Those of Us Who Lie


 

 

 

I’ve written this blog article several times. I deleted one version because it sounded too mean, and another version because it was too shallow and unrealistic. It’s a difficult subject. Talking about people with substance use disorder who lie has potential to feel accusatory and judgmental, but lying is part of the behavior of people in active addiction.

Some medical professionals see lying as a character flaw and prefer not to treat patients with addiction because of this trait. They feel patients with substance use disorders lie more than patients with other disorders. I’m not sure that’s necessarily true, since I remember lies of patients I treated when I worked in Internal Medicine: “Yes, I always take my blood pressure medication,” stated by a patient whose pharmacist called me to say she hadn’t picked up her refills for several months. Then there’s me: “Oh yes, I floss every day,” said to my dentist, who can clearly see I don’t floss daily.

We all lie. If we say we don’t, then we are…lying, at least to ourselves. Most lies are based in fear. We’re afraid we’ll appear to be irresponsible, or careless. We don’t want others to think we are bad people. We lie because we’re afraid we won’t get what we want. We’re afraid of the consequences that may occur if we tell the truth. We lie because we don’t want to disappoint other people, or because we feel shame.

With addiction, fear is amplified. Patients with addiction are afraid of so many things: running out of drugs, running out of money to buy drugs, physical consequences of using drugs, what friends and family will think if their drug use becomes known. Many addicts fear they are becoming bad people because they act in ways that violate their own values. They find themselves doing things like neglecting family or stealing in order to satisfy the addiction. So they lie.

Addiction needs lies to survive. A person with an addiction can’t get money for pills from a loved one if he says it’s going to purchase drugs, but he may be successful if he says it’s for food. If he tells family and friends how many drugs he is using, it’s likely he will encounter some opposition, making it harder for him to keep using drugs.

Lies are part of substance use disorders.

Sometimes what appears to be a lie is really denial. Denial occurs when a person has convinced himself something is true when it isn’t. In addiction treatment, denial is common. Here’s one example:

I was seeing a patient in one of the opioid treatment centers about her urine drug screens. Six out of the seven since admission to the methadone program were positive for cocaine.

“I’d like to talk about your cocaine use. Can you tell me a bit about why you use, what triggers cravings to use?”

“I don’t use cocaine. I hate it. I hate the way it makes me feel, all tired and depressed when I wake up the next day. It’s awful stuff. It’s from the devil.”

“OK, you’re saying you don’t use cocaine?”

“I don’t. I don’t use it at all. I stopped using it.”

“Um…, but how long has it been since you stopped?”

“I quit years ago, but I did slip up and use just a little bit the other day.”

“I’m getting confused. You’re saying you quit years ago, but used cocaine the other day. Let’s look at your drug screens. Almost all of them have been positive over the last six months, and I see where you have talked to your counselor about it four or five times. In her notes it says you denied any use. We sent off one of the urine samples for a second, more exact test, and it still showed cocaine. How can you explain this? Is it possible you’re really using more than you think you do?”

“That one time I was helping my boyfriend package it. He’s a coke dealer. I don’t agree with all that. I’m going to break up with him.”

I don’t think this patient was lying. I think she was in denial, and a part of her couldn’t accept the extent of her cocaine use. Denial needs to be treated as part of substance use disorders.

Addiction isn’t the only disease with denial. When I worked in primary care, I’ve seen advanced cancers in patients who were in denial about the severity of their symptoms. Patients with serious chest pain ignored their symptoms until having a massive heart attack. With any problem, one of our defenses against facing a difficult situation may be to deny it exists.

A few decades ago, harsh confrontation was felt to be necessary when dealing with denial in drug addicts. Now we know we get better results with gentler, more positive counseling approaches. For example, I’ve read Motivational Interviewing: Helping People Change, by Miller and Rollnick, third edition. I loved the second edition, which gave me ideas about how to change my goal from confronting to collaborating. This edition is even better. It’s giving me tools to help move patients from denial at their own pace. This feels more humane than old methods of yelling at patients, who already are turning away from unpleasant truths.

This method can also be used with patients who are intentionally lying.

