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An Interview with Paul Earley, M.D.

The following is the edited transcript of an interview by Bill Moyers with Paul H. Earley, M.D., on treatment and recovery. Earley is the Director of Addiction Medicine and Medical Director of the Impaired Professionals Program at the Ridgeview Institute in Atlanta. Portions of this interview appear in the CLOSE TO HOME television series. To ask Dr. Earley specific questions or to obtain further information on Ridgeview, visit Earley Associates (http://www.torecover.com).

Moyers: Do you consider addiction a disease?

Earley: Yes. A disease is anything that has a series of symptoms with a predictable outcome and a particular treatment. Addiction has a progression. It's treatable. And we're even more clear about what addiction is than we are about what causes cancer.

Moyers: How would you describe it as a disease?

Earley: The problem I think people have with seeing it as a disease is that it has so many different facets and it confuses those who observe it. There are the biological facets, the damage to the body, emotional facets, the damage to the self, where an individual begins to feel worse and worse about himself and overcompensates with more and more consumption of chemicals. And then there's the family aspects, where that individual who is addicted begins systematically decimating those around him. Then there are the sociologic aspects because of crime, and then there's the final kicker: the person who's addicted never thinks they are. It's the only illness that says, "I don't have it."

So, all that confuses society and it keeps us from focusing on the core truth that someone who develops an addiction illness has one primary problem that needs attention. And so they start focusing on all the things around it. A  family therapist sees the family problems. And a sociologist sees the crime, and no one's seeing the thing at the center. I think that's the primary problem we have.

Moyers: What is the thing at the center?

Earley: It's a compulsion which slowly eats away at the person, consuming a larger and larger part of his thought. It's an illness that starts taking hold and creating thoughts about use, or other addictive behaviors that supersede everything else. It can supersede any of our other basic drives, whether that's food or water or self-preservation, or family. It's a compulsion of the mind, an obsession of the mind, and that obsession takes over everything around that person.

Moyers: It helped me a great deal when I was here with my son to learn that it was an obsession of the mind and that the drugs themselves helped to create that obsession -- that it wasn't just, as so many of us used to think, a moral failure, an absence of character.

Earley: When you look at it from the outside, you tend to think about your interaction with the person. "How is my interaction with that person meaningful or involved in what they do?" And the truth is -- once you get in the middle of addiction -- is that it's not about anyone else. It is only the relationship of that person with the chemicals which is the problem. It's not about your loved ones. It's only about a relationship between you and the chemicals.

Moyers: Help me to understand that. A relationship between you and the chemicals. You and the alcohol. You and the drug.

Earley: It's a lot like having a jealous lover. All of us have fallen in love and had a relationship that wasn't going well. The other party began saying, "Well, I don't want you to see your other friends." Or, "You need to spend your time with me, because I'm important to you." It feels a lot like a jealous lover who starts tugging at you and, at first, you go, "Well, I do want to go spend my time with my friends." And, then after a while, you're so enthralled with that lover that pretty soon, the rest of the world disappears.

Moyers: What happens to free will?

Earley: Well, there ain't none when it comes to addiction. We like to think of ourselves, especially in the United States, as having lots of free will in our lives and being able to make decisions about what we can and can't do. But when it comes to it, there are some things biologically that we have no choice about. If we sat here in this room for five hours and had nothing to drink -- after a while, the obsession to drink a glass of water would overtake us. What happens with the addict is that the obsession around the chemicals and the behavior is wired into the part of our brain that deals with basic primitive sustenance. And just like we can't fast forever without becoming obsessed about food, the addict, after a while, becomes wired into that instinctual drive that says, "I must." Biologically, this is wired much deeper than that part of our brain that has anything to do with free will or choice.

Moyers: But some people are known to just stop, to go cold turkey, to quit without treatment?

Earley: That's an odd phenomenon we see often. In most of those people, two things happen. One is that often they have a catastrophe in their life. A heart attack or a stroke or cancer, or your wife leaves you, or something cataclysmic happens where there's almost a shift in the tectonic plates of the brain. When that shift occurs, there's a moment in time where that person can stop. Sometimes it's just a psychic shift. Sometimes you'll see people who will have an occurrence in their lives internally which creates an opportunity to stop. Some of those people have genuine peace in stopping their chemicals. The majority of them don't, however -- they become bitter and angry, and that's really what treatment and recovery is all about. To take a person who's been jailed by their chemicals and say, "Well, you're going to be, in some ways, jailed by your recovery early on 'cause you can't use." And for you to develop some happiness and some compassion and some contentment in this jail of not using, which just, for the addict, is just as much a jail at first as the using was before they came in.

