I have yet another media link to recommend. Charlie Rose, on his PBS program, has commenced a second series designed to provide new insights on the brain and its connection to human experience, and the first installment provides a great overview, led by neuropsychiatrist and Nobel laureate Eric Kandel. The panelists are Gerald Fischbach (neurology), Thomas Insel (of NIMH, on psychiatric disorders), and – most relevantly to this blog – Nora Volkow, director of the National Institute on Drug Abuse. With her unmistakable accent (the outgrowth of growing up in a Russian family while living in Mexico), she is a remarkably articulate explainer of addiction from a neurobiological standpoint.
What often strikes me is that new brain-based descriptions of how addictions develop and operate often dovetail with old observations. Those of us who have been working with alcoholics/addicts for a long time have tended to develop conclusions based on our collected observations. Now, we have some possible ways to understand the neurobiological mechanisms that may underlie these observations. For example:
[Observation] Even people who express a sincere wish to abstain from substances, or who think they should be able to exert enough “willpower,” usually find that they return to the kind of behavior that they have sworn off. [Neurobio Explanation] The process of developing an addiction includes developing a linkage between drug- or alcohol-related stimuli and a drive toward addictive behavior, co-opting the same reward circuit that drives us toward doing things we need to survive (such as eating and procreating). In addition, the repeated intrusion of drugs into our brains injures the prefrontal cortex, the part of our brains that helps us exert appropriate caution before acting.
At first, individuals enjoy getting high when they choose to use alcohol or addictive drugs. For those who become addicted or alcoholic, however, substance use has the primary function not of feeling good so much as feeling normal or OK. Neural reward circuits “light up” in real-time brain scans of non-addicts when they use the substance, but those who have developed addictions show little or no change. This fact, however, does not extinguish their urge to use, which is now driven by other factors.
With rare exceptions, addicts/alcoholics do not “rewind” and return to an earlier, more normal pattern of use. A purely learning/unlearning model does not seem to apply. Although learning and memory clearly play a role in the development of addiction, changes in brain circuits persist. Even in the absence of active substance use, the disorder is typically chronic.
A 30-day rehab alone is rarely successful if not followed by frequent and consistent follow-up, in some combination of support groups, professional contacts, and safer living environments. Brain changes resulting from months or years of addictive drug use endure for months or years; short-term treatment is far short of what’s necessary to reverse or compensate for those changes.
Sunday, November 6, 2011
Monday, August 15, 2011
Addiction and Neuroscience
One of the treasures of radio (nowadays expanded to include podcasts), even within the wonderful world of NPR, is Terry Gross’ daily Fresh Air program. To my mind, she’s the best interviewer in broadcasting. I recently listened to a podcast of her June 23 interview with Dr. David Linden, professor of neuroscience at Johns Hopkins University School of Medicine, and author of The Compass of Pleasure. He does a nice of job pulling together the exploding body of scientific research that reconfirms that addiction is a largely genetic and neurobiological condition rather than simply a matter of choice and self-control, as some opponents to the so-called “disease model” have argued for years.
There has been evidence for decades, from a large number of studies of identical twins, adoptees, etc., that addictions (most studies focusing on alcoholism) are largely genetic. (Dr. Linden quotes a figure of 40%; almost all the recent research references I have found say 50%.) Thus, a number of people, usually with genetic family histories of alcoholism/addiction, appear to be born with a predisposition to addiction. However, environment (including stress level), personality, and learning also play large roles. People who do have this predisposition but who barely use alcohol or drugs will still not become addicted to these substances. On the other hand, people without these genes (and there seem to be many genes involved, not just one) will have a lower chance of developing addictions despite heavy exposure to substance use.
Even the process of learning to drink or drug in progressively greater amounts, and increasing frequency, is heavily influenced by biology, which, for example, determines how good or relieving it feels to use a given drug and how much of the substance is needed to get an effect.
What is kind of exciting is how many of the characteristics of addictive behavior that we have observed for generations are now understood to be paralleled by neurobiological processes that can, at this point, be identified rather than merely inferred.
Anyone who took an introductory psychology course heard about both Operant (or Instrumental) and Classical (or Pavlovian) Conditioning, both of which are hugely important in the development of addictions. In operant conditioning, when a particular action of an animal (such as yourself) is followed repeatedly by a reinforcement/reward, the individual is likely to engage in more of that behavior. In classical conditioning, when a particular stimulus (e.g., a pub; white powder) becomes associated with a response (e.g., drinking, drug use), exposure to the first tends to trigger the body to prepare for the second (e.g., craving).
