Doctors sometimes joke about how our medical specialties affect how we view the world.  When I was an anesthesiologist, I became more and more aware of ‘the airway,’ a collection of anatomical findings that predict whether a person is easy to intubate—the term for inserting a breathing tube into the trachea.

In anesthesia, securing the airway is the ultimate concern, and most anesthesia injuries occur from ‘losing the airway,’ leading to brain damage or death from hypoxia.  Airway assessment is an important part of an anesthesiologist’s pre-op assessment, and eventually becomes unconscious and automatic. 

The individual considerations—size of the jaw and tongue, length and thickness of the neck, presence of facial hair, degree of mouth-opening, etc—become part of a gestalt, guiding an impression of whether controlling the airway will be easy, or instead will require additional safety measures or considerations.

During my life as a ‘gas-passer’ I sometimes was aware of assessing pre-op considerations even during dinner parties or while walking through the mall– So when my wife mentioned the nice person we had met, I had him catalogued according to those considerations.  “Oh, you mean the guy with the big neck and no veins?”

I am sure that I do the same unconscious assessment now, as a psychiatrist—even if I am less aware of doing so.  And if I had to choose the ultimate concern for my current practice specialty (and hopefully last specialty!), I would choose ‘level of desperation.’

My practice encompasses the entire spectrum of psychiatry, and I see ‘desperation’ as an important consideration across that spectrum.  Desperation is not mandatory to recover from all psychiatric illness, but it is, in my opinion, mandatory to recover from SOME conditions—namely those that require significant change— in personality, in world outlook, or in behavior.

Besides being a potent motivator, desperation causes ego-defenses and other facades to fall away, allowing the person’s unpolished ‘self’ to come into the light.  My favorite aspect of an earlier position as a psychiatrist in a maximum-security women’s prison was that many of my patients were, or had been, desperate enough to at least become aware of that unpolished version of ‘inner self.’  That awareness allowed for discussions on a much deeper level than would occur during a typical outpatient ‘med check!’

Of course many people, once so exposed, only become even more committed to layers of defensive BS in order that such desperation never occurs again!

Desperation is a particularly important consideration in regard to treating and recovering from addiction.  When I first meet patients presenting for treatment of addictive disorders, their level of desperation is my best indicator for how they will do.  As with the airway, determining a person’s level of desperation includes a number of observations, many that occur unconsciously:  What emotions are being displayed?  Are they congruent with the person’s inner reality?  Is the person’s story truthful?  How much minimizing is going on?  Does the desperation have ‘staying power,’ i.e. does the person tell the story and then break into cocky joking once unburdened by guilt, or does the person continue to experience emotions consistent with the severity of the situation?

I am grateful that desperation came quickly in the course of my own addiction.  Within several months of becoming obsessed with opioids, I hated myself for what I had become.  I remember looking in the mirror and literally cursing at the reflection.  “F-ing ADDICT,” I would spit out.  I became more and more depressed and filled with self-disgust.

I was walking around the block one day when I realized that I was cursing the birds for making such a racket—for making sounds that used to bring me pleasure.  That was when I realized that something was horribly wrong, and that something had to change.

AA is filled with simple slogans and sentences from group literature that carry a great amount of wisdom.  One of my favorites relates to desperation, describing how recovery works when an alcoholic clings to AA principles as a drowning man seizes a life preserver.  I got to a point where I was drowning, and ready to grab any life preserver floating by.  I didn’t care whether it was the right fit, the right color, or whether it chaffed around the neck.  People who are wondering why their recovery program is not helping would do well to compare their recovery to such an image!

My treatment in 1993 was not real intensive, but it was successful because I was truly desperate.   When my counselor said I needed to attend an NA meeting, I went.  When she said I needed to do ‘feelings’ exercises, I did them.  I knew that I was lost, and I KNEW that I had no choice but to do whatever was suggested to me to get better.   My isolation, depression, and self-disgust led me to drop any thoughts that I had about fixing myself.  I realized that I was powerless over my situation, and I desperately needed help.  That desperation saved me from a great deal of pain, as it forced me to drop my own twisted self-confidence and instead cling to the advice of those who knew how to treat my condition.  My desperation made me willing to do whatever was asked of me.

While the life-preserver reference may strike some people as hyperbole, that is not, unfortunately, the case.  Addiction to pain pills is a much greater problem now than when I became addicted, almost 20 years ago.  Overdose, usually involving opioids, has become one of the leading causes of death in the US.  There is no cure for opioid dependence, but there are ways to hold the condition in a state of remission.

I am still here, after all.

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    Last reviewed: 8 Sep 2010