Moyers: Have you any insight as to why people use?

Earley: We tend to think about addiction as having lots of different determinants. Sometimes I describe it to my patients as being an engine. And what builds the engine is often a series of things: your genetic makeup is a powerful piece of that; life events, especially things like trauma early in life for a child; family structures, especially families who pressure a child to not be a certain way, where they become, "Act like this."

Moyers: Tell me about that.

Earley: Those kinds of things create -- they build the engine. But the engine, just like a car engine, will not run without fuel. And so then there are other things which are the fuel for that engine. The fuel often is the everyday things. "I'm frustrated at work. I'm in a situation right now that I can't tolerate." Or maybe adult problems like pain, like the sadness of losing things. But the engine is often built very early on in life and some people go through their lives never having put enough fuel in that engine to light it up. Other people, however, have that engine, and then they start the process of fueling it. For the alcoholic, it's drinking casually, or drinking more heavily when there they are more disappointed in their life's events. And then something happens, as time goes on, where they fill enough fuel in that tank that the engine catches fire. The reason that analogy is helpful for us in treatment is because we spend our time looking at those two aspects. What can we do to drain the fuel from the tank? And, what can we do to even begin to dismantle the engine so that, even if fuel's there a little bit, it won't take off.

Moyers: So, what becomes the instrument of treatment? What's the core of treatment? Of change?

Earley: There are many different types of change that people go through in treatment. The first change anyone can understand. It's what we call behavioral containment. You are put in a place where you have to stop the behavior. In the old days, that meant having you in a hospital setting. Now, what we're trying to do within the limitations that are placed on us is to help the person set up an environment where the chemicals aren't around, or their friends who use the chemicals aren't around, or the alcohol's out of the house. In residential care, we bring them into a place like Ridgeview, and we try to pay attention, not only to the drug use, but also to the other behaviors involved in the addiction, and we try to stop them for a moment. Now, that doesn't do anything towards long-term change. All it does it set the stage. So, people come up to me and they say, "I quit smoking cigarettes." And I say, "Well, that's great. Anything else you did around stopping smoking cigarettes?" And they say, "Oh, well, no, I just stopped." I say, "Well, that worries me a little bit, because it takes more than that. That's the behavioral piece. That is the first piece. It's the numero uno. And the mistake we used to make in treatment, really, before the sixties, is that therapists didn't pay enough attention to stopping the behavior. They thought maybe if we can get this person to see themselves more clearly, the behavior will just stop on its own, which is kind of belying that biologic drive. We were saying, "Oh, well, there's no biologic drive here. It's just all about psychology," and we don't think that's true any more. So, the first step is the behavioral containment. You got to wrap that person in some kind of a container which stops them from using. The next stage that is what we call cognitive insight. People begin to see themselves clearly. Because after you stop the behavior, you can step back. You can put it out in front of you here and you can say, "That was not smart." When you're in the middle of it, you think it's the most smart thing to do. And it doesn't matter, I mean, it's remarkable. You can talk to people who are in the middle of their addictions, and they describe their behaviors and you say things like, "Can you see how this is hurting you?" And, they'll say, "Well, yeah I can, but -- " And there's always a but, and they don't pay attention to it. But, stopping the behavior gives them the distance so they can see. And during this learning period, there are several experiences that patients call kind of an "A-ha" feeling, like a popping sensation, where they say, "My goodness, is that what I was doing? You know, that was crazy." And it's a relief, because when you have taken someone that's addicted and you've put them in that cage of recovery, they feel miserable. What they've used the chemicals for is a way of coping with everything that's wrong in their lives, so that when you take it away, of course, they're going to feel worse. You've taken away their only coping mechanism.

The third thing that we look at in people is something that we call emotional understanding. It's an understanding of the full ramifications. It's where people begin to take a look at their lives and say, "Oh, my God. This has run my whole life." And at the same time, usually they begin to say, "Not only has it run my life. Look at what it's done to my family and my parents or my children." And during that phase, most people are profoundly depressed. If they don't get to that stage, however, they don't get better. So, it's again, what we're doing at this point is that treatment is all about feeling worse. And, my patients come to me, "Oh, I have these dreams at night about how much I've hurt my family. I've disappointed my parents and I've hurt my son by not being there and I've ruined my job. I feel terrible. I must be doing terrible in treatment." And, I look at them and say, "You are doing great." They say, "You got to be kidding. This is what doing great is?" And I say, "Yeah. It's coming to grips with who you are. It's that knowing that truth that, Yes, it has hurt you."

