Substance abuse and mental health treatment occupy parallel uni-
verses, divided by law in many states. Each has its own version of reality.
If an explosive person in your life is also a substance abuser, you may have
to experience both. Be prepared for confusion, because each universe is
largely unaware of the strengths of the other and of its own weaknesses.
Substance abuse must be dealt with first. Mental health treatment
will not work, and many medications will become dangerous, if an explosive
person is actively abusing alcohol or drugs. Psychotherapy that focuses on
why people abuse substances can go on forever without much benefit.
Likewise, 12-step programs have little success in treating mental disorders.
Outpatient Treatment
Primary Care Physicians
Primary care physicians are usually the first contact in treating the disorders
discussed here. They establish a differential diagnosis, prescribe medication
for the symptoms, and provide a referral for psychotherapy. Ideally, the
physician and the therapist will work together to coordinate care.
As we have seen, some explosive disorders respond to medication and
don’t require therapy, some need therapy and no medication, and some need
both. Primary care physicians sometimes perceive too many patients as
falling into the first category. For people who explode into fear or anger, or
depressed people who do not completely recover after about a month of
medication, you should press for a therapy referral, or find one for yourself.
Most primary care physicians are adept at prescribing the medications
we’ve discussed here. Unless the patient’s response is atypical, there is usu-
ally no need for a psychiatric consultation. These days, most physicians do
not prescribe regular doses of benzodiazepines for more than a week or two.
If yours does, you should find out why, and possibly get a second opinion.
Psychiatrists
Psychiatrists usually have a Medical Doctoror Doctor of Osteopathydegree.
Except in very large urban areas, psychiatrists are typically not the people
who do talk therapy. In private practice, their primary concerns are diag-
nosis and medication. Their expertise is critical in managing medically
276 ❧Explosions into Anger