willfully deceive others and themselves about their problems, patients who are in denial about their substance abuse are incapable of seeing that the drugs and alcohol they are consuming are what is causing the problems (and therefore resist the idea of seeking professional treatment, because they cannot comprehend how their substance abuse is part of the trouble).
To that effect, they earnestly deflect all criticism and concern away from themselves or their drug/alcohol habit, and towards external factors that they claim threaten their sense of self. They may blame their job (or lack thereof), their family, their boring life, their upbringing, or anything their addicted mind can fasten onto, to avoid confronting the reality of the substance abuse and evading treatment that will ultimately squeeze it out.
Denial can be countered: a “drink journal” can show the addict irrefutable proof that they drink far more than they should; hearing about other drinkers who were in similar stages of denial can help them recognize the unhealthy patterns of their behavior; and reading information written by psychologists and experts about how denial works can unlock some of the doors that the patient has erected in his mind.
Ultimately, the biggest steps of recovery will happen within the walls of a rehabilitation center, but untying the knots of denial (even if one step at a time) is key for gradually moving the patient toward accepting the need for treatment.
Another reason denial can come so easily is because some drinkers do not display the usual signs of an addiction. They drink to dangerous amounts, but they are still able to maintain successful work and family lives. These “high-functioning alcoholics” can reject the assertion of alcoholism (and the requests that they seek treatment) with seeming impunity, pointing at the lack of alcohol-related problems in their lives. They may argue that they deserve to drink or take drugs, because of the effort it takes to balance professional and personal obligations, and therefore do not require treatment (perhaps contrasting themselves to other substance abusers, whose personal and professional failings are a clear sign that treatment is required).
However, notwithstanding the juggling act that high-functioning addicts are able to do, they are nonetheless willfully or unwittingly blinding themselves to the issues that still exist:
- They still drink to deal with stress.
- They still drink as a habit.
- They are rarely, if ever, content with a moderate amount of alcohol.
- They (strongly) refute any suggestion that they drink too much and that they should seek help for their drinking.
In addition to these signs, a high-functioning alcoholic is at grave risk for doing considerable damage to their bodies with all the unhealthy drinking in which they partake. Even if their responsibilities are not significantly impacted by the drinking, they cannot stop the liver disease that comes from chronic alcohol abuse.
The danger facing these addicts is that their refusal to acknowledge the need for seeking treatment pushes the stakes even higher. A user or a drinker who sees the problem and checks into a treatment facility is doing damage control; a user or a drinker who doesn’t see a problem with her behavior, does not consider treatment, and continues with her behavior, sets herself up for death and disaster by continuing to poison herself, and the world around her, with her substance abuse. In an interview with The Fix, the author of Understanding the High-Functioning Alcoholic: Breaking the Cycle and Finding Hope explains that it is impossible to avoid serious trouble while drinking heavily.
Entering Treatment and Losing Face
Sometimes, the denial falls along the lines of certain common characteristics shared by groups of patients. In professional football, for example, athletes are encouraged to “be a player, not a patient.” While the context there is primarily about football players not reporting injuries for fear of losing games (and then taking painkillers in what the Washington Post called “a culture of prescription drug use and abuse”), it points to a larger picture of people in particular positions of power, fame, or status refusing to seek help for a substance abuse problem because they are afraid of losing face.
Some walks of life do not allow for any sign of weakness, where admitting a problem and seeking help for it is tantamount to a resignation. A clinical psychologist tells Fortune magazine that alcohol is an expected and encouraged part of the CEO lifestyle, so much so that the idea of getting therapy for a drinking problem, and then being expected to abstain from drinking thereafter, becomes a part of the barrier to treatment.
Another barrier is getting driven, ambitious, and powerful people (men, in this case) to open up about their feelings, their innermost thoughts, their turbulent childhoods, their fears, and their anxieties.
Male-Oriented Obstacles to Entering Treatment
Traditional gender roles like that may also go a long way in explaining why some addicts refuse to enter treatment. Men are (still) expected to be the “strong, silent type,” the man who does not look outside for help but instead solves problems on his own. A substance abuse problem may play into that psyche, alienating a man from concerned friends and family members who (from his compromised perspective) are belittling and insulting his masculinity by suggesting that he get treatment for his drinking or drug use.
Live Science explains that men externalize their emotions, focusing more on outward stressors as the cause for their problems. When men feel threatened, they tend to react aggressively (angrily rejecting the idea of seeking treatment) or impulsively (drinking and using drugs more). The chief medical officer of the Hazelden Betty Ford Foundation explained in the Forbes magazine article above that people with addictions have an easier time recognizing the problems in others (external stressors) than they do in their own lives. A man who fits this pattern will sooner find fault with the people trying to help him than accept the necessity of seeking treatment for himself.