The fourth stage that people go through is what we call transformation. And that's the part that looks the most, I think, to outsiders as being a little bit like voodoo, or a little eerie or strange. But yet, when they see the people who have gone through this experience, they say, "I like this guy better." Because all of a sudden, they become someone else. One of my patients came in and said, "I think I've got it figured out about you guys. You're brainwashing us." And, I looked at him and said, "Would that be all bad?" Because after all, what happens when you become addicted is your head is filled with this horrible stuff. People on the outside think that having an addiction problem -- that those folks are out having fun with all this. Yet, when I interview my people and I listen to the folks who go through treatment with me, they're all miserable. They hate what they're doing. But they're stuck. As much as you and I are stuck every lunch time to go eat lunch, these people are stuck on the fact that at certain time of day, the bell rings and they're out using drugs or alcohol or engaging in some other addictive cycle.

Moyers: So what are you trying to wash the brain free of?

Earley: Of all that hurt, of all those thoughts. But you can't take someone who needs a brainwashing and shove anything at them. They have to willingly pull it in and they have to pull it in a way that they want it.

Moyers: And that's where the accountability and responsibility come in. The moral agent has to operate there to want to do this? Right?

Earley: Right. And the moral agent wakes up sometime in the process of recovery. What you find of people who have good recovery is they're moral people. They become very anxious about doing the right thing, because after all, they feel like they've been doing the wrong thing for long periods of time. The problem is when you see people that are addicted, you say, "Look at these people. They're ruining everyone around them." They're doing crimes. They must be totally immoral people. Well, when they're using, they may be. Just like if today we outlawed food. There would be a lot of criminals out there breaking into grocery stores.

Moyers: And by immoral, you mean that in the pursuit of the drug, some of them will do anything it takes to get that drug?

Earley: Yes.

Moyers: Whereas they wouldn't have done that before the addiction.

Earley: No. Now, I want to be clear with you that there are people who suffer from other psychiatric problems which can impair their morals. But those people are by far the minority amongst addicts.

Moyers: My father used to say that if you get a horse thief sober, you still have a sober horse thief.

Earley: That's right. And if this fellow is a horse thief and if his thief qualities are deeply embedded in his character, getting him to stop drinking is not going to stop him from stealing. However, if, in the course of his drinking or drug use, he starts doing things like stealing horses, maybe it has nothing even to do with his addiction and you stop the drinking, there's a chance that that guy might not stay a horse thief. He might become a sheriff.

Moyers: We used to have a notion that -- that one size fits all in treatment -- that the same thing would work for everybody. That's changed?

Earley: Treatment has changed dramatically. Part of that is an increase in our knowledge base. Part of that is the insurance climate and coverage climate. I think the positives are that we're beginning to see each person as a unique individual, to figure out how to individualize the length of stay, the level of care, and the types of interactions he or she may need. When someone comes into me, I like to think of them as a puzzle. They arrive at the door, and on the surface, they've got their addiction behavior, which is, by the way, very stereotypic -- and that's the thing that may have confused us early on, because alcoholics, when they're drinking, they do the same nutty stuff, and so you hear people in twelve-step meetings, in group therapy saying, "Yeah. I did this." And half the other room chuckles because they did it, too. So, in the using part, it reduces us from very complex people into very simple people. And so treatment people thought, "Oh, I see, this is a simple kind of thing." When people arrive at the door, they seem to be simple. But then, as they begin to stop drinking, all of a sudden, you realize there's this series of psychological linchpins that need to be pulled for that person to shift into recovery. And my job as a therapist and as a program director is to figure out how we can start pulling the right linchpins that make the changes occur. We have to figure out how to pull the right linchpins so that the personality shifts into being more who they really are.

Moyers: And some of the linchpins would be . . . ?

Earley: An example is a woman who really wanted to have a career, but decides instead, because of society's pressures, to have children, to do what her husband says is right. Maybe she had a father who also said, "Do the right thing. Do this." So, she gets married, she has children. And then, as the hubbub of her life begins to slow down, she starts to drink a little bit. And maybe she has a father who's alcoholic or a mother that's alcoholic, and so that she's got that engine going that's going to create addiction. Well, as her addiction gets deeper and deeper, she comes in, she looks like any other drunk, frankly. We get her sober. And then, you realize that she has become someone in her life that she didn't want to be. So, the linchpin to pull is to allow her to say, even if it's just saying it, "I don't want to be this." Now, does that mean that she's not going to be a mother anymore? No. It means that she's going to be able to say, "This is not what I was planning." But she spent all of her life saying, "Well, I should love my children. I should be a dutiful wife. I should be this." But there's a part of her down deeper that says, "No, I -- I want -- I want to be something else." Even in the acknowledgment of that is a pulling that linchpin.

