The Dilemmas of Addiction

Welcome And Purpose Of The Show

0:04 Michael Mackniak: Hello and welcome to the Holding It Together podcast. I'm your host, Michael Mackniak. Here we will get real in our conversations about mental illness and caregiving and the messy reality of keeping it all balanced. There's no sugarcoating, no clinical jargon, just real talk about the hospitalizations, medication battles, and the toll it takes on the home and everybody in it. This is for the parents, siblings, and partners who are doing the impossible every single day. Holding It Together is a home for the overthinkers, the multitaskers, and anyone who's out there that's feeling like they're just one spilled cup of coffee away from a complete meltdown.

0:47 Michael Mackniak: Find us on YouTube at HITKinda, that is at H-I-T-K-I-N-D-A, and subscribe. Like, follow, comment, I don't know, vent, throw rocks, tantrum, whatever you need to do today, uh just to make yourself feel better, but please follow us. Um, I need to make sure that I send out a special apology to all of you who are watching us via video today because I messed up. I tried to convince my my panel today that they were doing something wrong, and of course it turns out that I did something wrong. So please excuse the uh backward banner behind me.

1:29 Michael Mackniak: I was so proud to show off our new banner, and um Sara and Marielle got it right, and of course, I did not. So, best laid plans. I hope you will uh give me a pass for this week at least. Anyway, I hope you enjoyed this episode. Thank you very much for being here. Thank you for the work that you do for everybody else.

Jamie’s Story And Core Dilemma

1:51 Michael Mackniak: Jamie was the kid who noticed everything. She was the one who rescued stray animals and remembered every birthday, but today, the only thing that Jamie notices is the gap. The agonizing space between her last hit and her next hit. She's been through detox on countless occasions. To the system Jamie is a success story because she's still alive, walking around, and breathing. To her family, Jamie is a ghost. She's trapped in a loop of near-death uh experiences, temporary rescues, um, abuse, victimization, etc. I'm Mike Mackniak.

2:26 Michael Mackniak: I'm the uh host here today of Holding It Together. We are stepping into the delicate intersection today of autonomy and suffering.

Autonomy Versus Suffering Framed

2:35 Michael Mackniak: When we look at the crisis of drug addiction and untreated mental illness, we often focus on clinical symptoms. But what about the person underneath? I want to explore today the harrowing ethical dilemma of intervention. At what point does a society's responsibility to save a life override the individual's right to live it? So we'll be discussing the thin line between compassion and control and how we define quality of life when the mind and the body and the chemical imbalances that we have are at war.

3:13 Michael Mackniak: This week, my panel consists of Sara and Mariell, who you all met in our first week. And guys, I you know, this case of Jamie is one that has been perplexing to us in our office for a decade. I have to say anecdotally, I think that this one particular person is by far the most addicted person I've ever met in my life. She's it's very sad and it's very scary what she's capable of putting into her body and what she's capable of doing to her body. It's also very sad and it's very scary how resilient her body can be.

3:58 Michael Mackniak: We were introduced to Jamie by a psychiatrist, actually, one of the head honchos in the state of Connecticut. I don't want to mention any names, but he asked us to meet with the family because the family was struggling so mightily with the addiction as well as the underlying mental illness. And and what he really wanted us to do was to work with the family to find some level of acceptance of where they were, where she was in this big maze. Now, I should say that Jamie also represents a lot of other people.

4:35 Michael Mackniak: And I want to touch on that a little bit today because we you know, I think about one case where we had a veteran social worker talking about a gentleman who had an alcohol addiction to the point where he was he was just he was such a lovable guy. That's why I just can't I chuckle when I think of him. He's no longer with us, but she was just breaking down sobbing because she loved this guy so much and she was just so frustrated with her inability to reach him and do for him everything that she wanted for him.

5:06 Michael Mackniak: So, you know, this is heart-wrenching stuff. And of course, we're talking about addiction, we're talking about the impact on an individual, but we also have to recognize the individual's family and the hurt and the loss that they feel. So I don't want to make much more of it, Sara. You have been working on this case from the get-go with me and continue to do so.

Co‑Occurring Disorders Explained

5:30 Michael Mackniak: What are some of the key factors of Jamie and perhaps maybe on a global universal level that we can discuss about this ethical dilemma of addiction and and what we do and what we call quality of life?

5:47 Sara: Yeah. So I think what's what is important to highlight for the Jamies and the other folks that we work with that have significant addiction is that it's it's a co-occurring phenomenon. It's not just the addiction. And so a lot of the folks that we work with that have the more significant addiction issues have significant depression. And so I think one of the things that sits with me on on the handful of cases that we do work with where the addiction is just so, so profound profound and uncontrollable, is this in it almost comes at this ambivalence to live.

