Monday, November 1, 2010

Some Contentions/Misconceptions about AA and Mainstream Treatment

This is Part II of a look at some often-heard (or, at least, posted on the internet) statements that might elicit much doubt in people pursuing mainstream treatments for alcohol/drug problems -- with my attempt to provide balance. The last post focused on statements regarding the nature of alcoholism/addiction and recovery. The subject of the current post is statements about AA (and other self-help groups) and about treatment approaches.

AA loses many of its attendees shortly after their first exposure to the program, and 95% by the end of the first year.
It’s been my repeated experience that most people don’t like AA when they first attend, and not surprising that many drop away, especially if they are far from feeling ready to embrace a goal of abstinence. I wonder if the percentages often quoted are misleading, since my experience is that many of the same people return and connect to AA months or years later. Those who find another program for the same purpose, such as SMART, may find that their needs for recovery support are well met there. And while AA has been so successful that there are now over 115,000 groups meeting regularly around the world, more alternatives are clearly needed. (Here in Massachusetts, the only non-12 step peer program that has any kind of meaningful presence is SMART Recovery.) The early dropout rate (but not necessarily the outcome) is probably somewhat lower for professionally-run programs, where there would be a stronger sense of obligation (to a particular person) to continue to attend. But I don’t know of any professional program that offers groups available so conveniently and frequently over the long term (and if there is one, it would involve ever-escalating financial burden).

If a medication treatment was only successful on 5% of patients (the percentage of new AA attendees still regularly attending a year later), it would never be FDA approved.
I’m not so sure about that. If there were a medication that was highly effective for 5% of those with a given illness, and if no other treatment were more widely effective, I think it would be approved. The fact that people drift away from AA does not, by the way, prove that it is ineffective, only that people tend not to keep up the new behavior. You’d find a similar trend, for example, in how many heart patients who have never exercised are still going to the gym regularly a year after they begin – that doesn’t mean that exercise is ineffective, only that it’s difficult to get people to stick with it. Nevertheless, let’s keep looking for treatments that are more likely to keep alcoholics/addicts involved, and that have a salutary effect on their alcohol/drug use.

Twelve step programs teach people that they are powerless, which leads them to keep relapsing because they don’t think they have the power to stop drinking.
The AA notion is that the alcoholic is powerless over drinking – i.e., once s/he begins to drink, s/he loses the capacity to exert control. (For other 12-step programs, substitute the other addictive behavior for the object of powerlessness.) This does not mean that one is powerless of everything in one’s life. In fact, it clarifies the importance of one’s ability and personal responsibility to do what it takes to avoid taking the first drink. (But it takes a lot more than for a non-alcoholic to make that choice.)

AA should not claim to be the only way to recover. People should not be told that they are doomed to failure or death unless they keep coming. Most people drop out – they should know that AA is not their own option.
I don’t believe that the founders of AA ever took the position that they had found the only way for anyone to get sober – just that it was the only way that had worked for them. The 12 steps are phrased not as “You should” or “You must,” but as “We did” – in other words, here is our example, which you may or may not find applicable to yourself. Certainly, it is not uncommon to hear someone say that those to fail to make use of AA are destined for failure, but this is the opinion of individuals, not the program. It is likely based on having seen many alcoholics who did not stick, and whose lives continued to deteriorate. But AA itself, in its recurrent surveys, indicates that only a minority of new attendees form a lasting connection with the program. People getting ready to take a shot at sobriety who do not already have a positive connection with any particular approach should certainly be informed about the full range of options for treatment and support, none of which has consistently been proven superior to the others. [See below, discussion of Project MATCH.]

Treatment providers get attached to their own ideas about what should work, sometimes from their own personal experience, overriding their objectivity and thus shortchanging those who come to them for help.
Yes, this is in the realm of “cognitive dissonance.” We are all inclined to want to stick with beliefs into which we’ve already invested a lot of time, effort, etc., and to be motivated to dismiss or ignore contrary evidence. But it is equally true for those who firmly and vehemently embrace alternative perspectives and treatment approaches. My two cents: Whenever someone says, “I know the right way, the only way, the unimpeachable truth” – it’s a good time to politely excuse yourself and briskly walk away.

So-and-so’s exciting new form of treatment is the one that really works. OR: No treatment works for alcohol or drug dependence.
Project MATCH was a large, seminal multi-site study of over 1700 patients conducted under the aegis of the National Institute on Alcohol Abuse and Alcoholism for several years beginning 1989 (findings reported in 1996). Most people anticipated that certain treatment approaches would work better for certain patients considered well-matched (who would be considered well-matched based on characteristics such as severity of drinking, cognitive impairment, conceptual level, motivation for change, gender). As it turned out, all 3 treatment approaches (12-step oriented, cognitive behavioral, and motivational) were about equally effective, regardless of patient characteristics. The degree of improvement, regardless of type of treatment, was considered impressive because of dramatic and sustained reduction in drinkin (though unfortunately there was no control group of patients receiving no treatment). Many studies have found that more treatment is associated with better outcomes than less treatment, and in this respect AA has some advantages, since it is (a) free, thus cost is no obstacle and (b) more available than any other resource (with regard to numbers and frequency of accessible meetings).

Monday, October 25, 2010

Responding to Anti-Abstinence and Anti-AA Claims

If you were to web-search topics like AA and sobriety these days, you would actually come across more web sites challenging prevailing treatment approaches and beliefs (including the “Disease Model”) than representing the points of view of the vast majority of professionals in the field. I suppose the same may be true for other conditions – there must be loads of sites touting the efficacy of exotic cancer treatments or of zinc or Vitamin C for the common cold (neither of which are regarded as helpful by actual experts).

