I had just completed a workshop on relapse prevention. As I was leaving the conference room, a thin and frail-looking man from the audience approached me. In a voice tinged with quiet desperation, he asked if he could talk with me privately. We moved to the side of the conference room, pulled up a couple of chairs, and sat down to talk.
“Mr. Gorski,” he said, “My name is Malcolm. I am recovering from chemical dependence and have been sober for nearly eleven years. I’ve had AIDS now for over two years and I’m beginning to get very sick and I know I will die. A big part of me wants to start drinking to deal with it and, to be quite frank, considering my condition, I can’t think of any good reasons to stay sober. What should I do?”
Many counselors are asked this question. Their clients struggled to get sober, only to become a statistic in the growing in the growing AIDS epidemic. Other sober people also ask this question when, in sobriety, they are diagnosed with cancer or other chronic and fatal diseases. Many of these people find the courage to face their death in sobriety. Others return to alcohol or drug use. Of those who relapse, some get back into recovery and die sober, but many others die a horrible death from the combination of AIDS and out of control chemical addiction.
What can we say to these people? How can we convince them that it is in their best interest to stay in recovery in spite of the horrors of their disease. How can we give them the courage to face their death sober? Should we even try? If an addict is dying, why should he or she stay sober? I can think of many good reasons for staying sober in the face of death.
Alcohol and Drugs Won’t Help!
It is tempting for terminally ill patients to believe the mistaken notion that alcohol and drug use will somehow make their disease easier to cope with. It does not. I ask patients to think back to the times when they were using alcohol and drugs and to remember the quality of their lives.
No matter how painful or debilitating your terminal illness may be, alcohol and drugs will only make it worse. The mental anguish and pain you may be experiencing will increase and your ability to cope with your disease will progressively disappear. At best, alcohol and drugs will provide brief moments of temporary anesthesia, followed by periods of shame, guilt, and dysfunction. As the chemical dependency progresses, and it always progresses, the resultant loss of control will prevent you from responsibly treating your illness, destroy any hope of having quality moments of life, and escalate your movement toward a painful death.
For people who are addicted, alcohol and drugs are never a solution to any of life’s problems, including terminal illnesses. The temptation to believe that alcohol and drugs are a solution is part of the delusional system that accompanies chemical addiction.
The Choices In Facing A Terminal Illness
When facing a terminal illness, we only have three choices. We can deny it by pretending everything is fine. We can fight it by learning all that we can about our disease, fortifying our sobriety, steeping ourselves in courage and hope, and doing everything we know how to do to increase the duration and quality of our survival time. Or we can accept it. We can face the inevitability of our death and surrender to it. By surrendering we can reinvest our energy in finding a sense of dignity, and meaning in the experience of our illness and death. We can finish our business here on earth and turn to strengthen ourselves spiritually to face the transition from this life to the next.
Which is the best or correct way? There is none. We each will have to choose which of these alternatives we will embrace at each stage of our movement toward death. At times, it is best to deny our illness and live as if we will live forever. At other times, it is best to steep ourselves for the battle and fight for our lives with everything we have. At still other times, it is best to surrender to the inevitable and face our death for what it is, the final transition of our physical lives.
The bottom line, however, is this — none of these alternatives will be available to us if we choose to use alcohol and drugs to cope. Our disease of chemical dependency will rob us of all choice and self control. It will make our pain worse and rip us away from ourselves, our God, and those who love us. Alcohol and drugs can never be a solution to anything for a chemically dependent person.
Reasons To Stay Sober
When Malcolm asked me the question, “Why should I stay sober?” my response was very direct, “Because you owe it to yourself and those around you. Because you are in recovery and you are able to face anything sober and this includes your own eventual death.”
For a moment I became philosophical. “We can all create precious moments in time,” I said as I leaned forward and looked him in the eyes. “We can, at times, transcend our fear and carve out moments of joy and wonder.” I looked away for a moment a realized how often I had failed to follow my own advice. Then I continued: “We can choose to laugh when we feel like crying. We can live fully, even in the face of death. This is just true for us all.”
My mind flashed words of Earnest Hemingway: ‘All true stories end in death.’ In other words, we are all dying in every moment that we level. We are all living in every moment we are dying. We can choose to embrace life and revel in it, or we can choose to embrace death and quake in horror, fear and despair. Many people have told me the most painful thing they faced when confronted with their own impending death was how many moments in their lives they had wasted.
