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.”