As you can surmise, I’m probably closer to the mainstream in my ways of looking at alcoholism and drug addiction. But I have never been a “joiner” or a “true believer” in pretty much anything, and I like to think that the plus side of my chronic uncertainty is that it keeps me inclined toward objectivity, or at least willingness to hear many sides of an argument. I feel like most of what I’ve concluded was learned from listening to and observing my patients in the last few decades. I also hate contentious squabbling, perhaps a result of my own upbringing in an alcoholic family, and unfortunately for me there is quite a lot of infighting among those who share a wish to reduce the human suffering that flows from addictions (or, for some, substitute “a wish to attain wealth or reputation by marketing solutions to addiction”).

As I’ve mentioned in a previous posting, we never suffer a paucity of new books exclaiming, as if they were the first to discover a truth, that alcoholism is not a disease, and that its most prevalent support group, AA, is wrong or bad or at least misleading. The latest to be sent my way, whose title is fairly gentle in noting that AA is “not the only way,” comes from a young woman who begins the book with her own extremely chaotic story of drug abuse and bipolar disorder, a story that one senses is far from having reached a stable denouement. She goes on, in this book that carries endorsements from two prominent behavioral addiction psychologists, to convey a series of positions, opinions and “facts” that are very much in accord with many of the aforementioned web sites. The problem with these kinds of assertions is that, just like many that come from the AA side of the fence, they don’t provide any kind of balance. It is like looking to the Republican or Democratic National Committee for a “fair and balanced” perspective on our national interests. [Let me mention, although I am refraining from advertising this book, put out by a small Alaskan publisher of all alternative-addiction-treatment books, that the bulk of the book provides a fine compendium of alcoholism treatment providers who offer alternatives to AA.]

Reading the introductory section of the book inspired me to repeat and offer some counterpoint to a number of antagonistic contentions that one hears redundantly, and which must be quite confusing to the consumer seeking some kind of map for navigating alcohol/drug treatment territory. The bold-faced statements are my way of restating these assertions, and do not represent my own perspectives, which are summarized in the paragraphs that follow each statement. Some of my perspectives are based on available research; many of them are based on my clinical experience.

Since there are many arguments to address, I’m breaking this entry into 2 posts. This one will address the phenomenon of alcoholism/addiction. The next one, coming soon, will address various perspectives on the value of AA, and by extension NA and other 12-step programs (the most commonly recommended and widely utilized kind of help for these problems).

Some Contentions/Misconceptions about Alcoholism/Addiction:

Alcoholism is not a progressive disease because it is not always progressive.
True enough that there are plenty of cases where an individual may actually be drinking less alcohol, or less frequently, later in life than earlier. I can think of a couple of atypical cases I’ve seen where people who exhibited daily uncontrolled drinking through their 30s were drinking only once a week, and often fairly lightly, at age 60. Please note: (a) These cases are atypical, not the rule; (b) When I’ve seen this phenomenon, generally the less severe drinking remains an unstable, unpredictable pattern.

77%, or 82%, of all kind of figures, of those with alcohol problems recover on their own.
It does seem that some people do, though these high figures raise questions about methodology and interpretation. To the extent that many alcoholics are recovering spontaneously, that’s great. (I’d like to meet them!) My guess, however, is that most of these are alcohol abusers and not alcoholic in the sense that most of us in the field understand the term (close to what the current diagnostic manual calls “alcohol dependence”). These days, someone can do a questionable study (almost always knowing what they want to prove before they begin – on either side of any dispute) and post their findings, which before you know it go viral and are being quoted as fact.

A very large epidemiologic study (known as NESARC) begun in 2001 initially found that 75% of those deemed alcohol dependent in community samples (simply by virtue of self-report in retrospective interviews) were in better shape (not necessarily in consistent recovery) during the year just before the interview than they had been the year before that. Most of these individuals had never entered any kind of treatment. But when these people were re-interviewed a couple of years later, the majority found that their drinking problems returned. So, while it does seem to be true that most problem drinkers never get help, it does not mean that most of them recover in a lasting way. Existing treatments leave much to be desired, but seem to be better than no treatment. It’s worth mentioning that almost everyone who comes to see someone like me has already tried more than once to overcome the problem on their own, often with temporarily good results that did not last. Finally, there is also no question that environment plays a major role. A move to less stressful circumstances (famously, soldiers who leave a war zone), to less enabling circumstances (such as a new, less codependent spouse) may very well have a more powerful impact than treatment.

Treatments that focus solely on alcohol and drugs can do someone a disservice by not treating a co-existing mental illness such as a mood disorder.
True. But people seem so much readier to view depression as an illness than to see alcoholism/addiction in that light. On what basis? Over the years, many substance abuse treatment settings have ignored other mental health disorders, and it is at least equally true that many mental health treatment settings have completely ignored their patients’ alcohol and drug problems. Both are cases of “not my department” or of “when your only tool is a hammer, everything looks like a nail.” Ignoring either kind of condition reduces the chances of a good outcome.

Alcoholic drinking is a learned behavior, not a disease.
It turns out that many things in life are more complicated than that. Behavioral conditions, including addiction, depression, anxiety, and more, develop as the result of multiple converging factors, including both biology and learning, and might not express themselves if either of those factors were absent. But let’s compare a learned behavior that has a biological component (e.g., chronic smoking) with one that probably does not (e.g., driving on the right side of the road). One person gives up cigarettes; the other moves to England (where they drive on the left). They both now have an opportunity to relearn the habituated behavior in question. Let’s look in on them a month later – see any difference?

There is no science behind the assertion that addiction is a disease.
Aside from semantics (e.g., addiction is clearly not the same kind of disease as the measles), the evidence of important genetic/neurobiological factors in addiction has been accumulating for many years, and is overwhelming. The best central resource for reviewing this information yourself is NIDA, the (highly scientific) National Institute on Drug Abuse ( NIDA is quite open to acknowledging a large range of treatment options, and always looking for whatever shows promise.