What neuroscientists have clarified is that underlying these behavioral experiences are chain reactions in the brain’s reward system (located in the medial forebrain and involving structures you may have heard of, such as the ventral tegmental area and nucleus accumbens, as well as chemicals, neurotransmitters, especially one called dopamine that is increased in reaction to addictive drugs). This reward system evolved because it promoted the survival of our species; it is turned on by food, water, sex, and also by exercise, altruism, and the experience of learning – all essential and all pleasurable to most humans. (And Linden notes that non-substance related behaviors, such as eating and sex, can also become addictive for predisposed individuals.)
One kind of genetic predisposition, according to Linden, is that people born with a “blunted pleasure circuit” are driven to put more energy into risk, and seeking pleasure and novelty. Clinicians have noticed for years that some people seem unusually drawn to seek excitement/sensation and that they are more prone toward substance abuse – now we have a way to understand why that may be.
As Linden also notes, the heavy and repetitive substance use of addicts seems to actually change the cellular structure of their brains, in a way that tends to be irreversible. Over time, the addictive behavior actually comes to have less to do with pleasure/reward than with simply feeling OK and functioning adequately. He calls this a transformation from “liking” to “wanting.” I think “wanting” is too weak a word, and that in the addict’s experience it is closer to “needing.”
None of this is to say that addicts are without any level of choice or responsibility. Obviously, the only way anyone moves in the direction of recovery is by acknowledging and taking responsibility for his or her addiction, and making choices, developing new behaviors, etc., in an effort to get around these established but ultimately self-defeating patterns. But let’s recognize that when we advise people to give up addictive behavior, we are typically asking them to take on a herculean task, to use their intelligence and consciousness to override what has become their natural mode of brain functioning. That’s why so often they need strong support, frequent reminders and motivators, etc. And, since changed brains don’t revert to their pre-addictive structure, it is for good reason that the term “recovering” has replaced the term “recovered.”
There has been evidence for decades, from a large number of studies of identical twins, adoptees, etc., that addictions (most studies focusing on alcoholism) are largely genetic. (Dr. Linden quotes a figure of 40%; almost all the recent research references I have found say 50%.) Thus, a number of people, usually with genetic family histories of alcoholism/addiction, appear to be born with a predisposition to addiction. However, environment (including stress level), personality, and learning also play large roles. People who do have this predisposition but who barely use alcohol or drugs will still not become addicted to these substances. On the other hand, people without these genes (and there seem to be many genes involved, not just one) will have a lower chance of developing addictions despite heavy exposure to substance use.
Even the process of learning to drink or drug in progressively greater amounts, and increasing frequency, is heavily influenced by biology, which, for example, determines how good or relieving it feels to use a given drug and how much of the substance is needed to get an effect.
What is kind of exciting is how many of the characteristics of addictive behavior that we have observed for generations are now understood to be paralleled by neurobiological processes that can, at this point, be identified rather than merely inferred.
Anyone who took an introductory psychology course heard about both Operant (or Instrumental) and Classical (or Pavlovian) Conditioning, both of which are hugely important in the development of addictions. In operant conditioning, when a particular action of an animal (such as yourself) is followed repeatedly by a reinforcement/reward, the individual is likely to engage in more of that behavior. In classical conditioning, when a particular stimulus (e.g., a pub; white powder) becomes associated with a response (e.g., drinking, drug use), exposure to the first tends to trigger the body to prepare for the second (e.g., craving).
What neuroscientists have clarified is that underlying these behavioral experiences are chain reactions in the brain’s reward system (located in the medial forebrain and involving structures you may have heard of, such as the ventral tegmental area and nucleus accumbens, as well as chemicals, neurotransmitters, especially one called dopamine that is increased in reaction to addictive drugs). This reward system evolved because it promoted the survival of our species; it is turned on by food, water, sex, and also by exercise, altruism, and the experience of learning – all essential and all pleasurable to most humans. (And Linden notes that non-substance related behaviors, such as eating and sex, can also become addictive for predisposed individuals.)
One kind of genetic predisposition, according to Linden, is that people born with a “blunted pleasure circuit” are driven to put more energy into risk, and seeking pleasure and novelty. Clinicians have noticed for years that some people seem unusually drawn to seek excitement/sensation and that they are more prone toward substance abuse – now we have a way to understand why that may be.