Then my rational brain took charge and I began explaining to Malcolm that there are seven good reasons to stay sober even if you have a terminal illness.
1. There Is Always Hope:
Only God decides when we die. In recovery, we learn that we are not God. Although we will all eventually die, the timing of our death is never certain. Many people with HIV will never develop AIDS. Of those who have AIDS, some will have spontaneous remissions and others will live a long and meaningful life before eventually dying. On top of that, there is always the hope of a major medical break through in treatment. Perhaps a cure will be found! Even if such a break through never comes, people are happier and healthier when they live with hope than when they live in despair.
2. Staying Sober Increases The Length And Quality Of Survival Time:
Staying sober, eating right, exercising moderately and managed stress (all of the components of good recovery program for chemical dependence) will increase the length and quality of survival time.
3. Staying Sober Allows Us Connection With A Higher Power:
It is only in sobriety that we can experience a deep connection with our Higher Power and contemplate with hope what lies beyond the limits of our physical existence. This is the only true source of comfort when facing our own death.
4. Alcohol And Drug Use Escalates Disease Progression:
Alcohol and drug use inhibits the immune system and accelerates the development of AIDS. Alcohol and drug use will also interfere with the effectiveness of many of the new medications and other treatments that slow down the progression of AIDS.
5. Staying Sober Gives Us The Possibility Of Death With Dignity:
By staying sober, we can approach our death with dignity and self-respect. We can reflect upon the meaning of our lives, the loves we’ve shared, the experiences we have had, the things we have accomplished and contributed. We can bring closure to our lives and our relationships. We can search for and find a deeper meaning to our lives and to our death.
6. Relapse Adds Pain And Problems To An Already Bad Situation:
When a chemically dependent person returns to alcohol and drug use, there is a big price to pay. Physically, the booze and drugs rip our bodies apart and make us more vulnerable to the progression of other illnesses and less responsive to treatment. Psychologically our self-esteem suffers and we develop shame, guilt and anguish. This emotional response accelerates our plunge into depression and eventual despair. Socially we become isolated and unable to give or receive love. We inadvertently hurt the people we love most and cut ourselves off from one of the few sources of true comfort, the loving embrace of other human beings. Spiritually we become bankrupt and disconnected from the God of our understanding. We lose conscious contact with our source of courage, strength, and hope.
7. It Is Better To Die Sober Than To Die Drunk:
I strongly believe that it is better to die sober than it is to die drunk. Using alcohol and drugs is never a solution for anything. Alcohol and drugs cut us off from our inner source of courage, strength, and hope. Addiction destroys our self-esteem and self-respect. And, on top of that, it will make whatever other disease we have worse. In the long run, it will create more pain and misery.
The Difference Sobriety Can Make
Staying sober in the face of terminal illness can and does make a difference. I had two friends in recovery who died of cancer. One of them gave up hope and used his terminal illness as an excuse to relapse. He spent several months bingeing on booze and drugs and wallowing in self-pity. His behavior deeply hurt all of us who loved and cared about him. Most importantly, he ultimately hurt himself. He cut himself off from those he loved and alienated himself from his higher power and his inner source of courage, strength, and hope. He ultimately decided to take his own life. He left devastation and scars on all those who touched him and died in personal misery.
My other friend faced his death sober. As a result, all who were involved with him benefited from his courage, his willingness to work through the steps and stages of accepting his own death, making his own personal peace, and being prepared to surrender himself spiritually. This friend died in a hospital surrounded by family, friends, and AA associates. His death was not pleasant, but he was able to face it using the wisdom and courage he learned in his twelve step program and through his years of recovery. As a result, he died in peace with himself and with others. He finished the unfinished business of his life and he left behind him a legacy of the power of recovery, courage and compassion. He showed us all the true strength of sobriety when supported by an effective recovery program. He gave courage and hope to all who were involved with him in his final days.
Any recovery program that is strong enough to help people to face their own death in a sober and dignified way is a powerful program indeed. I wish that everyone suffering any chronic disease can learn to tap into that power. As counselors and therapists, we need to believe in the power of the recovery tools that we teach and realize that they can assist a person in living a high quality life for as long as possible. They can help people to face the reality of their eventual death while finding the courage to live – even when they know we are dying.