6:29 Sara: And so it almost feels like on a daily basis that there's, you know, that there's kind of like, okay, well, if today is the day, then that's then that's that. So I think that's what hits me the most is that, you know, I kind of focus more on the mental illness, right? Because of the nature of kind of the work that we do and how that impacts the addiction. And that's kind of where I get stuck a lot in terms of like really wanting to help people because I I want to help treat the mental health issue in hopes that the addiction will relent a little bit.

7:05 Sara: And that's not always the case.

7:08 Michael Mackniak: No, it's not always the case, and we I definitely want to jump back into that in in a second, but you brought up something important, Mariell. Comorbid, dual diagnosis, co-occurring, uh all used interchangeably from my layperson's perspective. What do they mean just to give everybody sort of a background?

7:30 Mariell: Means you got more than one thing going on here. You got more than one diagnosis that you're looking at. Right.

7:37 Michael Mackniak: And typically in these cases, we're talking about an addiction along with a mental health issue. Typically, you know, any any level of mental health issue. But as Sarah indicated, very often depression is one of them. And that's the chicken or the egg kind of a that's a certainly a chicken or the egg discussion, you know, what came first the depression or the addiction, and or and vice versa, but we're not going to get into that biochemical thing today, and we're certainly not experts at that. But but Sara brings up a really two interesting points.

8:14 Michael Mackniak: Number one is the family, the phone call dread of the family that's sitting there, and what they want for their loved one, what they see for their loved one, or what they don't see for their loved one, versus the reality of their beloved, what their loved one is capable of. And that goes back to that ambivalence. All right.

The Front Line: Families In Crisis

8:34 Michael Mackniak: Well, this seems like a good place as any to step out to the front line. The front line here is the space where theory ends and reality hits. It's those two o'clock in the morning phone calls, the hospital coffee and the waiting room in the in the in the hospital. It's the absolute exhaustion of trying to save someone you love while the world keeps on turning. This is what it looks like when a family becomes the only thing standing between a crisis and a catastrophe. You know, I did a poll years ago asking family members to give me just a one-line blurb of their perspective on their loved ones' mental illness, and a lot of them were really heart-wrenching.

9:20 Michael Mackniak: But one of them that stuck out to me when I was this preparing for today's episode was the woman who said, I wish my daughter would get arrested so that I would know that tonight she's safe, at least for the night, sleeping in a bed with the roof over her head. And that is just heartbreaking. Um, but it's a reality for for a lot of these parents who are sitting there waiting for the phone to ring, hoping the phone rings, but also dreading when the phone rings. And and Sara, you bring up a point that seems lately that I keep kind of trying to bring up, especially in in this particular case, but also others that have we've dealt with with with addiction issues, and that is our system is really set up right now that when we have these comorbid issues, particularly the the degree of addictions that we're talking about, that it's really set up that we want to treat the addiction, try to stabilize and get the person clean.

10:30 Michael Mackniak: We'll talk about what that definition even means. And then once the addiction is is set up, then we can discharge them back into the community and hope that they have the wherewithal to stay clean and now work on their mental health aspect of the dual diagnosis.

A Broken Safety Net After Detox

10:51 Michael Mackniak: We do not have in place a system that seems to want to address both. Would you agree with that?

10:58 Sara: Yeah, I would. I think the systems are very reactive instead of proactive. And I think, you know, I I think about that scenario, you know, you spend, you know, 28 days in a program, okay, and you discharge out, and you know, you get some referrals to maybe an outpatient program, you get some referrals to like an AA meeting, an NA meeting, but you know, typically there's nobody there walking you through the process, holding your hand, checking in with you. And I think that the system is finally catching up and and knowing that that is needed, but it's it's very uh sporadic that you come in contact with a program that might have a navigator or someone who's gonna follow up after that treatment program.

11:44 Sara: And that that's exactly where the person falls through the gaps of the system because they've done all this work to get clean. And now they're right back in the same environment that they came from with all the same triggers, with all the same stressors, with the same, sometimes the same level of depression or mental health issue that they came in with. So it's I think the safety net is is surely broken for a lot of systems.

12:10 Michael Mackniak: So funny, we use that safety net analogy so many times, and I just go back to that. I think we said it last in our last episode what you know, a net is really nothing but a bunch of holes. In order for a net to work, it's gotta have a whole ton of holes in it. That's no, and and it's just God people who don't struggle with addictions, Marielle, can't understand the power of the addiction over the person. And we sit back and say, geez, why don't they just pick themselves up by the bootstraps? Why don't they just get better and stop doing the drugs, stop, stop drinking, stop, you know, just stop.

12:48 Michael Mackniak: And and and then we have a system that and I don't know if this is fair or not, but I'm gonna say it anyways. We expect our our loved ones to lower their expectations, as we said earlier, right? And then we also expect them to hold the br the bag and deal with with Jamie when she's on the outside, when she's supposedly getting this the mental health treatment. So are we effectively offloading the cost of the public health onto the family and letting them absorb the private trauma?

13:26 Mariell: I think it takes a village. I think we all we all have a piece in it. The providers, the family, the client. I think in order for everything to work, we've all got to show up.