As Linden also notes, the heavy and repetitive substance use of addicts seems to actually change the cellular structure of their brains, in a way that tends to be irreversible. Over time, the addictive behavior actually comes to have less to do with pleasure/reward than with simply feeling OK and functioning adequately. He calls this a transformation from “liking” to “wanting.” I think “wanting” is too weak a word, and that in the addict’s experience it is closer to “needing.”
None of this is to say that addicts are without any level of choice or responsibility. Obviously, the only way anyone moves in the direction of recovery is by acknowledging and taking responsibility for his or her addiction, and making choices, developing new behaviors, etc., in an effort to get around these established but ultimately self-defeating patterns. But let’s recognize that when we advise people to give up addictive behavior, we are typically asking them to take on a herculean task, to use their intelligence and consciousness to override what has become their natural mode of brain functioning. That’s why so often they need strong support, frequent reminders and motivators, etc. And, since changed brains don’t revert to their pre-addictive structure, it is for good reason that the term “recovering” has replaced the term “recovered.”
Friday, April 22, 2011
Report on Marijuana
The National Institutes of Health are a kind of clinical national treasury, staffed by researchers who may be motivated to make a name for themselves, but at least not by a need to make a profit for a pharmaceutical company or other greed-driven enterprise. Based on what they pay my daughter, who is currently involved in a post-baccalaureate research fellowship there, they are certainly not doing it for the income.
The two particular institutes that I follow most closely are the National Institute on Alcohol Abuse and Alcoholism, now celebrating its 40th anniversary, and the National Institute on Drug Abuse, which recently published the latest revision of its “Research Report Series” on Marijuana Abuse (http://www.nida.nih.gov/PDF/RRMarijuana.pdf).
These plainly worded summaries of the current state of knowledge on various substance-related topics are so valuable as relatively objective sources of information. It is easy, on the web and elsewhere, to find those who celebrate the wonderfulness of marijuana and its medicinal uses, or, on the other hand, those who warn us vehemently of its dangers (reminding me of the narcotics officers at assemblies in my Baby Boomer high school, who assured us that this “gateway drug” would lead inevitably to cooking heroin in rusty spoons).
As usual, reality is somewhere in between. Marijuana certainly can be addictive, and can also produce adverse effects including psychosis, impaired learning/memory, and possible negative impact on the body’s immune system. On the other hand, it also appears to have some legitimate medical uses, and certainly its negative impact on the body is much less than that of drugs such as alcohol. (Speaking of high school talks, I myself once acknowledged, in response to a question, that alcohol could be regarded as the more dangerous of the two drugs – and was never invited to speak there again.)
As in the case of alcohol, someone who uses marijuana on an occasional basis, perhaps less than once a week, with no distressing symptoms or impairment, can probably be regarded as a non-problem “social” user (though often less social in behavior than a drinker). Let us not deny that. But let us also not deny that many of our peers use marijuana daily, or more or less continuously, and have great difficulty coping with life without it. Their drug use is more than a casual choice, and their ability to assess its impact is probably compromised. With all such substances, a particular concern is that use begins, often heavily, among individuals in their teens and early twenties, whose brains have not yet fully developed – further development may well be altered by the drug, in ways not yet fully understood.
It is very difficult to “treat” marijuana abuse or dependence, because the negative consequences of use are so often less than catastrophic, i.e., providing quite limited incentive for change. Though I approve of the moves toward decriminalization, those changes have only increased the difficulty of developing “healthy fear” of marijuana dependence. That is one of many factors to be taken into account in the assessment of each individual, as an individual.
The two particular institutes that I follow most closely are the National Institute on Alcohol Abuse and Alcoholism, now celebrating its 40th anniversary, and the National Institute on Drug Abuse, which recently published the latest revision of its “Research Report Series” on Marijuana Abuse (http://www.nida.nih.gov/PDF/RRMarijuana.pdf).
These plainly worded summaries of the current state of knowledge on various substance-related topics are so valuable as relatively objective sources of information. It is easy, on the web and elsewhere, to find those who celebrate the wonderfulness of marijuana and its medicinal uses, or, on the other hand, those who warn us vehemently of its dangers (reminding me of the narcotics officers at assemblies in my Baby Boomer high school, who assured us that this “gateway drug” would lead inevitably to cooking heroin in rusty spoons).