The idea that all alcoholics must seek abstinence is a myth; lots of alcoholics become normal drinkers.
Actually, there is little evidence that moderate drinking is a workable goal for the vast majority of alcoholics. Even those studies indicating that some return to moderate drinking, upon further examination, find that (a) this only happens for a small minority, generally somewhere between 5% and 20%, and that (b) as time goes by, those moderate drinkers tend to slide back into alcoholic drinking – so it matters at what point in time you look at outcomes. The consensus among most professionals in the field is that (a) abstinence is by far a more stable outcome, and that (b) those who do return for non-problem drinking for any period of time had fewer symptoms of dependence in the first place – in other words, might not have been considered clearly alcoholic in the first place. For essentially normal drinkers who happen to abuse alcohol enough to cause problems (such as a drunk driving arrest), yes, they may very well return to moderate drinking just by gaining maturity or learning from experience.

Next post: Some Contentions/Misconceptions about AA and Mainstream Treatment.

Thursday, August 26, 2010

Adult Children of Alcoholics - looking back at a perspective and a movement

When, as a doctoral psychology student, it was time for me to research and write a dissertation, my first proposal was turned down because my advisors did not like the idea of a retrospective study. I wanted to study the impact of parental alcoholism on adults who had grown up in alcoholic homes. Just a few years later, others who were not burdened by the need for scientific empiricism wrote about the same topic based on their clinical experience, and the huge Adult Children of Alcoholics (ACOA) movement was born. This movement peaked during the 1980’s, supplanted years later by clinical interest in the broader topic of survivors of abuse/trauma.

But the ACOA movement had significant and lasting influence in at least two ways:

• It contributed greatly to changing the role of the therapist to a more active and educative one, abandoning the assumption that people in therapy could be expected to find the answers within themselves given a long enough period of time responding to insight-eliciting questions and comments.
• It gave rise to a new kind of 12-step group – geared not to alcoholics/addicts or to their spouses, but to adults with problematic self-esteem/relationship problems that date to childhoods in unpredictable, often frightening and burdensome family environments. At least three of these groups still exist: (1) a subtype of Al-Anon meetings (Al-Anon being the 12-step group begun not long after AA to address the needs of family members of alcoholics,; (2) Adult Children of Alcoholics (ACA), a fellowship specifically for this population ( ; and (3) CODA (Codependents Anonymous, , for people including ACOAs who, generally as an outgrowth of being raised in a dysfunctional family, tend to develop relationships that are not healthy for them.

Before the ACOA movement waned (at least in professional circles), a few key books became classics, and they still come readily to mind when the subject arises.

Janet Woititz’ book, simply titled Adult Children of Alcoholics, enumerated 13 characteristics that she felt were especially noteworthy in ACOAs. [Let me note here that one problem with all of these perspectives is that almost everyone relates to at least some of these. In addition, they can apply just as well to individuals raised in other kinds of inconsistent environments with behaviorally unpredictable parents – it is not the parental alcoholism per se, though that is the most common source, but the parents’ behavior.]

1. Adult children of alcoholics guess at what normal behavior is.

2. Adult children of alcoholics have difficulty following a project through from beginning to end.

3. Adult children of alcoholics lie when it would be just as easy to tell the truth.

4. Adult children of alcoholics judge themselves without mercy.

5. Adult children of alcoholics have difficulty having fun.

6. Adult children of alcoholics take themselves very seriously.

7. Adult children of alcoholics have difficulty with intimate relationships.

8. Adult children of alcoholics overreact to changes over which they have no control.

9. Adult children of alcoholics constantly seek approval and affirmation.

10. Adult children of alcoholics usually feel that they are different from other people.

11. Adult children of alcoholics are super responsible or super irresponsible.

12. Adult children of alcoholics are extremely loyal, even in the face of evidence that the loyalty is undeserved.

13. Adult children of alcoholics are impulsive. They tend to lock themselves into a course of action without giving serious consideration to alternative behaviors or possible consequences. This impulsivity leads to confusion, self-loathing and loss of control over their environment. In addition, they spend an excessive amount of energy cleaning up the mess.


Again, in reviewing Woititz’s list, it is important to realize that these items were not derived in a rigorous, scientific manner, and that there is probably no one who has all of these features and no one who has none of them. Nevertheless, they clearly captured something that rang a bell with many ACOAs and clinicians. (And the many clinicians who were, themselves, ACOAs, since this experience lends itself to becoming one or another kind of caretaker.)

Another classic book was Claudia Black’s It Will Never Happen to Me, in which she vividly and movingly captured the pain of alcoholic family life and its impact on the children. (In the 1980’s, we also used a film called Soft is the Heart of a Child, which similarly brought the viewer into the world of these children during active parental alcoholism; few could watch without tears.) Black identified the common unspoken rules in alcoholics families: “Don’t talk; don’t trust; don’t feel.” Indeed, many ACOAs find it very difficult to identify what they are feeling or to convey their feelings in words, and it is harder for them to go about their lives assuming, as most of us do most of the time, that things will be OK.

While Black also labeled family roles, the labels that became most familiar in the field were those coined by Sharon Wegscheider-Cruse, in her book, Another Chance: Hope and Health for the Alcoholic Family. Hers was a variant of family systems theory, in which changes in one member’s behavior necessarily bring about changes in all family members, as the system attempst to maintain balance, reduce anxiety, look OK to outsiders, and otherwise survive. In this case, the alcoholic (or addicted) parent’s behavior deteriorates as their condition progresses, and the children tend to take on certain family roles (which are combined when the family size is smaller). The roles that Wegscheider-Cruse identified were:

Family Hero: Usually the oldest, seeking perfection, achievement, outward success, social approval, both to make the family look good to others and out of the unconscious fantasy that, if only they are good enough, the alcoholic parent will be OK. The Family Hero can look like a little adult, but inside has a strong sense of faking it.