13:38 Michael Mackniak: And I I think that's an awesome answer. And I what I wrote for myself here, I think this is that statement that I just made is it was too simple.

Stigma And The Power Of Addiction

13:47 Michael Mackniak: It's too simple. It's a simplification of a very complicated set of circumstances. And you said it perfectly eloquently without me having to be too verbose about it. So we'll leave it right at that. I I yeah.

14:05 Sara: Can I add something though? I feel like the family has the most to lose, though, in these situations. So as social workers, we may come across, you know, four Jamies in a month. And and you know, you're trying to help everybody, but the family to the to these families, this is life or death, you know, for some of these families. And this is the difference between hope and hopeless. So I feel like the trauma that the families experience in these, you know, in these situations is significant. Um, and sometimes that makes the family members look a little unhinged, right?

14:42 Sara: But I think when you think about it, these families are dealing with despair and they're desperate. And I think what we need to remember as clinicians, social workers, nurses is that this isn't a pain in the butt family member. This is a desperate family member.

15:03 Michael Mackniak: Absolutely, absolutely. And that pain, that sense of loss, that sense of grieving is like groundhog day. They go through it. I mean, this isn't like a death, in that it repeats itself. It's on an it's on a never-ending loop. And we have to appreciate that the trauma that that that experience brings. And and as we say here in this frontline segment that that we we are in of our of our podcast, you know, it's this is what it looks like when the family becomes the only thing standing between crisis and catastrophe.

15:46 Michael Mackniak: And and very often that is true. Yeah, and and it it's it's not completely on the system. We cannot say that. And Marielle, it takes a village. Yes, perfect. It takes a little bit of the onus on the person to get over that ambivalence and want to live and want to do better. It takes the system to look at all of the circumstances that surround it, as opposed to a very narrow focus of holy cow, let's get them. What's the word that they go into the they're in withdrawal, let's get them stabilized, get them out of withdrawal, let's get them over to a detox program and work with them in groups and then get them back into the community.

16:25 Michael Mackniak: And it's a tough one. It's a tough place to be, it's a tough place to be for the for the individual, it's a tough place to be for the family. And as I indicated, it's a very tough place very often for providers. Marielle, have you experienced that kind of frustration, uh, deep, deep sadness over a client's inability to just pick themselves up and overcome this?

16:50 Mariell: Oh, absolutely. And I think everyone's reaction to it is differently too. You know, I I have my own personal family history of addiction, too. So I do feel like that helps me remain empathetic to these families and these clients and to keep showing up for them over and over again. And, you know, people say self-care and yada yada, but yeah, we gotta be checking ourselves. It is exhausting, but we still have to show up for them. We have to show up for our client and our families.

17:22 Michael Mackniak: Well, and Sarah, if mental illness is supposedly something that impacts one in four of us now, which is basically, I mean, every family's four people, right? That's been our national standard for decades. So if every if if mental illness impacts one in four of us, it basically impacts every single one of us. I keep don't know off the top of my head, statistically speaking, what the impact and what the numbers look like for those who are addicted. But I venture to say that on some level, that trickle down, trickle up, trickle sideways impact of a mental illness is it affecting every single one of us, whether we are addicted to something or not.

18:02 Michael Mackniak: I mean, we have a an uncle who's an addict who impacted the mother, who's now impacting the son, right? And I'm pointing right at myself. You know, I lost an uncle who was highly addicted to lots of things, and it really impacted his relationship with my mom, and my mom, you know, teaches me through osmosis or whatever it is, and we have to be we have to recognize that. Okay, welcome to our system overload segment where we talk about the clinical need exceeding the infrastructure's capacity.

System Overload And Survival Metrics

18:43 Michael Mackniak: We're looking at the you know, the blown fuses, the revolving door discharges, the 400-mile record gaps, and and data blackouts. This is where we stop asking how the patient is doing and ask more about why the big machine is glitching, why the machine is breaking down for that particular patient. All right, I want to talk about the survival. How do I say that? What I want to talk about now is the is the survival metric, right? Where our systems and us, frankly, we we want to keep people alive. We don't want people dying on our watch.

19:30 Michael Mackniak: We don't people we don't want people dying, period. But at what point in time is this idea that keeping somebody alive is our best metric? Sarah, do you have any thoughts?

19:46 Sara: I think that's one of the ethical dilemmas that we grapple with on some of with some of the folks that we work with, because do they have a right to go out and and use and put themselves at risk on the streets and engage in all this risky behavior? I mean, yeah, they they have the right to do that. Like, I mean, yeah. But as providers, do we have an obligation to try to you know help them through the stages of change? Yeah, we have an obligation to do that too. So I think it's I think what Marielle said is very important.

20:23 Sara: And I think this applies to the families and to the workers. You can't give up because you never know which which time is gonna work, Michael. And I think back to that case that you said where the social worker was crying and that she loved the client. I don't know that those tears were of that she loved the client so much. I think that those were tears of frustration that she was giving up. And I think that's one of the things that families and and frontline staff have to remember is it's really hard, but the client does have the ability and the right to make their own choices.