Moyers: You're not suggesting, are you, that the frustration over her life's choices and courses created the addiction, but that the use of the alcohol or the drugs was a way of medicating the frustration that she felt?

Earley: Yes. There's always a dynamic challenge between those questions. Was the chemical use created by the frustration, as you say? The answer to that is no. But, it did spark that engine rolling. Now, once it's set in motion, the downhill course of the addiction is probably to a large degree biologically determined. But the uphill part of the recovery needs to have the linchpins pulled for that person to feel whole again. And that "whole again" experience is transformation, and it helps people remain in recovery for long periods of time, hopefully the rest of their lives. There's a careful balance, because sometimes the therapy is painful and it makes people think about drinking and using again. What I spend my time late at night worrying about with someone like Donna [a woman seen in the program with sexual abuse issues] is making sure we move in the right direction. Should we be doing this therapy now, in order to make sure she stays sober? Or should we wait? It's kind of a staggering thing. Sometimes we say, "Okay, let's turn down the energy on the therapy for a bit. Do you feel better? Or worse?" She comes back two or three weeks later saying, "I'm less churned up, I'm less anxious. But I have more cravings to drink." So then we go the other direction and say, "Okay, let's do more therapy." There a kind of titration. You need the right kind of therapy to keep them sober. But not too much, because the soul is a very fragile thing.

Moyers: What is the change you're after here? Is it change of heart? Change of habit? Change of mind?

Earley: All those. But for people that have been through transformational experiences, they describe it as though everything around them has changed. Remember, people that are addicted have problems seeing themselves, 'cause they've got this denial over their head. When transformation occurs to someone who can't see himself, what he first notices is, "Geez, this is funny. The world looks different. My wife, she seems different. My job used to drive me crazy, and it's not so bad." And, so, they come in to see me and they say, "The weirdest thing happened to me. I got out of treatment and I went back, and everything changed." And I say, "Well, you know, sure, that happened to you. The entire world orchestrated itself around you so that you could stay sober." And, they laugh and they say, "Oh, I see. I'm the one that changed." But it feels like everything else changed. It feels like the rules changed. Now, that doesn't mean that there are fewer rules. It just seems like they are less harsh, that they don't have to struggle so much with the rules of reality. Like, "I used to argue with my boss all the time -- he didn't know what he was doing. And I got in recovery and came back, and realized that sometimes he does." That's the transformational experience.

Moyers: Don, whom I talked to yesterday at the picnic, described that change as spiritual. What's your read on that? So many people tell me they've had a spiritual change.

Earley: All of us are composed of various parts. The thing that is so striking for me is that as a physician, we're not taught anything about dealing with a spiritual part of the self. But, yes, absolutely, it is a spiritual awakening. It is as if the world was dead and it is alive now. Different people experience it differently. Some people find it a religious experience. They find that God is all of a sudden where the addiction was. Other people find that the humanity around them is suddenly sweet and supportive, and provides a safety net under which they can kind of live their lives. It is indescribable and has nothing to do with anything else in medicine. That's what makes working in this field so great. People become something they always wanted to be. And they feel as if their lives have meaning. And, that's what the spiritual piece is. Some people wind up becoming profoundly religious. Others become profoundly humanitarian and move down that road.

Moyers: One woman said to me yesterday that for her the group was her higher power. Now, some people would say that's profane. That's heresy.

Earley: The spiritual awakening, I think, also comes in stages. Many people who are addicted are very hurt. And if you are hurt a lot, you might have difficulty with faith. And so, sometimes people wind up growing spiritually in stages. One of the great sayings in recovery is, "It's not important that you find God, it's important that you know you're not God."

Moyers: Yeah.

Earley: The first step in that is saying, "Okay, I'm not God. Maybe this group, who I care about and I know I can trust, is my God for awhile." And it may be a way station, or that person may stay at that place for the rest of their lives. For many people, they start off and say, "Well, I'm not going to swallow this God stuff." And, I say, "I don't care. All I want to be clear about is that you know you are not God." "All right. Well, I -- I can see my life is a -- is a wreck. If I'm God, I've done a bad job." Well, that's a good place to start. And we start with that principle. And that's the first path towards spirituality. And it's that hunger which really also sets the addict apart. I have even come to believe that in some people their alcoholism is nothing but a misguided spiritual hunger. Because the alcohol becomes early on in their life, when their drugs are a spiritual being to them.

Moyers: In what sense?