Scapegoat: The child who rebels and acts out (e.g., cuts school, abuses substances), providing the family with someone at whom they can conveniently point the finger as “the problem,” rather than have to deal with the alcoholism. But in a way, there is something healthy in the Scapegoat for being able to express anger on behalf of the rest of the family.

Lost Child: The child who adapts by becoming invisible, and thus no burden to the family, quiet, isolated, ignored, and often depressed.

Mascot: The child who uses humor, cuteness, entertainment to lighten things up for the family and provide another kind of distraction from the family’s pain, but who has difficulty getting real or genuine.


In a general sense, we are all in some way affected, in our adult interpersonal functioning, by the family dynamics and roles that took shape during our childhoods, and in that sense, for all of us, a key purpose of therapy is to become aware of those coping maneuvers that helped us survive in our younger years, but which may now be working against us. In more highly dysfunctional or stressed families, however, these roles tend to be more limiting and to leave adults with a more restricted repertoire of behaviors and access to feelings. ACOAs, on the whole, are also highly reliable, dedicated workers, and have much to offer. The good news is that, through the support and insight offered by the above groups or by a therapist, it’s never too late to grow beyond these limitations and in the direction of greater flexibility and sense of inner security.

[The books mentioned above are available as inexpensive paperbacks from and other sources. The film/DVD is available at various outlets including, source of myriad addiction-related publications.]

Wednesday, August 18, 2010

Who is an "Alcoholic" or "Addict"?

I have noticed, often when meeting with family members of people with alcohol/drug problems (sometimes those who are considering an “Intervention”), that it is difficult for me to point to a book that does a great job of summarizing the features and realities of alcoholism/addiction that most clinical workers in the field generally share and take for granted.

One major source of addictions literature, (the bookstore arm of the same corporation than offers one of the longest-running and best-known rehabs), has a plethora of books, pamphlets, videos, and whatnot, on many specific aspects of addiction and its treatment, but seems to come up a bit short on books providing an overview. Do an search for “alcoholism” and there is a similar paucity – loads of books on particular points of view (e.g., it’s not really a disease, or nutrition is the answer, or how to live with your alcoholic spouse), lots of memoirs (like Drinking: A Love Story or Dry, almost all worthy of reading other than the one that was faked by the guy who went on Oprah), but no grounded summary to help the layperson understand the landscape.

So I decided to begin putting down some of this, for now in blog form, largely in order to have something to which to direct those who come to me for consultation.

This "chapter" is for those who wonder how to determine whether they, or a person about whom they are concerned, may be alcoholic or addicted.

The terms “alcoholic” and “addict,” like most such labels in the larger field of mental/behavioral health, are attempts to meaningfully categorize conditions shared by subpopulations of people who have a lot in common. But there is no one litmus test, no blood or urine test, no genetic marker, and no precise list of symptoms that they all share. As is also the case for depression, anxiety, etc., no two alcoholics or addicts (and I regard the term alcoholic to mean “alcohol addict”) are exactly alike. The fact that it remains a struggle to define these terms is reflected in the fact that, with each new edition of the Diagnostic and Statistical Manual (DSM, the psychiatric “bible” of diagnoses), the criteria and terminology keep changing, evolving to keep step with current research and social/professional perspectives (and even politics).

But there are key concepts with regard to what most of us consider “addiction” that continue to apply. (By the way, the DSM does not use the words “addiction” or “alcoholism”, but rather the terms “abuse” and “dependence;” the latter is closest to reflecting what I believe most of us clinicians mean by addiction.)

As you read through the (non-exhaustive but key) list of features below, bear in mind that (a) one need not have all these characteristics to be considered alcohol or drug dependent – in fact, perhaps most people don’t; (b) most of these traits are probably more biological than psychological in nature.

· Tolerance: It takes more of the substance (whether it be alcohol, cocaine, Oxycontin, etc.) to achieve the same effect formerly achieved with smaller amounts. Most people develop some level of tolerance to alcohol, but alcoholics usually can “hold their liquor” to a much greater extent – they are often proud of that fact, but ironically it is indicative of a problem, or a potential problem.

· Loss of Control: Once the person begins drinking or drugging (often after reaching a certain point, say the 2nd or 3rd drink), s/he can no longer reliably limit or regulate how much will be consumed, and will in many cases continue to intoxication, or beyond that until reaching the point of passing out, running out, or being kicked out. Many people try to prove that they can control their drinking (or drugging), and quite often they can do so for a period of time – by paying a lot of attention to it, just as you might be able to hold in your stomach while walking along a crowded beach. But this is quite different from normal drinking, in which the person, without much thought or attention, reaches a point of satiety (i.e., had enough, no desire for more). Eventually, one relaxes and does what comes naturally – for the alcoholic or addict, that will generally mean reverting to loss of control. Loss of control is what’s behind the fact that most alcoholics have tried, repeatedly, to cut down; if it were simply a matter of choosing to change behavior, it wouldn’t be trying so much as just doing it. Note that this term does not refer to losing control of one’s life or behavior per se, just of one’s consumption of the substance.