Counseling The Terminally Ill
Counselors who are working with chemically dependent patients who are terminally ill need to develop a firm belief that alcohol and drug use will only make the condition worse. Most importantly, they need to clearly and forcefully communicate that conviction to their patients. They need to recognize that it is never in the best interest of the chronically ill patient to relapse into alcohol and drug use.
They also need to know that the use of pain medication, as prescribed, to improve the quality of the life in the face of severe pain is no a relapse. Without proper management, which usually includes a properly supervised pain medication regimen, the pain can become so severe that it destroys any ability to have quality survive time.
Therapist also need to be able to redirect their counseling and therapy towards three primary goals. The first is to maximize the use of treatment interventions that can produce a cure of the fatal condition. This means encouraging the patient to fight back against the disease by using the most effective treatment methods available. The second is to maximize the quality of survival time so that the person can live to the fullest in the remaining years, months, days, or hours of life. This means helping people to consciously bring closure to unfinished business, explore his or her values, and spend time engaging in valued activities. The third is to develop a sense of spiritual fulfillment, which can allow patients to face their death with dignity and self-respect. This means working through the stages of denial, anger, bargaining, and depression. This can bring people to a deep spiritual acceptance of death.
It is difficult for counselors in a death-denying society to realize that there are vital counseling interventions that can be used with terminally ill patients. It is important to help people work through the stages of accepting their illness while still maintaining a sense of hope and a proactive vision of the future.
Counseling the terminally ill patient who is in recovery is the most challenging and, at the same time, the most meaningful experience that I have ever had. Working with these patients in learning how to realistically face their own death has helped me come to terms with my own mortality.
When working with terminally ill patients who often experience chronic and incapacitating pain, we have to think carefully and realistically about how we define relapse. One of the most difficult challenges in counseling terminally ill, chemically dependent patients is to help them make wise and prudent choices about the use of medically prescribed painkillers.
I am a strong believer in abstinence as a primary treatment goal. I also recognize, however, the need that many patients have to find relief from intractable pain. I have been approached by many people and asked if I consider it a relapse when terminally ill patients use painkillers such as Demerol or morphine. My answer is a strong and resounding “No! It is not a relapse!” These pain medications are necessary to allow some quality of life.
It is important to remember that the pain associated with many chronic diseases can be more incapacitating than the use of legally prescribed painkillers. There is a big difference, however, between using prescribed drugs under careful medical supervision and self-medicating addictively.
Counselors and therapists can learn how to help their patients come to terms with their needs for medically prescribed pain medications. Counselors can help patients in the severe intractable pain to accept that this is not a break in sobriety. They can work with responsible pain-management physicians to develop an effective pain management plan that allows the longest and highest quality of survival time.
Relapse Warning Signs For Terminally Ill Patients
There are a number of relapse warning signs that can help terminally ill, chemically dependent patients recognize that they are moving toward a chemical relapse and take corrective action. These are:
1. The belief that returning to the addictive use of alcohol and other drugs will make the illness more manageable or provide relief from pain. As we discussed, the use of alcohol and other drugs will only make the disease worse.
2. The belief that the use of previous drugs of abuse will be more effective in pain management than the use of prescription drugs. Most people quit using their drug of choice because they no longer get the desired effect. This is the result of tolerance. Your drugs of choice didn’t work well before and they won’t work well now. Find a physician who will work with you in finding an effective medical regimen for the management of pain and supplement the medication with other forms of pain control. This will be more effective in the long run.
3. The belief that returning to alcohol and drug use will bring about a quick and painless death. Many terminal ill patients want to end the pain and mistakenly believe that alcohol and drug use will be an efficient way to commit suicide. This is not true. Death from chemical addiction is a slow and painful process both physically and psychologically. If a person has decided to end his or her own life, there are other more effective and painless ways to commit suicide.
4. The belief that having a terminal illness means that there is nothing left to live for and, therefore, alcohol and drug use is justified.
When I finished, Malcolm stood up, put on his hat and said: “Thank you, I have a lot to think about.” As I shook his hand and turned to walk away, I realized that, like Malcolm, I also had a lot to link about.