Earley: It is a source of solace, peace, and meaning at first. And so, a lot of us that are in recovery tend to say, "Gee, my alcohol was my God, wasn't it? You know, 'cause I looked to it for solace, peace. So, it's not there. Now, I must look elsewhere."

Moyers: What happens in the group? Why is the group so important to this process? Everybody in the field says to us, "The group is important." Now, watching you with your group, I keep asking myself, "What's he really doing there? Is he just getting them to let their feelings hang out?"

Earley: Much more complicated than that. The first thing is the group offers a light at the end of the tunnel. If you see someone a little further along, they can offer hope. And when you have an addiction, you are hopeless, whether you acknowledge that or not.

Moyers: You mean, if somebody who's just come in, the first two weeks, and looks and sees somebody who's been here three months, and that person has a different look, a different step, a different attitude, there's hope?

Earley: Absolutely. They see someone who's maybe just two weeks later. Maybe they're worried they're going to not stop shaking, you know. And the guy says, "Boy, I was shaking like you last week. And I'm not anymore." And the guy says, "Oh, okay."

Moyers: All right. Comparison is one thing. I compare myself to you and I see, "Hey, if you did it, I can do it." What else?

Earley: The other piece that I think is so critical is that when we develop an addiction illness, we become actors, and we become exquisite actors. And, we can act in a certain way and fool any one given person almost all the time. The group process prevents people from acting because you got a bunch of actors in there in the group, and they're all actors. And they've all acted, and they've all played some incredible roles. And they start in the group process, they start acting. And then the other one looks at him and says, "Yeah, I hear what you're saying, but let me tell ya, this looks like gobbledy-gook. This looks like you're just trying to play a part here." And that gentle, hopefully, but directive, confrontation helps. Because as a therapist, if I sit with any given addict, they'll fool me, too. I mean, I've been doing this a long time and you sit one-on-one with a patient, and they'll fool the pants off of you. They'll leave the individual session and you'll say to yourself, "That guy's doing well." And then my front office staff says, "Well, his wife just called and said he's drinking like a fish." But if I take that one person and put him in group, that group will be able to figure out that there's a problem there. And I don't know why that is. It's the power of unmasking that that group has.

Moyers: Let's talk about honesty. When I interviewed Chick yesterday at the picnic and I asked him what's the most important thing that happened to him here, he said, "I learned to get honest." Why is that important?

Earley: Well, we've got all kinds of lies we tell in life. The little white lies, "Oh, I'm late 'cause there was a traffic jam." And, then, we've got secrets that we hide from other people because we don't want to hurt them. And then we've got the things we just plain lie about. And, there are the things we lie to ourselves about. The problem is that lies are like the denial of the illness. Remember that the crux of this illness is that it has to be in the dark. That the person who's addicted cannot see it for what it is, because if they do, they're going to be appalled and they may actually change. So, it has to lie in the subconscious part of the mind and it has to be covered by lies over lies. So, the part of getting better is peeling off those lies one by one. And it's usually just not one lie. It's usually a series of things. And so as we go through the treatment process and we peel away those lies, people become more who they really are. The denial starts to drift away about having an illness.

Moyers: What do you mean by denial?

Earley: Denial is an unconscious mechanism which distorts that person's understanding of what's happening to them. The thing that I think people who aren't in the addiction world find so frustrating is that they will see people that clearly have problems, and they can't see it. Some people say, "I just want to go up and shake 'em and say, 'Do you see what you're doing?'" But that wouldn't do any good, either. That's the tragedy. However, in treatment, as the addict begins to peel the layers of the lies off of himself, the denial begins to drift away and he sees himself for who he truly is. And it's that kind of self-knowledge that is critical for recovery. Denial helps keep us alive in many ways. There are so many things in our lives that hurt, that enrage us, that, make us grief-struck, and that denial is like a buffer. It helps hold the lid on strong feelings that we can't tolerate feeling. For the majority of us walking on the planet, having a little denial about what's happening with them keeps us alive. After all, we're all going to get sick. We're all going to suffer infirmities and we're all going to die. And, if we had to spend all of our lives sitting around and thinking about that, we would be pretty miserable. So, denial is a functional thing that each of us have. The problem in addiction is it's denial run rampant because the denial kind of gets ensconced in all those addiction behaviors, and it hides those behaviors. And if you've got an addiction that is a fatal problem. It's not just a problem. It's a fatal problem, because if you start lying to yourself, then one day, the addict will say, "I can have a beer. I could use a line of cocaine." And that can be a fatal lie.

Moyers: Are addicts more uncomfortable in their skin than other people are?