· Withdrawal Symptoms: Although many alcoholics never get significant withdrawal symptoms, for those who do it becomes difficult to deny the addiction. At one time, withdrawal symptoms were seen as a key defining characteristic, but that is no longer the case. Some withdrawal symptoms (such as shakes or DTs for alcoholics, seizures for alcoholics or those addicted to tranquilizers, flu-like symptoms for opiate addicts) are readily observable and call for medical detoxification, while others are likely occurring at an unobservable, more cellular level. The essence of withdrawal symptoms is this: Your brain has become accustomed to regularly incoming chemicals that push it in one direction or another (e.g., stimulants up, alcohol down, marijuana maybe sideways), and has adapted by compensating, finding neuro-chemical ways to push back. Suddenly, the when the substance is removed (the person stops drinking or drugging, either out of a decision or because no supply is available), the push-back sends the nervous system out of kilter. Some withdrawal symptoms, such as seizures, can actually be fatal, which is why medical detox is the safest way to go. In detoxification, the individual is given either the same substance to which s/he is addicted or another substance that is similar enough to “fool” the brain (e.g., tranquilizers are used to substitute for alcohol, since they are actually quite similar in their mechanism of effect on the brain), and then the dosage is gradually tapered off, usually over a period of days (though some detoxifications can go on much longer).

· Centrality of Substance Use and Psychological Dependence: For the “normal” drinker or drug user, drinking or using is an optional activity, whether its purpose is to relax or make socializing easier, or even to provide a temporary escape or relief from stress. For the alcoholic/addict, thoughts of using (“I’ll be able to have some at 5 o’clock when I leave the office) and plans about using (“When we drive to Newport, I’ll keep a stash in the trunk, and then I know where I can get some once we’re there;” “My dealer is missing in action; where else can I get some?”), take up a lot of mental space. Alcohol and drug use (not to mention hangovers, fatigue, and other after-effects) become a central activity and concern, often pushing other interests, activities, and relationships out of the way. Some people get to the point of having no idea how they would cope with various situations if their substance were unavailable.

· Negative Consequences: Even with all the above, the diagnostic criteria are not fulfilled unless substance use results in recurrent, predictable negative consequences – and yet the individual continues to use. These consequences may be social (e.g., inappropriate/embarrassing behavior), legal (most commonly a drunk driving arrest), medical (e.g., signs of damage to the liver or esophagus from alcohol, holes in the nasal septum from cocaine snorting, contracting hepatitis from heroin needles), vocational (e.g., job loss or probation), psychological (e.g., increased depression from drinking, psychotic symptoms triggered by THC), relational (e.g., marriage on the rocks, friends alienated), etc. Quite often, the addict/alcoholic does not recognize that these developments are actually a result of drug/alcohol consumption, pointing the finger instead at others (“With my wife….,” “The cops need to fill a quota of DUI arrests,” “Of course I’m depressed with parents like these,” “My boss is a jerk who only likes people who kiss his ass.”

One additional note for those who wonder, “I’ve been taking a medication [such as a tranquilizer] for years, and my understanding is that it would be dangerous for me to abruptly stop taking it – am I not addicted?” This is where the terminology gets very confusing. You might consider yourself addicted to your medication in the sense that you would probably experience withdrawal symptoms (even dangerous ones) if you discontinued it without a gradual taper. But if you never developed much tolerance (i.e., it works for you at the same dosage it did years ago), experience no significant negative consequences or loss of control, you are probably not addicted in the behavioral sense. Obviously, if you have needed more and more of the medication and repeatedly exceeded the prescribed dosage, for example obtaining extra from friends or “doctor shopping,” you probably do have an addiction for which it would be wise to get help.

Ultimately, what matters most is not whether someone else thinks someone has developed alcoholism or addiction, but at what point the individual in question reaches that conclusion, because no one can implant a commitment to recovery in someone else. (That is not to say that one has no influence – much more on that another time.)

Sunday, August 1, 2010

Codependent and More

You know you're codependent when:
  • You bring your own Kleenex to the therapy session rather than use the ones the therapist put out.
  • You feel guilty about Global Warming because once you discarded the whole pizza box rather than cut out and recycle the clean sections.
  • You pretend the allergy pills worked so that your doctor won't be disappointed.
  • When people ask, "How are you?," you tell them how your spouse is.
  • Your kid gets a B and you conclude that you've failed as a parent.
  • You stand on the subway so the seat can go to someone who needs it more -- and you're 78.

    Maybe you have some more of these? Email them to me.

    Not everyone would agree that these are all indications of codependency, and they certainly don’t cover the whole area – more the un-entitled variant. Codependency, of course, is not a scientific term, not in the diagnostic manual, so probably no two clinicians define it quite the same way.

    I first came across the term as “co-alcoholic” around the late 1970’s. At that time, it referred to the alcoholic’s spouse, the Enabler, who played her/his own role in keeping the alcoholic behavior going. When rehabs expanded their horizons to other substances and adopted the term “Chemical Dependency”, the term “codependent” arose – in other words, it did not refer to the individual’s dependency, but rather on his/her collaboration with the behavior of the person who was chemically dependent – this often involved putting aside one’s own needs and taking on responsibilities that properly resided in the spouse’s hands. Codependent individuals had often grown up in alcoholic or otherwise dysfunctional families.

    Over time, the term codependent came to apply more broadly to people who, regardless of whether they had an alcoholic/addict in the family, shared certain characteristics. In my book, the organizing belief is, “I am responsible for you, and not necessarily for me.”

Sunday, July 18, 2010

The Ebb of Personal Morality

This morning on a new PBS program that I commend to your attention, Need to Know, I listened to a reasoned discussion of the problem of what amounts to corruption in the alliance between pharmaceutical companies and physicians/scientists.

If you think about it, it is obvious that if my company (and I) will be more enriched by hiding scientific information indicating that our drugs may be unsafe or ineffective (or both), I may be more inclined to do so. (By the way, let’s say that we do 20 studies and our treatment shows up as significantly effective in only 1 of these – that will happen by chance. But if we report only on that one study, it will seem like something worth taking, and paying for.) Similarly, if I am a physician or scientist on the payroll of (or enjoying speaking fees from) a pharmaceutical company, saying nice things about their medications, and recommending them to others, will of course be in my financial interest.