20:56 Sara: But we have the obligation to kind of stand and and walk through that with them without judgment, but knowing that it's not our will. Like we we we have to let go of the control at some point too, and be the person who's kind of rolling with it, rolling with them and their resistance, and and that's really hard to do. It's really hard to do sometimes.

21:20 Michael Mackniak: It is, it's what I was jokingly saying. Let go and let God, isn't it? The trip, let go, and let's get so hard, it's so hard to do watching your loved one kill themselves slowly, it's a slow motion crash, and I don't know, man.

21:40 Sara: Some some families, can I just add something too? Some families can't do that, and that's okay too. I mean, I again there's no right or wrong in any of this. Some families have to distance themselves because they can't watch the train, you know, the train wreck. And that's where some that's where kind of providers can come in and

22:00 Michael Mackniak: Well, okay. And Marielle, what does that guilt look like in a family? I mean, I can't deal with this.

Boundaries, Guilt, And Culture

22:06 Michael Mackniak: If I deal with it, it's just going to impact me and my family. Is that selfish of me or is that healthy of me?

22:14 Mariell: I uh feel like it depends on the family. Like some of them are like, nope, this is what I gotta do. I need to help them. That's my job. You know, you have to look at like the cultural and the ethnic background too, and how that determines their view of like the family and what you do for your loved ones. And I've had families that are like, I want nothing to do with this until you're clean, I don't care. And then you have the other ones that can't set a boundary at all. And you just gotta meet them where they're at.

22:41 Mariell: Everyone's different.

22:43 Michael Mackniak: Yeah, I guess to Sarah's point, there's no right answer. No, you know, I mean, how many times have we seen somebody steal, rob their family blind because they're getting their drugs or their jewelry to buy the next hit? And you know, the family just keeps going back to the well. Whereas others, as you say, nope, you know what, you're not allowed in the house anymore. I don't care that it's the coldest winter we've seen in the northeast in in uh decades. I can't bring I cannot bring the chaos that is you into this home.

23:18 Michael Mackniak: And you know, and and our that's going beyond our system overload, right? That's going beyond what our system can even handle because our system is really I think I think, and I could be wrong, Sarah. Tell me if I'm wrong. We have people out there who are grossly psychotic that are making poor choices, right? And those people aren't listened to, okay? Or they are listened to, and they're and we couched that under choice, and we're gonna get into this here in in a bit in a bit. But when it comes to people who are addicted, to me, it feels that the the inquiry is different.

24:02 Michael Mackniak: And I don't know if I said that in in a way that even makes you understand what I'm getting at. It's like when we know a person has a mental illness, we almost have some degree of forgiveness of the outlandish decisions that they're willing to make. But when people have an addiction, we're almost like, well, that's just the dumbest thing I ever heard in my life. What's the matter with you? We're not, you know, and why do we go there? What what is where where does that come from?

24:36 Sara: So I think it goes back to the whole pull them up by the bootstraps type of thinking. And that's an old school way of thinking. What I'm so happy about lately is that, and I really do think neuroscience is just going to explode in the next 10 years. But what I'm happy about is there's all sorts of research that's being done right now that shows that addiction really is not just a pull yourself up by the bootstraps issue. It really is linked to all sorts of stuff going on in the brain. And so, like some of the things that I'm hopeful about, they're actually doing research on ultrasound techniques to help addiction.

25:13 Sara: They're doing things like the new Ozempic that could help with cravings with addiction. So there's a ton of research being done in this area. And I'm hoping with more research comes more education so that we all can be on the same page. That addiction is is very much, in my opinion, a mental illness. I think that if people could stop, they would. It's not, I mean, the the tragedy is not.

25:40 Michael Mackniak: If they could stop hearing voices and returning responding to internal stimuli, they would. If they could stop being depressed and manic, they would.

25:48 Sara: And if they could stop their addiction, I think if they felt like they could stop it. I mean, some of the folks that we work with really have tragic stories in terms of the levels that they will go to with their addiction. And I I think choices, I think when you get to that level, I don't know that choice is a hundred percent.

26:08 Michael Mackniak: And that is exactly what I'm asking. Why do we tend to put so much more faith in somebody that has this mental illness of addiction, if you will, uh, versus the the straight up schizophrenia, schizoaffective, those those types of things? Or or or do we? I don't know.

26:33 Mariell: I think it's societal too. I think so. I said I think it's societal too. I think it's so embedded in our society and like the whole just say no to drugs and the war on drugs, and just that it's simple. I think things are shifting though. I think people are starting to understand it more and that it's more complex than just saying no, but it's just so embedded in our society.

26:56 Michael Mackniak: Well, I certainly think the conversation is shifting, people are talking, yeah.