Earley: I think they are because they have become disenfranchised from themselves, because they have pulled out of who they truly are. People who are really comfortable in who they are, you walk down the street and you can see them. You meet them in a restaurant and you chat with them for a few minutes and you can say, "Now, that person's comfortable with who they are." And it has no correlation, by the way, with intelligence or what you're doing for a living or anything. It's just some people are comfortable about who they are. And it's a blessing. And what treatment is all about is getting that self back in the center of the true self and displacing the addiction out. Pushing it off to the side and not forgetting it. You can't forget about this. People in recovery say sometimes to me, "Being in recovery is a little bit like having a bowling ball suspended over my head." It's like you're always walking around saying, "Boy, that's really going to hurt if it -- if it goes. So, I have to be real careful. So, I've always got my eyes up waiting that bowling ball to fall." And what they do is spend a lot of their lives trying to do whatever they can to make sure it doesn't fall. They reinforce the chain that's holding it up and that's the recovery piece. They're trying to reinforce those behaviors, those ways of thinking, that way of living -- the honesty, the directness that is recovery.

Moyers: That's why you said to the group in your lecture the other day that treatment can lead to a richer and more expansive life, that it isn't just a bounded little piece of territory where everything's constricted and confining?

Earley: Yes, that's a miserable place. And some people who just quit drugs on their own find that that's where they stand. They stand on a very thin platform, and they keep their life experiences very thin because they're very afraid of returning to the chemicals or the alcohol. True recovery is where you experience more different parts of yourself, and that platform on which you live becomes wider and wider and wider. And that's hard, because you have to realize that it's hard for the addict because they're, as you said earlier, uncomfortable in their skin. You have to encourage them to explore new avenues. Find out more about themselves. And, to do that and not relapse, that's the trick.

Moyers: How do you see relapse?

Earley: Relapse is a return to how it used to be. That's the best way of describing it. Sometimes people relapse simply by returning to their chemical use or their alcohol use. That's a relapse. But also, sometimes long before that happens, people return to the way it was in terms of their behaviors. They start acting like a drunk, or they start acting irascible or angry or they've lost that peace. They become uncomfortable in their skin again. They become more anxious about things.

Moyers: That's the knock on treatment from people I talk to. They say, Look at all the people who relapse. Look at all the people that never make it. So, why should we invest in it given the poor success rate?

Earley: Because it works just as well as treatment for any chronic illness. Chronic illnesses are marked by relapse. Recent data shows that. People don't comply with their anti-hypertensive medicines or their diabetic medicines to keep the diabetes under control. They do just as poorly as addicts or alcoholics do. But you don't hear people saying, "Well, you know those diabetics, they're not following their insulin regimens, so we just ought to stop giving healthcare dollars to them. Let 'em die." It's a prejudice. But what happens with addicts is that they piss people off in a big way. They piss off families and, even worse off, they piss off the police and they make people angry because they're doing something which is destructive, not only to themselves but to others. And so, it's right to be angry in some ways. If you feel angry about addiction, that's right. But let that anger be a catalyst for us to figure out how to do it better rather than in a way of punishing a person.

Moyers: So, relapse to you is a setback, but it's not a surrender, a final defeat?

Earley: No. That's the natural course of the illness of addiction -- a process of relapse and recovery, especially early on. Many people have to go through phases of relapse, devastating to those around them, heartbreaking to their families and their loved ones. But oftentimes it takes that. It's really as though people who are addicted have a learning problem. They have a problem learning that they're addicted. They could learn anything else. You can send them to school and they can learn rocket science. But if you say, "You can't drink," they go, "I can't drink. Okay, I got that." And walk out the door and they drink. And they come back and you say, "What part of that did you not understand? You can't drink." "Oh, okay, I got it. I can't drink." And, then they go off and learn how to be a brain surgeon. And, then they come back drunk again. And, you say, "What did you not get there? You can't drink." "Oh, okay. I can't -- " They have a learning disability. They can't learn that fact. They can't learn that fact. And that not learning is the psychological wonder of that addiction. They can learn anything else, but they can't learn that fact.

Moyers: And why is that? Because the drug itself has so affected the processes of the brain?

Earley: Addiction gets its tendrils in the part of our brain that is much deeper than reason -- the survival part of the brain. The tendrils of addiction are intertwined in that part of your brain that wind up dictating a lot of your basic primitive behaviors. And so, what we try to do is use this thinking part of our brain that's saying, "Oh, my. Maybe I shouldn't do this." And meanwhile, this driven instinctual part says, "I will." And that thinking part in the part says, "Maybe you ought not." The "just say no" part of the brain on the top says, "Oh, well, just say no." And that basic primitive drive says, "The heck with that 'just say no.' I'm going to do it." And that's the dilemma.

