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
Saturday, January 23, 2010
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.
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. (http://www.thisamericanlife.org/Radio_Episode.aspx?sched=1330)
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!
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!
Saturday, November 28, 2009
More on Moderation
Most people who come to see me about their drinking, and who have had little prior treatment or connection to self-help groups, are not coming with a goal of abstinence. This is totally understandable – anyone who has run into a problem with any gratifying activity would want to give up only the problem part of the activity, rather than the whole experience. As I often point out, alcoholics and addicts are, in most respects, no different from the rest of humanity. Remember the days when eggs were bad for your cholesterol? (I think that changed, but I’m no authority on that.) Did you choose to give up eggs altogether, in order to be safe? Or did you just cut back?
Of course, the problem that most alcoholics and addicts run into is that cutting back on behaviors that have become addictive (whether alcohol, drugs, lottery tickets, internet porn, etc.) is, in fact, different from cutting back on eggs. Addictions, in fact, are different from “regular” behaviors, which is why applying logic or reasoning has much less impact on alcoholic behavior than on most decisions we make. If we were to learn, for example, that one brand of bottled water contained more carcinogens than another brand at the same price, we would choose to purchase the safer brand. If we had repeatedly been robbed when walking alone in a certain part of town, we would stop walking alone there. But drinking poses much greater danger for the alcoholic, yet s/he does not seem to learn from the negative experience. There are at least two reasons for this: [1] behavior tends to be shaped more by immediate consequences (which, in the case of alcohol and addictive drugs are mostly experienced as rewarding) than by later consequences (e.g., losing one’s family, job, or health); [2] addictive behavior is driven largely by parts of the brain other than those involved in reasoning. (For more on the evolving science of the neurobiology of addictions, visit the web site of the National Institute on Drug Abuse – you might start with the review found here.
Of course, most people who use alcohol are not alcoholics. They are able to decide how much to drink (which, in the case of college students, is often enough to get drunk), and after a relatively small amount of alcohol they experience satiation, with no drive to continue. Most alcoholics, on the other hand, feel a very strong pull to continue drinking once they have consumed one or two drinks. Some say they can’t really fathom why someone would bother drinking if having only one or two. Why the difference? Most clinicians and scientists in the field (but not all) agree that it is biological rather than psychological, likely a difference in genes, nervous system, metabolism, rather than a matter of so-called “willpower.” Most alcoholics have had no problem applying willpower to other aspects of their lives, and have tried repeatedly but unsuccessfully to apply it to their drinking. To further complicate the matter, many alcoholics can limit their drinking temporarily by paying extra-close attention while seeking to prove the ability to exert control. Over time, however, they relax into doing what comes naturally, as anyone would. Even a review of the epidemiologic studies suggesting that some of those with diagnosable alcohol problems can achieve non-problem drinking indicates that abstinence is the most stable resolution, especially for those with more symptoms of alcohol dependence.
That’s what makes moderation such a difficult goal. Nevertheless, almost no one is prepared to “surrender” to these probabilities at the outset. So, as a therapist, I hang in with them as they do what I describe as a series of experiments, in which the hypothesis is, “I can keep the good part of my drinking and delete the bad part.” I don’t have to tell you what the outcome usually is. But everyone has to do his or her own “research.”
Of course, the problem that most alcoholics and addicts run into is that cutting back on behaviors that have become addictive (whether alcohol, drugs, lottery tickets, internet porn, etc.) is, in fact, different from cutting back on eggs. Addictions, in fact, are different from “regular” behaviors, which is why applying logic or reasoning has much less impact on alcoholic behavior than on most decisions we make. If we were to learn, for example, that one brand of bottled water contained more carcinogens than another brand at the same price, we would choose to purchase the safer brand. If we had repeatedly been robbed when walking alone in a certain part of town, we would stop walking alone there. But drinking poses much greater danger for the alcoholic, yet s/he does not seem to learn from the negative experience. There are at least two reasons for this: [1] behavior tends to be shaped more by immediate consequences (which, in the case of alcohol and addictive drugs are mostly experienced as rewarding) than by later consequences (e.g., losing one’s family, job, or health); [2] addictive behavior is driven largely by parts of the brain other than those involved in reasoning. (For more on the evolving science of the neurobiology of addictions, visit the web site of the National Institute on Drug Abuse – you might start with the review found here.