Changing Narratives And Neuroscience

27:00 Michael Mackniak: But I don't know, I don't know that I see where the the conversation is is happening, and that's great because we've we'll we've been around long enough in our generation, right, of doing this work, we've seen a shift in that conversation going from never happening to at least happening. So there's something, and it could be another two, three decades before we have monumental change, which for those of us who are in this right now, that's not very uh reassuring, but it's something and it's a hope.

27:36 Michael Mackniak: But I still see where, for instance, in Connecticut, we have the Department of Mental Health and Addiction Services. And my dog has to bark and tell us all about what we're talking about. So in Connecticut, we have the Department of Mental Health and Addiction Services, and and I love he could go around the doors open right here, but he chooses to sit at sit at the door that's not open and bark at people. Anyway, so in Connecticut, we have our Department of Mental Health and Addiction Services, and we've been obviously working with them for over 20, almost 30, going on 30 years now, very closely, and I think that they do really well compared to other places and horror stories that I've that I've heard.

28:32 Michael Mackniak: But even in in a in a state that is progressive, I think we still really tr struggle with getting our arms around and tackling head-on these substance abuse issues. From what I can see in in the hospitals, the I mean, if if I had to draw a scale, I would say that believe it or not, folks, the money for a mental health treatment is way up here, the money for addiction treatment is way down here. That's my anecdotal analysis of the situation, Sarah. Would you agree with that?

29:09 Sara: I'm not sure because I think the opioid epidemic has really opened up some pockets. I think that's fair.

29:17 Michael Mackniak: That's a good point.

29:18 Sara: But and again, going back to the societal stuff that Muriel was talking about, I think it's easy to blame the folks who are addicted because I think, and you know, everybody has their own opinions, but there is treatment out there, right? And so the thought is okay, well, like if you had cancer and there's treatment, why wouldn't you go for it? If you had diabetes, uh, why would you keep eating sugar? So I think that's part of the cycle that we get into as a society that, okay, well, you're doing this to yourself, it's self-inflicted, there's treatment out there.

29:52 Sara: Why aren't you doing it? Why aren't you getting involved? And when I talk, when I'm talking about addiction, I'm talking about those folks that are not just functioning in society. I think what we're talking about today is those folks that are really on the fringe, who are homeless at times, who are, you know, really in the throat prostitution. Right. We're not talking about, you know, you know, someone who is able to hold down a job or or something like that. These are folks that really it's life or death.

30:19 Michael Mackniak: Yeah.

30:20 Sara: Yeah.

30:20 Michael Mackniak: And I guess what I'm getting at, I think what I'm getting at is that when you have these co-occurring disorders, we have to focus on one or the other. It doesn't seem like we we are very strong at focusing on both at the same time. Would you agree with that, Muriel?

30:35 Mariell: Yeah, I think it's hard to focus on both at the same time because how do you work on someone's mental health when they're coping if they're in active addiction? Not that we shouldn't try, but it's a dance. Yeah, it is a dance, an ongoing dance that changes every day, every time they come in. Where are we at today? Like, where what's yeah?

30:55 Michael Mackniak: The music changes every time.

30:57 Mariell: The music changes every time, and you think you're oh, I got it, I got it down this time. Then they come in, and it's we're a whole different dance now.

31:03 Michael Mackniak: Yeah, the line dance changes every song.

31:06 Mariell: Yeah, and I can barely dance, so right, right.

31:09 Michael Mackniak: No, and and and it's so true. And I'm obviously, folks, I hope you understand that we're not making light of this.

Laws, Commitment, And Practical Barriers

31:15 Michael Mackniak: We're our our chuckles are just the frustrated chuckles of people who are living it right along with with all you providers and families who are who are going through it. Sometimes all you could do is just say, it's just so overwhelmingly complicated and it's frustrating, but we've got to we have the obligation on some level to pull ourselves up by the bootstraps as a society. As you've seen, we often talk about this concept of a safety net, but now I want to look at the cracks. This is our segment that we call the cracks, these are the invisible lines where families lose their voice and patients lose their way from rigid privacy barriers that prevent or isolate loved ones to financial abysses, which are always halting progress.

32:09 Michael Mackniak: We're we're asking why are these gaps here and who is falling through them? In this segment, we stop looking at the person who fell and start inspecting the holes in the floor that they were forced to walk upon. But and here comes the big butt because when we talk about cracks in the system, right, and we're not just talking about the the net that's full of holes, we're talking about the cracks in a system that we either created or create themselves because of policy and procedure that are in place, and I think that one of the things that we have to recognize with what we've allowed to grow as it relates to addiction is what we were talking about earlier, where we think that people who are only quote, unc that's in quotes, only addicted to drugs or alcohol should be able to make a better and more informed decision for themselves than people who are only or quite mentally ill in their overcome with schizophrenia or whatever other severe and persistent mental illness we may we may be speaking of.