Moyers: It's the base drum responding to the piccolo?

Earley: Exactly.

Moyers: Some physicians have said to me that it's very frustrating working with addicts because the disease is so tenacious and they just often don't get better very fast. Do you find it frustrating?

Earley: Treating addiction is frustrating and heartbreaking. When you see someone who has cancer dying, you have this sense that, "Yes, an organism was taking him away, and you look at the tumor and you say, 'That tumor killed him.'" The part that's frustrating about addiction is I can't pull out the tumor and say, "Dammit, if that isn't the thing that did it!" What is constantly important for those in the field to remember is to be clear that we are but vehicles for this change, that we ain't the change. We are not the source of the change. We are vehicles of knowledge and of training that can help people change. And, sometimes that helps. But the number of my patients that I treat and relapse and some die -- you take to bed at night and when you can't sleep, they move around in your head. So, yeah, it's hard.

Moyers: What brought you to this work?

Earley: My own addiction and recovery. The joke in my family is that Paul hasn't figured out what he wants to do when he grows up yet. The only thing that I was very clear about in my early life was my drug and alcohol use.

Moyers: Early?

Earley: Early. Really from age 16 on.

Moyers: Why did you use?

Earley: I'm not sure. I can't tell you. There were a combination of things. I felt like that I wasn't good enough. I wasn't what my parents wanted. I wasn't what I wanted to be. I felt like I should be more. Well, drugs and alcohol, as soon as they got in my system, they said, "Well, you are more. You're more. You're just fine." And so, I sat in that place that I created early in my using. And in some ways, early in my own using, I felt very comfortable. I felt at peace, and I was able to maintain a fairly normal life. Several things triggered it to go downhill, however. One was some tragedies that occurred in my personal life. That increased my using and then suddenly, I didn't feel so good, doesn't matter how much I used. But I didn't know how to get out. I was so hopelessly trapped. And that's the part I can see in patients -- that sometimes, they can't even see. I can see because I have had enough distance from it and I remember what it felt like to be trapped. And all they can see is, This makes me feel better and I can see, "Yeah, you're trapped. Now, I feel better, but you're trapped." After a while, a lot of them come around to my way of seeing and thinking about it. They say, "Yeah, I was trapped." So, it was my own personal struggle with addiction that got me here.

And, like a lot of people who work in the field, your personal recovery provides a passion. It's no substitute for education. But, it is a passion. And the passion sometimes helps overcome the frustration of dealing with addicts who do dumb things over and over again and you'd like to go and shake 'em and bang 'em over the head and say, "What are you doing?"

Moyers: Did you do dumb things?

Earley: Oh, did I do dumb things! The part that's amazing is, doing dumb things and thinking no one would notice.

Moyers: Such as?

Earley: Well, when I was working on charts in the hospital, I would be sitting in the medical records room drinking a beer. Now, did I have patient contact that day? No. But you don't drink while you're sitting in the medical records room of a hospital. You don't do that. That's nutty. And probably the most nutty part about it was that I thought people wouldn't notice.

Moyers: That's the denial you were talking about.

Earley: That's the lie. I was saying, "Oh, this is not a problem." The fact that my behavior became more and more eccentric, I couldn't see that. And my friends around me later told me they were very convinced I was a severe manic depressive and I was almost psychotic. And even now, when I look back on that, I say, "What made you think that?" The mood swings, the crazy thoughts -- and, the omnipotence of it all. That you, somehow, could fool people.

Moyers: You were God?

Earley: I was God. And, I was a very bad one. So, what happened to me is that someone came in and said, "You're not going anywhere." And in that moment there was a shift where I said, "I probably wasn't God. 'Cause if I was God, I'd be out of here." And, as a matter of fact, I was not only not God, I was not anything.

Moyers: What do you mean, somebody came in? A friend? The doctor?

Earley: A series of doctors came in and, basically, helped me. First there was a confrontation about my using and they said, "You need to do something about this." And I listened to that for a while politely and then went back to drinking. Finally, what happened was writing prescriptions for myself resulted in the police helping me understand that I wasn't God. And, by the way, they didn't listen to me. It was so shocking that they didn't listen to me. As they put me in the police car and drove me off, I said, "You don't know who I am." And, they looked at me and they said, "We don't care who you are. You're going to jail."

Moyers: I saw a study recently which suggested that the people who do best in treatment are airline pilots and physicians, because they stand to lose their licenses, their way of making a living. Did that happen to you?