As usual, reality is somewhere in between. Marijuana certainly can be addictive, and can also produce adverse effects including psychosis, impaired learning/memory, and possible negative impact on the body’s immune system. On the other hand, it also appears to have some legitimate medical uses, and certainly its negative impact on the body is much less than that of drugs such as alcohol. (Speaking of high school talks, I myself once acknowledged, in response to a question, that alcohol could be regarded as the more dangerous of the two drugs – and was never invited to speak there again.)
As in the case of alcohol, someone who uses marijuana on an occasional basis, perhaps less than once a week, with no distressing symptoms or impairment, can probably be regarded as a non-problem “social” user (though often less social in behavior than a drinker). Let us not deny that. But let us also not deny that many of our peers use marijuana daily, or more or less continuously, and have great difficulty coping with life without it. Their drug use is more than a casual choice, and their ability to assess its impact is probably compromised. With all such substances, a particular concern is that use begins, often heavily, among individuals in their teens and early twenties, whose brains have not yet fully developed – further development may well be altered by the drug, in ways not yet fully understood.
It is very difficult to “treat” marijuana abuse or dependence, because the negative consequences of use are so often less than catastrophic, i.e., providing quite limited incentive for change. Though I approve of the moves toward decriminalization, those changes have only increased the difficulty of developing “healthy fear” of marijuana dependence. That is one of many factors to be taken into account in the assessment of each individual, as an individual.
Friday, April 1, 2011
Alcohol/Drug Relapse
It will not come as news to you that the relapse rate among those addicted to alcohol and/or drugs is quite high. Of course, the same is true for a number of chronic conditions, including other mood/behavior problems. Alcohol/drug relapse can be more discouraging to new therapists (not to mention family members), because it is often marked by a dramatic change in the individual’s state, and it is easy to feel as if any progress has evaporated. When treating, say, depression, a setback is more likely to seem like an expectable and non-catastrophic event.
When I was collecting background material for my dissertation, back in the late 1970’s, Emrick’s relapse curve was commonly referred to. Statistics have become more sophisticated (sometimes to the point of not meaning much) since then, and thousands of studies done, but I have not found another picture of relapse that is as comprehensible or that matches my own clinical experience as well as Emrick’s curve. (Here is an approximation of that curve -- not precise.) 
Please note that this representation of relapse (a) is based on individuals (mainly alcoholics) who have entered treatment programs, and may be way off when it comes to people in the community who somehow deal with drinking or drugging problems on their own, and (b) looks at relapse from a standpoint of continuous abstinence (in the AA tradition), which is only one way to measure it.
The headline is that, on average, only about 20% to 25% of alcoholics have sustained continuous sobriety for a year after initially stopping (which, in many studies, means leaving detox). And the vast majority of these relapses occur within the first 3 months.
But 100% sobriety is a high “bar” (perhaps not the ideal word here). It is also usually true, and much more encouraging, that about two thirds of such individuals show great improvement over the course of the year – e.g., they drink much less frequently and/or less heavily. Some small percentage probably achieves a lasting pattern of low-level use, but total sobriety is by far the most stable outcome.
Again, these statistics are fairly old and often challenged, but they match my own clinical experience. One dimension that makes for different conclusions from different researchers is the nature of the population we look at. College students and soldiers, for example, often meet diagnostic criteria for alcohol/drug dependence but evolve into non-problem users within a few years after they’ve left school or the service. My own contention is that those who seem to “recover” in this way differ biologically from those who exhibit a more lasting, chronic course of alcoholism/addiction.
The nature of the biological aspects of, especially, alcohol dependence is not fully understood and is certainly complicated – for example, there will be no one gene that accounts for all the possible features, and no two people have exactly the same combination of features. Nevertheless, and despite the fact that people continue to argue about it, there has been compelling evidence, dating back decades, that alcoholism (and probably other addiction) runs in families, and that this tendency is based more on biological heredity than on family culture or learning from parents’ behavior. Much of the early work was done by the late Donald W. Goodwin, whose name (sadly) I can barely find in a Google search. In those days when we were far from being able to examine genomes, researchers looked, for example, at identical twins (if one is alcoholic the other is much more likely to be alcoholic than, say, another sibling), as well as adoptees (whose drinking status more closely resembled their biological parents than their adoptive parents).
So, those whom we might assume are less biologically “wired” for alcoholism/addiction, and who might self-correct their behavior in their natural habitats, may not fit the relapse curve as closely as the people we see in treatment settings (who, in most cases, have failed in their own attempts to correct their drinking or drugging behavior).