33:30 Michael Mackniak: And that's as Sarah pointed out, that's not fair on the person who's struggling with severe addiction. So when it comes down to it, as I said earlier, sometimes we're more inclined to listen to the person who is struggling with severe addiction and what their choice may be, whereas very often we don't pay as much attention to the person who has the mental illness and what would be their clear choice and what it is that they want to do. But we also fall into some traps that are really touchy, and we're gonna get more into this in our next episode.

34:08 Michael Mackniak: But we have to, we would be completely remiss if we did not talk, as Sarah tried to bring up earlier, the idea that people do have the option, they do have the right until they don't, they do have the right to be grossly psychotic or to be quietly psychotic over in the corner. They do have the the right to spend all their money on their crack pipe. And I'm probably dating myself going back to the crack, but you know, they do have the right to go to heroin and to go to the opioids and and whatnot.

34:40 Michael Mackniak: The real struggle for people in the communities, the real struggle for the families and the providers is at what point does that respect for individual liberty become state-sanctioned or or or society-sanctioned neglect? Is there truly self-choice and free will, Sarah, if your self-choice and free will is dictated by everything you're doing because you are addicted to a drug?

35:19 Sara: Well, like I mean, like I said before, we're we're talking about the cases that are life or death right now. And so I think that most states have a mechanism, and it's called involuntary commitment. Uh, when when that scale is tipped a little bit too far, I think the problem is that the lay person doesn't know how to use that tool as a as a life-saving mechanism. And so we as social workers know how to use that. And and and we do, and sometimes that gives the person the clarity, you know, the 28 days or the six 60 days of clarity to to regroup.

35:56 Sara: But I think that's where the struggle is, that that's you know, there's not a whole lot of options when you're when you're feeling like it's life or death.

36:04 Michael Mackniak: To be clear on two different things here. Number one, most states do have involuntary commitment statutes. I would agree with that. I would also say that most states, most governments, most courts, most judges, most clerks in those courts, and most people working within the courts on a regular basis do not know how to use that and do not use it effectively. It's uh it's uh people are more afraid of it and think it's more of a hassle to use than than what than what it's worth, so to speak.

ACT Teams And Intensive Support

36:38 Michael Mackniak: So there is that. We have experienced that, Sarah, and we I think have been very instrumental in helping our state to overcome some of that. Essentially, folks, what the issue is is twofold. Number one, and very you need to be able to show that there's a likelihood that the intervention is going to succeed. That is, if you involuntarily commit somebody, that it's more likely than not that it's going to succeed, which I think is a pretty easy burden to overcome. The harder burden, folks, is that the statutes basically say there has to be a bed ready to receive the person as soon as the judge makes that order.

37:12 Michael Mackniak: That's the tough one. I mean, that's why a lot of it gets passed over and that doesn't happen. Those statutes are not enacted. The other side of the coin that's a much bigger global issue is this concept of outpatient commitment that we do not have in the state of Connecticut. I think we're one of only like five people five states in the in the country that don't have outpatient commitment. And that basically is where a judge can keep jurisdiction over an individual who is put out into the community.

37:40 Michael Mackniak: And if they are not following certain treatment protocols, they can be brought back in and in front of the judge to answer as to why they're not doing what they're quote unquote supposed to. The states that do have those laws, those outpatient treatment laws, find them to be very cumbersome, very expensive, and very difficult to enforce. So again, this is a technicality versus a practicality discussion because there may be laws on the books, but if we can't use them, what good are they? At the same time, we have to understand that there are financial, there are personnel limitations to what's possible, what we can possibly achieve.

38:25 Michael Mackniak: So, yeah, those would be great answers. Marielle, how much experience do people typically get involved with, say, our act teams? And what is an act team?

38:38 Mariell: An act team is a very intensive, outpatient team meant for you know some of these clients that we're talking about that really need like weekly, daily, ongoing supports, hands-on engagement is the piece. It's it's really for these folks that are very difficult to engage, that often they're struggling with substance use. The teams are pretty helpful, but yeah, the stuff we have in Connecticut and I think other states too, it is it is cumbersome, it is difficult to kind of get all of these stars aligned, is what I like to say.

39:16 Mariell: It's my saying, not that it's impossible.

39:19 Michael Mackniak: No, no, and and that's one of the things that we talked about in our last episode was trying to get your your your history lined up. You're keeping keep in mind the people who are working on your team, keep that organizational chart handy so that you do have an idea of getting those stars stars aligned. But an act team is it stands for assertive community treatment. As Muriel said, it's a highly intensive outpatient treatment for people who are struggling to maintain existence in the communities.

39:52 Michael Mackniak: Frankly, I don't know that the act teams can work very well with people who are highly addicted because the person who is highly addicted is not as inclined to be around to have those meetings. And it's not through any fault of the act team. I think they do much better with folks who are who are their primary issue is is mental health. Sarah, would you agree with that?

40:15 Mariell: No, I was gonna say I don't want to agree, I wouldn't agree.