What this morning’s interviewee (Jerome Kassirer, MD, former editor-in-chief of the New England Journal of Medicine) recommended was not increased government oversight, but rather holding individuals accountable for their unethical behavior. Without fear of consequences, and shielded from their consciences by being part of a large organization, people are likely to do what feels rewarding now, and blind themselves to the larger or longer-term effects.

One place we could look for evidence of that, I’m sure (but, by the way, not bothering to do a literature search for the purpose of this blog that 3 people read), is in social psychology. If everyone around me is doing something, and it is embraced (either overtly or with a wink) by the organization of which I am a part, it will be much easier for me to rationalize my behavior, even if in the back of my mind I know it’s not the right thing to do.

We have only to look at the ongoing, worldwide economic crisis, which some economist say threatens to hit again in a second wave, or to the latest devastating environmental crisis in the Gulf (amid the echoes of “Drill, Baby, Drill”), to find one example after another of human beings blinding themselves to the very serious eventual impact of their irresponsible behavior because of the intoxication of immediate gain (more money for me, more recognition, more power, more stuff, more euphoria).

As is my wont, I will now note the obvious parallels to addictive behavior. It is often said that, in addiction, the brain gets neurologically “hijacked.” People go to great lengths to protect a pattern of behavior and sensation, as if it were necessary to their survival. Their choices are ruled by immediate rewards (and fear of immediate unpleasantness); longer-term and more momentous consequences are rationalized away or simply ignored in the service of maintaining the addiction. Of course, in the long run, no one’s life is meaningfully enriched by intoxication, euphoria, escape, riches, fame, or power. But, for us humans, it appears that this is how the game is played.

Since the addict (like other human beings) tends not to be guided toward rational, “good” behavior by his or her own instincts, it is usually necessary for him or her to develop what I (and, I’m sure, others) call “healthy fear” in order to summon the initial motivation to take steps toward recovery. The activities often referred to as “enabling” are the behaviors of those surrounding alcoholics/addicts who cushion them from the negative consequences of their actions. When the alcoholic/addict finally gets to the point of having more fear of what will happen if s/he continues to drink (or drug or gamble, etc.) than the existing fear of what will happen if s/he does not – that is often the moment when the first efforts toward change are made. (Not much different for the sedentary overeater who suddenly goes to the nutritionist and the gym after having a heart attack.)

Once in recovery, addicts often eventually need to come to terms with things they did while actively addicted that were foolish, hurtful, unethical, etc. Their retroactive guilt and shame can sometimes trigger cravings to return to their substance for relief. Those who participate in 12-step groups get some help in addressing and resolving the guilt through some of the steps specifically focused on self-examination and reparation. (Others, of course, may go through a similar process in other ways, such as psychotherapy – I don’t think we have a pill for that yet.)

People behave best, it seems, when they are subject to a strong sense of personal responsibility for their choices. I am not suggesting that personal choice and free will are the only, or even primary, factors contributing to how people behave, but that a sense of personal accountability, closely connected with “healthy fear,” may be the only or best route toward doing what’s best for ourselves, our communities, our country and world. Researchers who fabricate or distort scientific findings, or hide contrary results, should be subject to losing their careers. Corporate workers (from the top executives who green-light projects or ignore unprofitable information to the front-line workers who run studies or sell mortgages or check the mechanical integrity of oil wells or Big Dig tunnels) will never change their behavior if only the corporate entity is sanctioned, while individuals continue to be rewarded. Promoting a sense of individual moral responsibility may be the big challenge of our time, if we are to avoid becoming the victims of our own largely primitive brains.

Monday, May 31, 2010

Avoidance as Addiction

I know, I know – they call everything an addiction these days. Sometimes it seems like a convenient excuse for people like Tiger Woods or that guy who married Sandra Bullock. But sometimes the question isn’t so much “Is this a true addiction?” as “Does it help to apply the addiction model to this problem?”

One case in point is avoidance of professional tasks – in my work at the Massachusetts lawyer assistance program, I’ve noticed that almost every lawyer (maybe every person) reports at least occasional episodes. In some cases, it fits under the oft-discussed category of procrastination, in the sense that we all often feel like doing something other than work. In other cases, it is more clearly associated with particular feelings and relationships. The feelings may include anger, regret, etc., but most often there is a high degree of anxiety or fear, which can be compounded, as time goes on, by shame.

Like the use of an addictive substance, avoidance behavior is instantly and powerfully reinforcing. Imagine a situation where you have to tell your friend Fred that you cannot actually loan him the money you had said you would. This will be a terribly awkward, uncomfortable, conversation. You anticipate his anger, disappointment, dismay, and yourself feeling like the cause of it (in an immediate sense, though of course you had nothing to do with the reasons he needed the loan). As you pick up the phone to call him, your pulse increases and you find yourself holding your breath. Imagine, now, that you reach his voice mail and hear “Because of a family member’s funeral in another state, I will be away until next Monday.” You now have a very good excuse for putting off this unpleasant chore. The relief! Your breathing and muscles relax, and a sense of wellbeing returns.

In avoidance, you get the same immediate benefit – the difference is that the excuse is not provided by Fred’s absence, but by internally generated rationalizations – “I’m too tired to do it tonight;” “This can always be done later;” “Maybe if I shelve it now, somehow the need to do it will go away;” “I’ve avoided things like this before, and nothing awful happened.” It’s not hard to see how rewarding avoidance can be – it can dramatically lower anxiety and other negative emotions.

As one who lingers over the newspaper a few minutes longer every morning than makes sense, momentarily pushing away the commute and the day’s tasks, I certainly understand the appeal of avoidance in general. In addition, particular types of work present their own seductive opportunities for delay, evasion, momentary escape. Cues for lawyers, for example, include the following:

Having to tell a client something s/he won’t want to hear; e.g., your lawsuit no longer looks promising.