Just because a person with addiction enters treatment, lying doesn’t automatically stop. Habits are hard to break, and people in treatment may lie when it’s just as easy to tell the truth, merely out of habit. Then there are incentives to lie in treatment settings. For example, if treatment is court-ordered, a patient in treatment may face jail time if she admits to a relapse. If a patient’s children have been taken by social services, admitting to continued drug use or even to a relapse may delay getting his children back.

Particularly in opioid addiction treatment, patients have incentives to lie in part due to the extensive regulations put in place by the state and federal governments. Some of those regulations are in place to keep the patient safe, and some are to protect against diversion of methadone onto the local black market. Patients in treatment may lose take home doses if they are truthful about drug use.

Even if take homes aren’t at stake, many patients don’t like to talk about relapses, and lie about their drug use. Patients may fear their counselor will belittle or shame them for using drugs. Again, methods like Motivation Interviewing can help the counselor be more collaborative than confrontational. The counselor can have the approach of let’s look at this relapse and learn from it what we can, in order to help you in the future. When a patient admits to drug use, that’s a good thing. Now we’ve got something to work on. That means the patient is facing their disease, and we can now work on relapse triggers. We can track the events leading up to drug use, and the patient can decide if they would do anything differently the next time, if in the same circumstances.

Some patients cleverly say that if they always tell the truth about drug use, they should be rewarded for their honesty by not having any consequences for drug use. For example, a patient who had been in methadone treatment for about three weeks told me he was drinking his Sunday take home bottle on Saturday. I was alarmed, because I feared he could have an overdose death. I told him I was glad he told me, but that I couldn’t give him a take home dose for Sundays in view of that. He was angry and felt he was being punished for being truthful, while my main concern was a possible overdose death if he continued to get take homes.

I use a phrase from Ronald Reagan in my work with people in treatment for addiction: Trust, but verify. I can’t take everything that is told to me at face value. I’d prefer to believe all my patient all of the time, but they have this disease which leads them to lie. When patient safety is at issue, I have to confirm what the patient tells me with other facts, like clinical observation, patient history, and drug screens.

I’ve learned I can’t reliably tell when someone is lying. Years ago I foolishly thought I was really good at detecting lies, but I’ve been wrong so many times that I no longer make that assumption. Even lie detector machines are often wrong, which is why they aren’t admissible in court.

I’m learning not to take lies personally. Lying is part of addiction, and old habits don’t stop right away. How I react to a patient’s lie is more about me than about the patient. Lies sometimes still make me angry, and this happens more often when I’m not in a good place myself. I try to pay attention to my own physical, mental, and spiritual health. When I’m healthy I’m more likely to view people who lie (not only my patients) with more calm and acceptance.

I understand lies because I understand fear. If I come from a self-righteous place in my own heart where I believe I never lie, I am likely to judge another person who lies. So I’m no paragon of truthfulness myself, but I am a work in progress, as we all are.

 

 

Advertisements

5 responses to this post.

  1. This is a fascinating post. On one hand, you clearly recognize that everyone lies and that people with addiction don’t necessarily lie more than people with any other medical problem. But then you seem to revert to arguing that lying is part of addiction.

    However, I don’t think real data supports this idea: indeed when you separate out people with antisocial personality disorder (who, to be fair, are overrepresented among people with addiction— nonetheless most people with addiction do not have this) and when you give people the opportunity to tell the truth without consequences, the self reports of people with addiction are no less reliable than the self reports of anyone else.

    You can see this quite clearly in studies from the early years of AIDS where people are asked about clean needle use and about condom use. They (accurately) it turns out report far higher levels of using clean needles that they get from syringe exchanges than they do safe sex when condoms are distributed: the obvious reality is that clean needles improve the chances of getting a good hit, while condoms are not always an enhancement to sex. There is no reason to lie for social acceptability more about one than the other: if people with addiction were simply liars, they should lie equally about both. But they do not: the tell the truth when doing so won’t get them in trouble.

    As you note, people with addiction lie to doctors and counselors because of the power dynamics of the relationship: when someone can cut off the thing you need to function, you are less likely to tell the truth.