40:18 Sara: I would not agree with that, I would not agree with that. Um the folks who have the co-occurring diagnosis typically go to the act team because they are the most difficult to engage. So I think the hallmark of the act team is that they won't, they're not gonna wait for people to come in to see them. They're gonna go out to the community. So I think the act teams that we have in Connecticut are very successful in going out there and and really, like I said before, rolling with resistance and helping that person try to get to at least to one step in the stage of change.

40:51 Sara: But yeah, it's it's it's it's tedious work, but I I do think the act teams are are well, and as far as I know, act teams have become more or less universal from what I've seen in my travels.

Guardianship Limits And Realities

41:05 Michael Mackniak: Most states have adopted some form of act in talking to people around the country, which is which is inspiring. And I guess I didn't mean it so much that they weren't working with co-occurring, obviously. What I meant was that it seems to me, and and again, as a lay person, getting pinning down somebody who's out trying to find their drugs on a daily basis is a lot harder to do than it is to meet somebody or to have somebody come to or bring somebody to a doctor's appointment for their psych meds and things along those lines.

41:40 Michael Mackniak: You're right. Most most of the referrals that do go to the act teams are are the co-occurring. I'm just you know, I'm just curious about what their population balance looks like. Is it more which which which side of that scale is heavier? Is it the mental health or is it the addiction? And I don't know that any of us. If you folks haven't already looked into what's available through your Department of Mental Health. Another option that we've discussed and that we use primarily, almost exclusively in our agency.

42:22 Michael Mackniak: I don't necessarily subscribe to it in all aspects of law, but you know, there are limited conservatorships available, limited guardianships available, temporary emergency limited guardianships and conservatorships that the courts can help with in terms of getting somebody out there who can be really proactive in a real acute moment to try to jump on a situation to rectify it. But, but, but, but please, folks, understand that having a guardian or a conservator in place is not the silver bullet that you're looking for.

43:01 Michael Mackniak: I do entire seminars on this alone. The the answer is not going to be one person is gonna come in and be our Superman. It just does not happen. And no conservator can can fix some of the issues that we've raised here today and in other episodes. So we kind of talked about at what point does respecting one's rights become neglectful. I don't know that there's an answer for that, and I don't think that it's fair to necessarily say that one is necessarily going to lead to the other, but it's an issue that that comes up.

43:41 Michael Mackniak: It really does. So before I ask one last really kick in the butt question to you both, and I I think I have an answer for it. Do you have any last words on this topic of addiction and coping and seeking help, Sarah?

44:00 Sara: Yeah, I I think, you know, the one takeaway that I have, you know, for family members is educate yourself. You know, as you're advocating, educate yourself. Educate yourself what services are available to you in the community. Go on your local Demis websites or your state websites. Get familiar with the terminology for, you know, assertive community treatment, uh, community support programs, like comorbid, coexisting. Familiarize yourself so that when you are advocating that you can advocate for specific things, you're going to be more successful asking for something specific than just generally saying, you know, I need service.

44:42 Sara: So that's my one takeaway is educate yourself so that you can advocate effectively. And I always say, you know, if you don't feel like you're being heard, you know, you always kind of kick it up a notch to the next level. And then the most important thing I think that our family members can do for themselves is to focus on their own self-care. And if that means getting a therapist, that means getting a therapist. If that means going to an Al-Anon support group, a NAMI support group. I mean, all of those things I think are super, super important so that we can keep our sanity as family members, right?

45:18 Sara: So what's that saying?

Education, Advocacy, And Self‑Care

45:21 Sara: Charity begins at home. Is that yeah? I mean, you can't you can't help others if if you're hanging on by a thread.

45:29 Michael Mackniak: Yeah, well, like they say on the airplanes, help yourself to your oxygen mask before you try to help others, right? What do you think, Marielle?

45:38 Mariell: I think Sarah put it all beautifully, and I just want to emphasize to be gentle on yourself. Recovery is not linear. You're gonna make mistakes and not even mistakes, because there's no right or wrong way. I think everyone's just figuring out, but just give yourself grace, be gentle on yourself.

45:59 Michael Mackniak: Yeah, and grace is hard to come by. All right, so I know that we kind of don't get into a lot of the details of clients, and we do that sort of on purpose, but you know, this particular client and clients like her have been in and out of treatment. I mean, sometimes as much as four or five, six times a year into new facilities. I mean, this particular woman was living on the streets in New York City before her family pulled the right strings to get her home. Once they got her home, she has basically been working with us, for better or for worse, in and out of treatment facilities, and in and out of different kinds of treatments, hospitalizations.

46:45 Michael Mackniak: She has really learned how to work the system, how to get her drugs, how to med how to how to seek drugs and get doctors to prescribe them. I mean, stealing doing things that you just couldn't believe. So, for the better part of, as I said, probably about 10 years, we have been working with Jamie and keeping her alive. We have been keeping her going from more or less, more or less, from facility to facility to facility, with about two years out of 10, I'm gonna say, where she was really doing well in the community in a program, in a structured program.

