“How are you sleeping?”
“Well…really poorly. It takes me awhile to fall asleep.”
“What do you do for fun?”
“Nothing? Is there anything in your day that you enjoy?”
“Well, I drink a bit.”
“Okay, how many days a week do you drink?”
“All of them.”
“How much do you drink per day?”
“6 to 8 beers.”
“Hmmm. How would you feel about cutting down on the alcohol?”
“Please don't take that away from me! It's all I have left!”
How do we get to this point? In Kurt Wimmer's 2002 movie Equilibrium, character Mary O'Brien asks character John Preston, “Why are you alive?” He answers, with some difficulty, “I'm alive…to live.” She responds, “It's circular, you exist to continue your existence. What's the point? Breath is just a clock…ticking.”
How do we become hollow? Do we, as healthcare providers, have any obligation to ensure that our patients are not simply pretty shells being pulled back and forth with the tide?
The deception of alcohol is simultaneously magnificent in its skill and devastating in its effects. Deception is an elusive force that is exceedingly hard to combat. The deception of alcohol is almost impossible to penetrate in the absence of negative consequences, and even then it sends forth sirens to lure its victim back. Many things are deceptive in life. Multiple health issues can fall into this category, including eating disorders, self-injurious behaviors, and “unsafe sex.” Alcohol is by no means at the bottom of this list. My patient's statement that drinking is all she has left indicates that other things have been lost and that drinking is fulfilling some need. My patient, then, is either whole already or something vital is missing.
I have not been seeing this patient for depression or alcohol abuse. She has mixed connective tissue disease (MCTD) and no health insurance, so she is my primary care patient at a free clinic. She comes to the clinic for management of her MCTD. The alcohol was hiding. Can I ask her why she is alive? Probably not. There is no way to know where someone will go with that question in an outpatient setting. Why am I working so hard to control her MCTD? Is the goal for her to be able to drink with less pain? If the drinking is not addressed, what is the value in treating the presenting complaint? There is an emptiness into which she is pouring beer; the trouble is that the beer goes straight through the emptiness, perhaps sends in some imposter endorphins, and then takes up an inflammatory lodging in her liver. My “sick” patient is not living a whole life regardless of her MCTD.
There is another problem here, however. Emptiness is not a diagnosis. It goes beyond depression. Are there presenting symptoms? Potentially, but they may not be unearthed without some gentle probing. Are there labs or imaging studies to be used? No. Is there a treatment? This is where the complication enters. Almost everyone will attempt to self-medicate emptiness; however, why should we spend any of our valuable time focusing on a problem with no biochemical foundation and no treatment guidelines? Are there solutions? Perhaps it would be beneficial to address the detrimental means of self-medication; however, the arguably unfair advantage of deceit is that the mind believes it is seeing the truth. The mind will also use an extraordinary amount of creativity to preserve this illusion. My patient believes that alcohol is fulfilling some need, but in reality, her neurotransmitter-driven brain is deceiving her. How in the world to break through deceit?
Relationship is vital. We must develop a trusting relationship with our patients and also be willing to invest some extra time, or this malady may remain in the dark. How to fix emptiness? This ultimately is a philosophical question, and we must accept that philosophy and science are distinct yet intertwined. They affect each other. There are many claims to the cure for emptiness. God can fill emptiness. Money can fill emptiness. Social standing can fill emptiness. Social action can fill emptiness. Love can fill emptiness. Drugs and alcohol can fill emptiness. Adrenaline can fill emptiness. Both validity and deceit can be found in these statements.
My experience so far in working with emptiness as a piece of the medical picture is that it must be addressed. Quality of life, which is a component of the medical discussion, will not be improved if the emptiness is ignored. The deception of alcohol serves as one small window into the heart of the matter. Although the first step may simply be a counseling or psychology referral, we cannot have time for this. We also, however, need to perform some self-evaluation. Are we, ourselves, affected in any capacity by emptiness? We will find it rather difficult to help guide our patients if we are not whole. Why are we alive? We need to seek out the answers to these questions if we truly want to be able to lead our patients into wholeness.