Women and Obstacles to Entering Treatment
By comparison, women frequently internalize their emotions. In this case, the focus is turned inwards; the more women think about their problems, the more likely they are to shoulder the burden (instead of finding an external target). The result is that women tend to have higher rates of depression and anxiety than men, who push against their problems.
This, in turn, may dissuade some women for entering treatment for their substance abuse problems. > According to the National Institute on Alcohol Abuse and Alcoholism, women have multiple barriers to seeking help, and they are therefore much less likely to admit themselves to treatment.
Historically, alcoholism was rarely (if ever) considered to be something that affected women (women in treatment programs were a “rare sight,” in the words of a Stanford Medicine blog.) The truth, however, is that addiction affects women in different, and sometimes subtle, ways. The American Bar Association quotes the Alcohol and Drug Problems Association of North America as saying that even though women account for 40 percent of all alcoholics, only 25 percent of alcoholics who receive treatment are women.
The reasons for this are many but primarily fall along the fact that women are subjected to more socioeconomic factors than men. Women have more economic barriers that prevent them from seeking treatment. They are less likely to have the time to commit to regular treatment sessions (because of family obligations), and women tend to have less autonomy over their transportation than men.
Notwithstanding the various factors affecting each gender, both men and women have to overcome associated stigmas with accessing treatment; women, however, are particularly susceptible to stigma. More than men, women report feeling ashamed or embarrassed at having to get help for an addiction. The journal of Alcohol and Alcoholism explains that women feel social attitudes toward women who drink are more negative than the attitudes towards men who drink. Judgments are harsher, and younger women who drink report familial and social rejection for their drinking. Mothers who drink were also held in more critical regard than fathers who drink.
The National Institute for Alcohol Abuse and Alcoholism lists other barriers that women face when they want help for drinking or drugs (compared to men): they are young, do not have much education, and are usually low-income. Research has shown that women are more likely to be hostile upon entering treatment than men, and that the presence or concern of children in the woman’s life may also impede her entry into a treatment program.
In summary, the NIAA concludes that women face enough obstacles to make them less likely to find, start, or complete a treatment program. Rehabilitation centers that provide services such as housing, transportation, childcare, and income support can remove some of the hindrances faced by men and women who want to get clean, but more women than men need such services in order to enter treatment.
In the same way that gender throws up impediments to starting treatment, ethnic and cultural considerations have their own dynamics. Traditional Hispanic morals disapprove of women drinking socially (no such standards exist for Hispanic men). A Hispanic woman who develops an alcohol dependence disorder would thus risk incurring shame for herself and disrepute for her family if she had to admit to excessive levels of alcohol consumption, such that she needed help to treat the problem.
The issue of shame was also found among Asian-American/Pacific Islanders. The journal Psychiatry reported that for an individual to seek help reflects poorly on the family unit, as a sign of failure to solve the problem on their own. This results in the patient either using denial as a defense mechanism, trying to quit drinking or using drugs on his own, or the family refusing to discuss the topic.
Furthermore, some cultures have an innate distrust of Western medicine, preferring to use their own holistic and traditional methods to treat problems. While alternative medicine is not without its advantages, individuals looking to truly overcome a drug or alcohol addiction require a psychotherapeutic intervention (and follow-up) to undo a lot of the mental damage that substance abuse does, and then learn new ways of thinking and behaving when their formalized treatment ends.
Patients from cultures that eschew mainstream medical practices in favor of culturally influenced beliefs will likely be very resistant to the idea of divulging their innermost fears and concerns to a mental health practitioner.
Skepticism of “Unscientific” Psychology
Distrust of the psychological profession is not bound by culture, and this may present another obstacle for entering treatment. American Psychologist, the official journal of the American Psychological Association, asked why many people think of the study of human behavior as “unscientific.”
Perceptions that psychology is nothing more than common sense, that psychology doesn’t use scientific methods, or that psychology serves no societal purpose have contributed to a large degree of skepticism towards the field.
Even as people acknowledge the need for them to quit drinking (and may willingly detoxify), misapprehensions about the nature of psychotherapy (should it be an intuitive art or follow specific procedures, as asked by The New York Times) or its effectiveness (an “Ask the Therapist” blog on PsychCentral tells the story of a person who went to therapy for over a decade but felt no improvement) can keep the people who most need counseling away from treatment., 
There are many more obstacles, both realistic and perceived, that can prevent a person from entering treatment. Nonetheless, there are solutions for every concern. For all the different ways an addiction tries to hold its ground, the right combination of patience, understanding, and action can help a substance user take the first step in the right direction.
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