47:29 Michael Mackniak: And unfortunately, invariably, she winds up going right back on for some reason to a massive spiral of decompensation, drug use, drug overuse, hospitalization, drug seeking. She's she's very good at prescribing for herself what she wants to take or what she will take. I'm I'm I'm just reiterating all this so that you people that are listening and and that anybody who's a provider listening can also say, yeah, I've got I know that person, uh, you know, I I can relate to that that case scenario. So and this is the hard, hard, hard question.

48:12 Michael Mackniak: And I'm gonna put it to you guys individually. Marielle. If this was your daughter, would you consider her saved today?

48:26 Mariell: I don't know how to answer that. Would I consider her saved? I feel like she probably would have been dead by now if she wasn't with us. So I would consider that of course an improvement based on how she was before she got involved with our agency. Not saved, no, but this might be as far as Jamie can go. I don't know. I don't really I don't know the case too well, so but I think we gotta keep trying. Gotta try a hundred more times.

48:58 Sara: It might click. And I don't know that this is my own personal opinion. I don't know that we're in the business of saving people. I we're in the business of guiding people. And so uh this isn't my journey, this is her journey, and and all the Jamies like her. So I don't look at it. So if this was my daughter, so that's how that's why I take it as a social program. If this was my daughter, I wouldn't be looking at it as that like that defined of like saved or not saved.

Is Stabilization Success

49:30 Sara: It's kind of one day at a time. So I don't think and that's the way that our family members look at it as saved or not saved. I think it's more of the can I rest easy tonight and go to bed tonight without the anxiety of the 3 a.m. phone call. And so that's if this was my daughter, that's how I would look at it. I would just I would try to keep the hope. And I think that's I think that's the better question, Michael, is do I have hope today? Who do I have hope today?

50:00 Michael Mackniak: Yeah, I I'm not I'm not suggesting that my question is perfect and it may not be an answer. I mean for me, and and this is just I guess my cold-hearted, whatever you want to call it, way of looking at it, that when I look at quality of life, I find it very difficult to say that this person is saved and that that the system's working for her. I I find that very hard to say, and it's horrible.

50:28 Sara: You know what, Michael, in terms of all of the Jamies out there, I think the system is working for them because it gives them the ability to wake up and and and and have change possibly the next day. So I think could because it may click. It you know, I mean, you talk to people who have had 20 years of addiction and that now they're in recovery. I mean, at what point, you know, is enough enough. I I don't think I don't know.

50:58 Mariell: Give them the opportunity to get to that point where it could click. Without that, they probably wouldn't be here today.

51:03 Sara: So and void of the system, void of the supports, void of the family, I don't know that these folks would get the opportunity to have that new decision every morning, you know.

51:15 Michael Mackniak: I I agree with you. I I agree with you. I'm just saying, and and we you know, intelligent people should agree to disagree, even though it doesn't seem like we could do that in our in our American society anymore. But we have to be able to have these discussions very openly and frankly about what it means to be alive as a functioning member of society and what our responsibilities as a society are, what onus we place on the individual, what onus we place on families, what onus we accept as a family, and what onus we place on ourselves and our systems as providers and professionals.

51:51 Michael Mackniak: I think it's all it's all relevant. That's why I want to bring it up. And there is no right or wrong answer. So as usual, uh thank you guys for being here this week. And um I'm going to just give my final thoughts on on uh Jamie and the case, and um we will do this again. All right, guys, so there you have it.

Final Reflections And Next Topic Tease

52:23 Michael Mackniak: My final word. You know, Jamie's story isn't just a tragedy of individual choices, it's a clinical audit of a system that has mistaken, at some level, stabilization for success. Uh we need to ask ourselves if we are particular about saving life in the moment of an overdose, but careless about the quality of that life in the moment that they walk out of our hospital or or our emergency room or whatever, who are we actually saving? You know, they're not they're not mutually exclusive, but they're also not the same thing.

53:00 Michael Mackniak: To the families who are currently sitting in the dark kitchens with their three-ring binders and waiting for a phone call that may or may not come, you're not the only reason the cracks haven't swallowed up everything. Or I mean, you are the only reason that the cracks haven't swallowed up everything. We see you, we know that you're doing the heavy lifting, and and and sometimes you've got to help the machine to help you. Jamie's alive today because the system is very good at the save, but in my mind she continues to suffer because um the system isn't as good as the stay component, right?

53:36 Michael Mackniak: We've created a cycle where we prop people up just high enough to see what they're missing, and then we let them crash again. When we talk about quality of life, we have to ask, you know, is breath alone uh living? Or do we owe it to the Jamies of the world as a system and as a society that they're we value their potential and we we value that as much as we value just having them alive. We want to see them thrive. Next week we're gonna tackle another uncomfortable situation, which is you know the client autonomy issue.

54:17 Michael Mackniak: The we're gonna dive more into the right to choose, um, which is sometimes masking illness, or in this case addiction as well. So until then, I'm Michael Makniak. Thank you for listening to Hold It Together. Mind the gaps and try not to fall through the holes in the floor.