One reason for the high relapse rate is that problem of motivation. Pretty much no one is 100% committed to abstinence – their Mr. Spock-like logical minds may see that is the most rational course, but their animal-like side (residing largely in the primitive parts of the brain that we share with our mammal brethren) wants to repeat behaviors that have felt rewarding in the past. In a detox setting, I have met patients with many different levels of motivation, from those who express great and powerful determination to those who would say, “Half of me wants sobriety and half of me wants to use,” to those who quite overtly plan to drink or drug shortly after being discharged (if not before). Compare this, say, to depression. Most people who are depressed want to stop being depressed (though a few would admit that depression is so central to their sense of self the notion of losing it produces anxiety). But addiction is not the only condition for which many sufferers desire no change – many people with bipolar disorder, for example, and many paranoid schizophrenics who believe that their perceptions are realistic, will also have little interest in the kinds of treatment and behavior changes that their loved ones and treatment providers might want for them.
Readers who have no history of alcohol/drug dependence, and who find it difficult to understand the “choice” to relapse, may be able to relate to this irrational tendency through the experience trying to lose weight (a struggle for so many of us). We want to lose weight, to look and feel better, to maintain a good mood during visits to a clothing store, etc. On the other hand…. that sausage pizza looks awfully good, so let’s forget about weight just for now. Here’s what I want: to be thin and to eat whatever I want, in whatever quantity I want. Unfortunately, reality doesn’t work that way, but it is by no means clear whether, and when, rational choice will win the day.
OK, so let’s say I really, really want to achieve and sustain abstinence from my substance. What makes a difference in the long run?
Type of Treatment? You’d think so, you hear so many claims. But, no. There is precious little evidence that one treatment approach works better than another, even when we attempt to make a careful match between patient and approach. In fact, the same people tend to have a better prognosis regardless of the type of treatment.
The Specific Treatment Provider? Well, yes, there is some evidence that the match, and the quality of the relationship, between patient and therapist make a difference (not only with addictions).
Amount of Treatment? Yes. Although the long-term rehabs (typically 28 days or more) never made a great case for their lasting effectiveness (hence, no longer covered by most insurance), plenty of studies indicate that those who attend more treatment (broadly defined to include self-help groups as well as professional treatment, and probably even abstinence-oriented yoga or meditation classes would count) tend to have better outcomes than those who do less. Most commonly, this means more 12-step meetings, since no other resource is even close to being as available every day.
Environment? Yes. Newly sober alcoholics who continue to spend significant time in the settings where they usually drank, or with fellow heavy drinkers, are more likely to relapse. Duh, you may say, but many individuals insist on returning to those situations, over-estimating their ability to exert mind over urge and conditioned responses. Some clinician-researchers have experimented with intentionally exposing addicts to their substances in treatment, as a means of reducing the power of such exposure in “real life.” The results are mixed. My own strong impression is that what works best is to avoid exposure to substances and to settings and people strongly associated with the addictive behavior, for something close to a year, and then, depending on how things are progressing, gradually return to settings that still seem desirable. (A music fan, for example, may really want to go back to the club or concert situation. There is no reason (and usually no great wish) to return to settings that offer little besides substance use, such as a no-frills bar or someone’s parties where everyone is always “wasted.”
The Individual’s Characteristics? Yes. This makes a lot of difference, though most of it may be beyond one’s control. If you are employed and living in a home as a family or couple (in both cases, making for a stable, somewhat structured environment), your chances of staying sober are greater. Not a surprise when you think about it. In addition, the less severe your addiction (less charitably, we might say, the less “far-gone” you are) and the less severely affected by mental health problems (such as depression, schizophrenia, or sociopathy), the better your odds of staying in recovery.
One piece of good news about relapse in alcoholism/addiction is that it’s never too late to try again. I have met countless alcoholics/addicts who relapsed many times for many years and who, somehow, at some point, go on the sobriety train and stayed there. I have often asked them what made this last effort more effective than all its predecessors, wishing that I could learn a secret to impart to others who continue to struggle. Unfortunately, beyond the odds-improving factors noted above, the answer remains elusive.
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).
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 (drugabuse.gov). 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.
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 (drugabuse.gov). 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, http://www.al-anon.alateen.org/); (2) Adult Children of Alcoholics (ACA), a fellowship specifically for this population (http://www.adultchildren.org/) ; and (3) CODA (Codependents Anonymous, http://www.coda.org/) , 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 Amazon.com and other sources. The film/DVD is available at various outlets including Hazelden.com, source of myriad addiction-related publications.]
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