Facing an unfamiliar task, e.g., I’ve never filed this kind of petition before.

Dealing with ornery or otherwise unpleasant clients.

Of course, the particular situations that tend to elicit avoidant behavior will vary from individual to individual. Each alcohol or drug addict, similarly, will have his or her own set of “triggers” that elicit urges to engage in the addictive activity.

If the addiction model is at all useful to apply to avoidance, what measures would it suggest employing in order to “prevent relapse”? Here are some:

• Admit the problem. If history has shown that you have repeatedly avoided important duties in a way that is ultimately likely to lead to meaningful regrets, face the fact that there is a subset of your behavior that is not subject to your ability to think rationally.

• Don’t keep it to yourself; talk to someone else about it; make it real and accept that if you could fix it via internal dialog only you probably would already have done so.

• Identify the situations (external, emotional, etc.) that, for you in particular, are most likely to trigger counterproductive avoidance. This is done primarily by reviewing past examples.

• Though it’s just the sort of thing that we all tend to put out of our minds, practice thinking beyond the decision to avoid, and allow yourself to see the potential or likely consequences. For example, the client will be even angrier to find out about this at a later date, while if you get through the task now you will no longer have to dread it.

• If you are deceiving, hiding, or denying, recognize that these maneuvers perpetuate the avoidance and add to your burden.

With any addictive behavior (and I am only suggesting that avoidance can emulate an addiction*), few individuals will be motivated to take action until some kind of problem results from the behavior, but the hope is always that one need not “hit bottom” in an extreme (or career-heopardizing) way in order to accept reality and embrace healthy change. This is where a therapist may come in handy.

*It is worth noting, however, that there actually is a 12-step group called Procrastinators Anonymous:

Sunday, February 7, 2010

The "Higher Power" Obstacle, part 2

As discussed in my last blog, deriving the benefits of 12-step programs (which, all other considerations aside, are by far the most available resource for those in recovery) involves finding some kind of comfort with the concept of a “higher power,” and this can be uncomfortable for those with a more secular orientation. The 12 steps might well be worded differently if the program had developed in recent years, but it dates to 1935, and to the experiences of founders Bill Wilson and Dr. Bob Smith, who drew their initial inspiration from a Christian movement, the Oxford Group. Just as countless people with no traditional religious belief nevertheless value the Golden Rule, it is possible to make constructive use of the 12 Steps as a psychological program without embracing theism.

Among the alternative “higher power” concepts that I have heard over the years from many of my patients in recovery is “G-O-D = Group of Drunks,” i.e., the sense that the accumulated wisdom of everyone in AA is likely to be greater than that of the individual. Indeed, as captured in the title of Kurtz’ history of AA, of crucial importance in recovery, from the AA perspective, is that the individual recognize that he or she is “Not God.” That is, it helps a lot to assume a posture of humility, recognizing that one’s own attempts to gain mastery over addiction have failed (usually case prior to coming to AA), and that grandiosity or over-confidence tends to be counter-productive.

Others may choose, in the role of higher power, a generalized notion of spirituality, which may include:

· Something akin to “The Force,” a connection with nature, or with the interconnectedness of all human beings;
· A transcendent state or awareness characterized by full and liberating acceptance of the universe as it is, and of having one’s own place in it (something related to what has in recent years been dubbed “mindfulness”);
· A commitment to compassion, and to other higher values that in many cases have slipped away over time, as the addiction has taken up more and more space in one’s mind. Author Karen Armstrong has discussed key, overarching humanitarian values that characterize virtually all religious philosophies but do not require a particular theistic belief.
· A psychological conception of the higher power as a part of the self, an internal representation. Many of us, even atheists, finds ourselves praying, or asking for help or guidance – without a belief in an external God, we must be communicating with a wiser or more intuitive part of ourselves. The part, for example, that awakens in the middle of the night with a new way to address a problem, or that sometimes seems to come up with answer we did not know we had. (When I was a songwriter, on occasion I had the sense that a song was writing itself “through” me. It flowed smoothly, and took shape as if the song already existed, and in fact I often thought I might have unconsciously ripped it off. Sometimes I had, but other times these became some of my better songs. A believer would be likely to attribute the process to God; an agnostic or atheist would have to view the experience as reflective of an internal connection to another part of onself.)

This is by no means an exhaustive list. Perhaps there are other concepts that have worked for you.

Saturday, January 23, 2010

The "Higher Power" Obstacle

When embarking on a goal of abstinence from alcohol/drugs, which for many is the only realistic goal, self-help groups are certainly a key resource, whether or not the individual is involved in professional treatment. Self-help groups (which would more accurately be called mutual-help groups) offer a number of advantages – some level of relatively constant availability, a sense of comradeship with others in the same position, a venue for support, acceptance, congratulation, empowerment, etc., a wealth of practical advice – as much as needed, and at no cost (and no need for managed care authorization).

By far, the majority of self-help groups follow the Twelve Step model (mainly AA and NA). SMART Recovery also has a meaningful presence, at least in Massachusetts, but the sheer number of available meetings pales by comparison. (Comparing these two programs can wait for a later column.) In some states, other programs such as Women for Sobriety are also prevalent. Given the prominence of AA/NA, not to mention the impressive history of 12-step programs since their inception in 1935, it makes sense for most people in what is often called “early recovery” to at least sample AA meetings.