Of course, most people who use alcohol are not alcoholics. They are able to decide how much to drink (which, in the case of college students, is often enough to get drunk), and after a relatively small amount of alcohol they experience satiation, with no drive to continue. Most alcoholics, on the other hand, feel a very strong pull to continue drinking once they have consumed one or two drinks. Some say they can’t really fathom why someone would bother drinking if having only one or two. Why the difference? Most clinicians and scientists in the field (but not all) agree that it is biological rather than psychological, likely a difference in genes, nervous system, metabolism, rather than a matter of so-called “willpower.” Most alcoholics have had no problem applying willpower to other aspects of their lives, and have tried repeatedly but unsuccessfully to apply it to their drinking. To further complicate the matter, many alcoholics can limit their drinking temporarily by paying extra-close attention while seeking to prove the ability to exert control. Over time, however, they relax into doing what comes naturally, as anyone would. Even a review of the epidemiologic studies suggesting that some of those with diagnosable alcohol problems can achieve non-problem drinking indicates that abstinence is the most stable resolution, especially for those with more symptoms of alcohol dependence.
That’s what makes moderation such a difficult goal. Nevertheless, almost no one is prepared to “surrender” to these probabilities at the outset. So, as a therapist, I hang in with them as they do what I describe as a series of experiments, in which the hypothesis is, “I can keep the good part of my drinking and delete the bad part.” I don’t have to tell you what the outcome usually is. But everyone has to do his or her own “research.”
Sunday, November 22, 2009
The Question of Moderation as a Goal for Alcoholics
Obviously this question is too big for me to address comprehensively in one blog, or a series of blogs, and in fact it represents an ongoing conundrum dating back long before my time and that may well persist long after.
Every so often, new “evidence” crops up that alcoholics (and, by extension, other kinds of addicts) can transform themselves into moderate, non-problem drinkers. To the extent that this occurs, it seems to happen most often among those who have never sought treatment – and perhaps that is one reason why it is relatively alien to my experience and that of my colleagues.
Sometimes these reports come from treatment studies, such as the famous (well, to me, anyhow) Sobell & Sobell studies of the early 1970’s that purported to successful teach alcoholics to drink in moderation. (A follow-up study a few years later indicated that those relatively few individuals who had initially pulled off moderate drinking were now abstinent or drinking alcoholically or deceased.) More recently, some epidemiologic studies (in which large numbers of people in the community are interviewed retrospectively) have indicated that a significant minority of people who at some point met diagnostic criteria for alcohol dependence were currently drinking in a low-risk (i.e., non-problem) manner.
I should say that, in my student days, having read an early study by Davies, I was all for finding a behavioral strategy that could teach alcoholics to be normal drinkers. Over time, however, real life experience dampened those hopes, much as it has done for countless alcoholics.
Moderation Management is a self-help program that says it targets problem drinkers, as opposed to alcoholics. That may make some sense, since I suspect that some of those who reportedly manage to sustain moderate drinking may not be alcoholic in the same way as those I see most of the time -- for them, planning to regularly stop after 2 drinks is like planning to jump off a cliff and fall no more than 2 yards. MM reports that 30% of those who attend end up switching to a goal of abstinence. That includes the founder of that organization, who decided moderation might not make sense for her after she committed vehicular homicide.
More to come.
Every so often, new “evidence” crops up that alcoholics (and, by extension, other kinds of addicts) can transform themselves into moderate, non-problem drinkers. To the extent that this occurs, it seems to happen most often among those who have never sought treatment – and perhaps that is one reason why it is relatively alien to my experience and that of my colleagues.
Sometimes these reports come from treatment studies, such as the famous (well, to me, anyhow) Sobell & Sobell studies of the early 1970’s that purported to successful teach alcoholics to drink in moderation. (A follow-up study a few years later indicated that those relatively few individuals who had initially pulled off moderate drinking were now abstinent or drinking alcoholically or deceased.) More recently, some epidemiologic studies (in which large numbers of people in the community are interviewed retrospectively) have indicated that a significant minority of people who at some point met diagnostic criteria for alcohol dependence were currently drinking in a low-risk (i.e., non-problem) manner.
I should say that, in my student days, having read an early study by Davies, I was all for finding a behavioral strategy that could teach alcoholics to be normal drinkers. Over time, however, real life experience dampened those hopes, much as it has done for countless alcoholics.
Moderation Management is a self-help program that says it targets problem drinkers, as opposed to alcoholics. That may make some sense, since I suspect that some of those who reportedly manage to sustain moderate drinking may not be alcoholic in the same way as those I see most of the time -- for them, planning to regularly stop after 2 drinks is like planning to jump off a cliff and fall no more than 2 yards. MM reports that 30% of those who attend end up switching to a goal of abstinence. That includes the founder of that organization, who decided moderation might not make sense for her after she committed vehicular homicide.
More to come.
Thursday, October 8, 2009
Not a Disease? Again?
Recently I heard a radio interview with yet another mental health professional who has determined the addiction (a term that includes alcoholism) is not precisely a disease, but rather a matter of choice. Of course, debates about the nature of alcoholism/addiction go back a very long time. For ages, many viewed it as a moral failing rather than a condition, and perhaps for that reason a number of approaches to eradicate it came from the church. Although I'm sure addiction had been defined in medical terms before in some quarters, a major turning point in this country came in the 1930's, with the concurrent work of Dr. Jellinek at Yale and the formation of AA, itself an offshoot of a religious movement but one which embraced the disease model of alcoholism.