Earley: I came very close to losing my license. I had some people who were caring for me enough who said, "Look, you don't want to lose this. We want to prevent you from losing this." But I felt so decimated I didn't care. I really didn't care. I said, "The heck with that." Actually, I'm not sure I didn't care. It was more like I felt like I deserved to lose it because of all that I'd done. But I had some folks around me who said, "A year from now, you may want this back." Those were some wise people because later, my true purpose in life became known.

Moyers: Which was?

Earley: The reason God made me a doctor was so that I could do what I do now. But at that time I was so low that I believed that I owed it to society to never practice medicine again.

Moyers: That's pretty deep in the pit. So, what were your processes of change that brought you back?

Earley: The caring of the group, seeing the light at the end of the tunnel by having other physicians who said, "I felt like you did, too. And so, it slowly filtered into my brain. As my self-confidence increased, I realized that maybe I had done some bad things, but maybe I was not bad to the core. And I thought maybe eventually I could learn about addiction and help others to recover as well. But, the passion alone does not make someone know how to do that. It takes training and skills. Because at the core of this, all we can do as therapists is to figure out when to push and when to pull, when to lean back, when to move forward -- and, how to help nudge folks in the general direction of recovery.

Early on, I figured if you just get a big enough baseball bat, you'll get their attention. But addicts have this learning problem, so it doesn't matter how many times you hit them -- after all, they've been hit in the head by their addiction for most of their lives and they still don't get it. So, what would make me think that I could hit them hard enough to get it? Instead, it's the subtlety of the interaction and the caring that creates the healing.

Moyers: What about people -- Paul, what about people who are poor and can't afford treatment like this?

Earley: One of the traditions in the twelve-step recovery programs is that of sponsorship of watching over and helping those who are earlier on in recovery. Even if you don't have any money, you can go to an AA meeting. You can go to a CA meeting or an NA meeting or an Al-Anon meeting. And in that process of support, there is a wisdom which is passed down from generation to generation, which has a profound therapeutic affect and can do 99% of what psychotherapy does. I would love to think that we are coming up with all these new-fangled fancy profoundly psychotherapeutic techniques, and sometimes I think we've done that. And then, I hang around the folks in recovery and I hear what is being said in twelve-step meetings, or I hear it in a meeting and I say, "Humph, oh, gee, I thought I invented that." Twelve-step meetings do 99% or 98% of what we do. Sometimes what we do is faster. Sometimes what we do speeds up the process. But, the same thing could almost be done through twelve-step meetings.

Moyers: So, meetings, AA groups, Al-Anon, all of those support groups are important in aftercare to the continuing process of recovery. And, a homecoming like your graduates experienced this weekend here is important to continued success, is it not?

Earley: Absolutely. It's a chance to reflect, go back and look at things. And even in our homecoming, the central theme every day, interestingly enough, is AA meetings. Twelve-step programs are the bedrock of what we do. As a matter of fact, they give us the bedrock out of which we can stand on to do what we do. But if we don't have the bedrock, we wouldn't be able to -- we'd be in shifting sands.

Moyers: What do you think when you walk around at your picnic? At your homecoming? You see these people who've been here, been here many years ago, and come back and keep coming back every year. What goes through your mind?

Earley: I feel honored. I feel that to be part of something so vital is a dream come true for me. And I get to see people come back, and they fill me with such joy that the next patient I see who's just coming in the door, who is angry, and resentful, who thinks I'm something out of their worst nightmare, I can sit with them and be pleasant and know one of these days, they might be coming back to a reunion, too. One of the great metaphors I talk to patients about is when you come into a detox unit, the door makes this heavy, kind of leaden "gooshzz" when it closes. And, a lot of my patients look at the door and they have this kind of bolt of electricity go through them and I say, "The door closing bothers you, doesn't it?" And, they say, "I hate locked doors." And I spend a little time talking with them about it, saying, "Yeah, you've been behind locked doors for a lot of your life." And, they look at me and they say, "No. I've never been in jail. I own my own house. What do you mean, I've been behind locked doors?" I said, "You've been locked up in that addiction for many years, haven't you?" They go, "Oh, yeah." And that's what bothers them, that the door closes. When the door closes, they say, "This is it." It's kind of a message to them. That clicking noise is a message to them that says, "You got to deal with this."

Moyers: The door that closes also opens.

Earley: That's the other piece. Then, when people leave, one of their favorite sayings is sometimes they come back and they come back to run AA meetings, to give back a bit of their time in volunteerism. And they come back in, and every time they walk out, they say, "My favorite thing is getting to the door and knowing it's going to open when I walk out." And they say, "And, now, that's what my life is like, that the door is open again and I can walk out."

 

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