My experience, however, is that the majority of people, early in their exposure to AA, don’t like it. There are a range of reasons given, including a perception that “their problems are worse than mine” (and of course, an underlying preference to avoid getting involved with an organization that symbolizes loss of the beloved substance), but the obstacle about which I hear most frequently is “the God stuff.” There is, of course, no denying that AA itself began as an offshoot of the Oxford Group, a non-hierarchical Christian movement of the 1920s and 1930s which emphasized many of the themes still echoed in AA (but in the context of seeking to place oneself, nation, and world under God’s control). On the other hand, AA is explicitly not a religion, and invites multiple and individualized interpretations of “higher power;” in reality, there are many atheists and agnostics who make use of the AA program. But the wording of the 12 Steps can be a problem. The term “God” is used repeatedly, followed twice by the phrase, “as we understood Him” – making it sound as if the adherent must surrender to a God of the sort that could have a gender, and that in fact the gender is male.

A person of more secular, 21st Century sensibilities may well conclude, “This is not where I belong,” and walk away from a program that could, in fact, have much to offer him or her. In order to continue making use of AA, s/he must view terms like "God" and "Him" as metaphors for some alternative concept of a higher power. Some ideas on how that might be done coming soon.
© 2010 Jeffrey Fortgang

Sunday, January 10, 2010

Seeking The Answer

As I read a Boston Globe article the other day about the emergence of personal coaching as an alternative to psychotherapy (more oriented, they tell us, to goals/future/happiness than to addressing problems or illness), I picked up a glimmer of what must be a typical reader reaction: Now, finally, there's a new, better, right answer. Now I can access the people who really have the answer to happiness, rightness, etc. (Even though we learn that many coaches, though they have no widely supported standards or certification,are themselves mental health professionals, maybe that have just found a better path -- certainly one that allows them to charge more without having to deal with health insurance.)Within the established mental health field, of course, new/better/"the answer" therapy techniques never stop appearing. Each brings a series of books and traveling experts, and draws a slew of therapists who are, themselves, looking for an approach that will help them feel more effective and successful. Some of these techniques become passing fads, while others take root and hang around. Quite often, the new/better/special approaches eventually seem less different from what already existed, and blend in, to become partof the ongoing, fluid collection of perspectives on which the average therapist draws. The same thing happens with new medications – it is said, in jest but also accurate social perspective, that one should make sure to use new meds within the 1st 2 years, since after that their effects will become much less impressive.

In other fields, there is no scarcity or end to exciting new answers from the worlds of nutrition, exercise, and of course religious leaders (whose role in the last century has largely been transferred to mental health professionals).

Alas, it turns out to be a rare event when there is something genuinely new under the sun. And I’m not sure that anyone has The Answer. I recall, years ago, during the heyday of Stress Management, getting to know a professional who developed a nice sideline giving talks and workshops about stress. The techniques she had for making her audience aware of their stress level were eye-opening, and the relaxation techniques in which she guided them were, indeed, relaxing and provided a delightful break from the pressures of the day. So she was a local stress management guru, much like the long line of inspirational speakers on which we can overdose by watching PBS at fund-raising time. I got to know her, and liked her very much, but found her to be no less stressed than the rest of us and, in fact, to be juggling an untreated addiction. She was a very fine person and I’m sure she eventually addressed that issue – my only point is that we are all flawed, trying to get through, and not likely to be either finding or providing The Answer.

Yet we yearn to find a sage to follow and idealize, in our quest for a level of perfection and happiness which are not realistically attainable. We look at others, and they seem to be happier or more fulfilled or more successful, etc. Around 12-step circles, one sometimes hears the extremely useful guidance: “Don’t compare your inside to someone else’s outside.”

Of course, we should always be seeking more effective treatments and ways to alleviate suffering and advance wellbeing. But let’s abandon our fantasies of achieving flawlessness if we just find the right guru or hear the right infomercial.

As various forms of therapy/counseling/coaching/guidance come and go, and as those that seemed cutting-edge come to seem obsolete, what seems to be constant is that a crucial element in therapeutic outcomes is the quality of the relationship between patient/client and therapist – genuineness, acceptance of self and other, human connection, and appreciation of the moment – that’s probably as close to perfection as any of us can get, and maybe that’s enough.

Friday, January 1, 2010

Insane College Drinking

A recent episode of the wonderful NPR program, This American Life (which not only offers entertainingly quirky slices of life each week but can also be so much more informative than most of what we get from any media), trained its radio lens on the college drinking scene, and on the college deemed the nation's "#1 Party School." I recommend it to everyone. (

I have often noted that it is difficult to impossible to accurately diagnose Alcohol Dependence (colloquially, “alcoholism”) in college students – to identify those young men and women who will go on to function alcoholically long after college. Or, in other words, those who won’t radically curtail their drinking after moving on to the next chapter in their lives. Part of the problem is that, since so many college students so often choose to get very drunk -- because it has become normative! -- it is hard to know which individuals are losing control of their consumption, and which ones are choosing to drink like someone who has lost control.

The NPR program describes how one attempt after another to reduce college drinking through education, offering alcohol-free alternatives, etc. has failed to make a difference. What's so bad about binge drinking among the college crowd? The worst consequence is the recurrent deaths, through alcohol poisoning and dangerous (often unintentionally so) behaviors. And of course there is also collateral damage -- to property, people's jaws, private parts, or integrity, friendships, driving privileges, and, oh yeah, one's education.

I can't say I got the maximum benefit from my own college education. At that time, we were very distracted by the war in Vietnam and the many-faceted “Revolution” But I have to say I feel lucky that the drug of choice, at that time and place, was marijuana. It certainly presents multiple dangers of its own, and I'm not recommending it, but it does not approach alcohol in the potential havoc it wreaked on one's body, behavior, brain, legal status, family life, etc. Of course, most people engage in “normal” drinking in a way that produces little or no harm -- but it's hard to find anything like it at college, at a time of life when the brain is still developing. So, happy new year, and here's to those of us who somehow manage to survive our educations!