It was and is, of course, obvious to anyone that alcoholism is not the same kind of disease as, say, chicken pox. There is no germ, no contagion. It has, on the other hand, often been likened to diabetes or heart disease; though the analogy is far from perfect, these are illnesses for which there is no cure per se, but for which one can live a generally healthy life by making lifestyle changes. The diabetic avoids sugar (to over-simplify). The cardiac patient, depending on condition, perhaps avoids fats, maintains an exercise regime, etc. The alcoholic/addict refrains from using addictive substances. That is, to be sure, a choice. But it is a very different kind of choice from most of the choices we make – for example, whether to purchase furs, whether to buy a foreign car, or that pressing choice between “paper or plastic” at the supermarket. Those choices involve thought, belief, and behavioral follow-through. Avoiding alcohol, for the alcoholic, is an exceedingly more difficult task. A big part of his or her brain is creating an urge to drink, as powerful an urge as others might feel to eat when deprived of food, and powerful enough that there is often the risk that it will override rational thought (which is the province of a different part of the brain) -- hence, the familiar relapse-enabling rationalizations that seem so foolish in hindsight, which often take the form of: "I can have just one or two drinks this time because [insert reason that defies logic and previous experience]." This is nothing like even a tough non-addictive choice, such as "I got into Harvard, but my gut says I'll be happier at U Mass."
There is, I think, fairly wide agreement now among scientists who study addictions on some points (and a good place to read comprehensible reports on some of the latest research is at www.drugabuse.gov/Pubcat/ the website for NIDA, the National Institute for Drug Abuse). These include:
- Alcoholism, and probably most addictions, run in families, and while culture and learning, and other social/psychological factors are important, genes are of crucial importance;
- On the whole, the brains of alcoholics/addicts (and, it now seems, people with other conditions involving mood, thought, and behavior) are a bit different from the brains of those without addictions;
- Some of these differences are probably built-in from birth, while others are probably acquired as a result of repeated, substantial alcohol/drug use.
None of this means that one is doomed to keep drinking or drugging, or that no choice is involved, and of course recognizing the consequences of substance use can provide an incentive to make a less frightening choice. In fact, choice is critical, and to take a stance of "well, I have a disease, so we'll see what happens" is not at all likely to lead torecovery. But it's nothing like the choice you made this morning about what to wear, or the choice you made in the voting booth.
It was and is, of course, obvious to anyone that alcoholism is not the same kind of disease as, say, chicken pox. There is no germ, no contagion. It has, on the other hand, often been likened to diabetes or heart disease; though the analogy is far from perfect, these are illnesses for which there is no cure per se, but for which one can live a generally healthy life by making lifestyle changes. The diabetic avoids sugar (to over-simplify). The cardiac patient, depending on condition, perhaps avoids fats, maintains an exercise regime, etc. The alcoholic/addict refrains from using addictive substances. That is, to be sure, a choice. But it is a very different kind of choice from most of the choices we make – for example, whether to purchase furs, whether to buy a foreign car, or that pressing choice between “paper or plastic” at the supermarket. Those choices involve thought, belief, and behavioral follow-through. Avoiding alcohol, for the alcoholic, is an exceedingly more difficult task. A big part of his or her brain is creating an urge to drink, as powerful an urge as others might feel to eat when deprived of food, and powerful enough that there is often the risk that it will override rational thought (which is the province of a different part of the brain) -- hence, the familiar relapse-enabling rationalizations that seem so foolish in hindsight, which often take the form of: "I can have just one or two drinks this time because [insert reason that defies logic and previous experience]." This is nothing like even a tough non-addictive choice, such as "I got into Harvard, but my gut says I'll be happier at U Mass."
There is, I think, fairly wide agreement now among scientists who study addictions on some points (and a good place to read comprehensible reports on some of the latest research is at www.drugabuse.gov/Pubcat/ the website for NIDA, the National Institute for Drug Abuse). These include:
- Alcoholism, and probably most addictions, run in families, and while culture and learning, and other social/psychological factors are important, genes are of crucial importance;
- On the whole, the brains of alcoholics/addicts (and, it now seems, people with other conditions involving mood, thought, and behavior) are a bit different from the brains of those without addictions;
- Some of these differences are probably built-in from birth, while others are probably acquired as a result of repeated, substantial alcohol/drug use.
None of this means that one is doomed to keep drinking or drugging, or that no choice is involved, and of course recognizing the consequences of substance use can provide an incentive to make a less frightening choice. In fact, choice is critical, and to take a stance of "well, I have a disease, so we'll see what happens" is not at all likely to lead torecovery. But it's nothing like the choice you made this morning about what to wear, or the choice you made in the voting booth.
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