    This is the fundamental truth of motivational interviewing: it works because “denial” is often actually a response to confrontation and humiliation and other things done to try to “help” addicted people by imposing other people’s ideas of what they should do onto them.

    If we want to destigmatize addiction and get away from the confrontational and abusive methods of the past, we need to stop saying that people with addiction are uniquely dishonest and look at how the situations we put them in (criminalization of drugs being the most obvious) lead to dishonesty in some settings. It would also be nice to use the respectful person-first language we use for conditions like schizophrenia: ie, people with addiction, not “addicts.” It’s kind of hard to destigmatize a disorder when you see it as being characterized by a fundamentally bad trait like dishonesty, especially when you don’t have evidence to show that this is universally true, rather than a stereotype.

    All best,

    Reply

    • Hello Maia, and thanks for commenting. I’ve enjoyed reading your articles over the years and especially enjoyed your book “Help at Any Cost,” about the abuses of the wilderness camps for adolescents.

      I fear I didn’t make myself clear in the blog.

      In the blog I posted, I meant to say that BUT FOR the substance use disorder, patients with substance use disorders don’t lie any more than other people. It’s the compulsive and uncontrolled nature of the illness that leads to the lying. I think we see that with any compulsive disorder: compulsive gambling, compulsive sex, uncontrolled overspending, over-eating, etc. It’s demoralizing not to be able to control one’s behavior, and the shame associated with that leads to the lying, both to ourselves and others. And it can become a bit of a habit.

      In other words, it’s not in the nature of the person, (except perhaps as you point out – with antisocial personality disorder) but the nature of the illness that’s responsible for lying.

      Regarding stigmatizing language – I originally wrote and posted this 5 years ago. As I was re-reading it prior to posting last night, I thought “Oh this language sounds harsh and I need to change it.” So in many places, I deleted the word “addict” and changed to “person with substance use disorder.” But it was getting late (for me) and I was tired so I missed some of the language. Also, it’s less awkward in a sentence to use the word “addict” than “person with substance use disorder,” just like it’s easier to use the word “diabetic” rather than “person with abnormal glucose metabolism.”

      Also, I also don’t mean the same thing as other people mean when I use the word “addict:” When I use the word “addict,” I have in my mind a person with a horrible disease who is probably interesting and likeable. But I know most people don’t mean the word like that – it has a pejorative flavor in the mouths of many people. I do wish there was a simple, non-pejorative word that means “person with substance use disorder.” Maybe we should invent one.

      Reply

  2. Posted by Terry on March 15, 2017 at 3:41 am

    Well written-it is very frustrating when I can’t break thru denial, but I also believe in the gentle approach (telling the current patient stories about other patients-no name of course-that I have see over the years and how denial prevented them from getting better until they recognized it etc. Now,I apologize Jana but I would very much like to get your opinion on a completely different matter. I tried the search feature for THC to see if you had ever addressed pot in a methadone clinic and couldn’t find it. My basic belief is that someone is recovery from addiction should not take any other addictive drugs in the vast majority of cases. Some-like alcohol of course are very dangerous with methadone, but pot doesn’t have the risk of respiratory depression, but I still believe that under its influence a recovery person is more apt to make bad decisions that could have consequences, plus I believe there are other negative things about it, and I have had no qualms in not allowing my patients to use it. ( I haven’t had a patients who had a serious reason to use it such as recurrent seizures that couldn’t be controlled or I would have allowed that). Now Florida has made it legal if you have a medical card, such as for chronic pain to smoke pot, so I am re-evaluating my position. Medicine is currently trying to take a hard look at the potential benefits of THC as well as the complications, especially since the % of active ingredient has continued to rise. So, what are your opinions for a patient stable on methadone in recovery, who has not previously met criteria for cannabis use disorder in the past, who would like to take it for pain, or any diagnosis that it is felt to have some benefit? What about if they did meet that criteria for cannabis use disorder in the past, but stopped the pot to stay in my methadone clinic, but now would like to use it, and feel that they can “control it” this time. Thank you for your opinions. Terry.

    Reply

  3. Posted by Luke sampson on March 15, 2017 at 2:59 pm

    Thank you again for a very thoughtful, forgiving, kind and profound message

    Reply

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: