The most common question I get in my work and sometimes from my friends is “Am I an alcoholic?” This is usually followed by “Does this mean I have to go into rehab? Will I ever be able to have a drink again?” I believe that treatment for addiction should be individualized to take into affect each person’s individual needs, complexity and readiness to change. Every case is different. Sometimes the answer is undeniably “It’s complicated” I was trained to apply systematic screening and assessment in order to determine if say Alcohol Abuse vs Dependence is present based on DSM-IV criteria and make treatment recommendations based on the ASAM placement criteria. You can learn more about them here and here.
But sometimes I encounter cases of addictions that do not fit either.
After the tragic death of Amy Winehouse there was a lot of speculation on the web, even by professionals in the addiction field, as to who is to blame. There was actually one article I read which seemed to imply that if she had been able to drink in moderation maybe she would still be alive. I honestly can not comment on that either way. I will say that the harm-reduction model of treating addictions is not popular among people who advocate for abstinence as the only acceptable treatment outcome and people who support the 12-step program approach. Having worked at a methadone clinic for years and witnessed powerful positive change, I am not a big fan of one size fits all treatment approaches nor am I into labeling.
There is however one view on addictions that I have found very helpful, especially lately, in helping clients who do not seem to fit the traditional medical model of addiction.
That’s the Staton Peele approach.
Here’s a summary of Dr. Peeles’ view on addiction “addiction is not unusual, although it can grow to overwhelming and life-defeating dimensions. It is not essentially a medical problem, but a problem of life. It occurs for people who learn drug use or other destructive patterns as a way of gaining satisfaction in the absence of more functional ways of dealing with the world. Therefore, maturity, improved coping skills, and better self-management and self-regard all contribute to overcoming and preventing addiction. Addiction is a way of coping with life, of artificially attaining feelings and rewards people feel they cannot achieve in any other way.” Stanton Peele, “Cures depend on attitude, not programs,” Los Angeles Times, March 14, 1990.
Peele is a big advocate of the harm-reduction model. I think harm-reduction does not work for every one, in fact in can be detrimental to one’s recovery. But that’s subject for another article.
One area I find Peele’s theory to be applicable is in explaining how addiction and intimate relationships are so closely interconnected. Jim always ends at the bar drinking after a fight with his wife. Anna’s drinking always gets out of control after a break up. John had experimented with pain pills on and off in college but did not get addicted to them until after the devastating loss of his long time lover and best friend. Travis’s sex addiction gets worse after feeling rejected by a love interest. In the words of one of my clients “I was lost before I found love. I was on a path of self-destruction with drugs, alcohol and women but with my wife I have found what I was always missing, I have been clean and sober since. Now I’m high on life”
Staton Peele wrote Love and Addictions in 1975. Poets and writers have written about drowning love sorrows in wine since the beginning of time, from Rumi to Pablo Neruda to Shakespear to Bukowski to rock and roll and so on…
Amy Winehouse wrote:
“The man said, “Why do you think you here?”
I said, “I got no idea”
I’m gonna, I’m gonna lose my baby
So I always keep a bottle near
Ryan Adams, a singer song-writer from NC and my all time favorite, who battled alcoholism and addiction for years and sang relentlessly about sad, impossible, troubled love affairs, wrote:
“And I hold you close in the back of my mind
And raise my glass ’cause either way I’m dead
Neither of you really help me to sleep anymore
One breaks my body and the other breaks my soul”
Luckily he’s still alive and well and sober.
Addiction is a way to respond to unsafe relationships.
And by unsafe I don’t mean physically violent although that is the most obvious case. Unsafe means threatening to the ego as much as threatening to the body. What I’m talking about here is emotional safety. When we feel loved, accepted, nourished, protected and part of someone else we feel safe. That safety is often threatened when we feel unloved, uncared for, betrayed, lied to, yelled at, abandoned, neglected, rejected, violated.
To understand where we are going we have to understand where we come from.
Safety and the Primitive Brain
Let’s start with the evolution of the brain. In the base of our brain we have the reptilian brain. We share this part of the brain with animals including alligators and lizards. The reptilian brain takes care of those things we don’t usually think about: heartbeat, digestion, and breathing. It also is concerned with survival, and if it’s dangerous, it will help us respond in one of 5 basic ways: fight, flight, freeze/play dead, submit or hide. These are also the 5 basic survival skills of couples. Couples with fight, flee (leave), play dead (stare right through their partner), submit (OK, whatever you want, just stop the nagging!) or hide (go to another room).
On the other hand, if the reptilian brain is safe we will do one of 5 things: play, nurture, mate, work and be creative. Remember when you first met your partner? How you played, nurtured each other and had more sex? Do you remember being more creative and productive at work? As animals evolved, a second part of the brain developed called the mammalian brain. This brain developed when animals began to live in groups and take care of their young. This is the part of the brain where feelings are stored. That’s why most animals experience some feelings and live in groups.
Several million years ago a third part of the brain developed: the cerebral cortex. In humans this part of the brain is 5 times bigger than the other 2 parts combined and this where all logical processes happen: speech, writing, logic thinking, math, etc. The three parts of the brain work together simultaneously. If a tiger is coming at you your logical brain says “That’s a tiger”, your mammalian brain says “I feel scared” and your reptilian brain says “Run!” or “Freeze!”
But in relationships is often hard to articulate or identify who or what the “tiger” really is. We know something is not right but all we are left analyzing is the behaviors we can clearly see but can rarely understand. Like, how is it, for instance that when Jim and Linda fight he ends up getting drunk at the bar even though he knows that is not going to help the situation at home but only confirm Linda’s insults that “he’s nothing but a loser”? Sometimes fighting, fleeing or hiding involves addictive behaviors particularly sexual behaviors like masturbation, pornography, but also gaming, internet addiction and alcoholism. Often past experiences with these behaviors make a person more susceptive to going back to (if they have stopped) or increase the frequency of these behaviors. This explains why people engage in addictive behaviors even against their logical thinking. It appears that the primitive reptile brain has taken over the cerebral cortex. This is why people logically know it doesn’t make sense to engage in behaviors that often make the already troubled relationship even worse. They are “thinking” with their primitive reptile brain, which often means they are not actually thinking at all.
Sometimes we are not simply chasing a drink or a drug. Sometimes using is a maladaptive way of coping with unsafe relationships. In this cases treatment should focus on the relationship and reestablishing safety more than on changing addictive behaviors themselves. I have found that establishing safety and learning to evoke mental images of safe places/mental states is crucial in learning to calm oneself down and coping with highly stressful situations, which in return helps the addictive behavior dissipate.
This should also be the main focus of relapse prevention in more traditional addiction treatment.
Also read http://www.goodtherapy.org/blog/love-drugs-primitive-brain/
Many people I work with have often been successful at maintaining some sort of long-term sobriety/abstinence from alcohol or drugs. If you participate in AA/NA, getting your one month chip is often described as exhilarating. There is a boost in self-confidence and hope in one’s ability to regain control of one’s life. But something happens after the one year chip. All of a sudden chips stop coming. You don’t get as much attention and support anymore as you did in the beginning.
All of a sudden you are “cured” and/or you are supposed to know how to do this on your own. How are you supposed to know when you’re in “the clear”? Are you ever? Addiction is a relapsing disease. This means relapse is part of recovery and instead of refusing to accept this fact, it is important to put more effort into understanding relapse, warning signals and ways to prevent it.
Here are some signals I have noticed:
Experiencing Withdrawal: You start having problems with one or more of the following; thinking difficulties, emotional overreaction problems, sleep disturbances, memory difficulties, sensitivity to stress, etc.
Avoidance and Defensive Behavior: You start avoiding people who you know will give honest feedback and/or you start becoming irritable and angry with them.
Being in denial: You stop telling others what you’re thinking/feeling and start trying to convince them (and yourself) that everything is all right, when in fact it is not.
Building crisis: You start to notice that ordinary, everyday problems become overwhelming often because you perceive them as insurmountable. Feeling stuck: You start believing that there is nowhere to turn. You feel trapped and sometimes refuse to problem-solve.
Becoming Depressed: You mourn the loss of alcohol/drug and you feel the sadness and grief. You naturally miss it. But you start to rationalize your future actions based on perceived inability to handle the sadness.
Urges and Cravings (Thinking About Drinking/Using): You start to think that alcohol/drug use is the only way to feel better. You start coming up with justifications to drink/use and convince yourself that using is the logical thing to do.
Turning to behavioral, non-substance addictions: You start using one or more of the following- food, sex, caffeine, nicotine, work, gambling, etc. often in an out of control fashion.
As you may notice the list above has much to do with where you are mentally more than anything else. I like to refer to this “psychological space” you get into right before a relapse as “the danger zone”. Many times you know you will relapse, you just ignore that fact and either convince yourself that using once won’t make a difference or you set yourself up to fail intentionally. This is often a sign of ambivalence or resisting change.
If you want to avoid relapse when you are in “the danger zone” you want to look out for a few things that may potentially make the situation worse.
Being in the presence of drugs or alcohol, drug or alcohol users, or places where you used or bought chemicals.
Feelings we perceive as negative, particularly anger; also sadness, loneliness, guilt, fear, and anxiety. Positive feelings that make you want to celebrate.
Getting high on any drug.
Dwelling/fantasizing on getting high.
Suddenly having a lot of cash.
Using prescription drugs that can get you high even if you use them properly.
Believing that you no longer have to worry or loss of vigilance. A.k.a ‘I can use once” attitude.
Don’t be afraid to ask for help. And if you do happen to relapse, remember that relapse doesn’t happen because of who you are as person. What I mean by this is that there is no chronic “relapsers”, there is chronic relapse behavior patterns. Different choices lead to different results. Once the pain is gone away, we tend to forget it. Remember the pain and the hurt. Remind yourself why you decided to quit to begin with. Many people will say that if you “mentally” relapse you have already relapsed “so might as well get high”. This is not true. Wanting to get high is not the same thing as actually doing it.
What have you learned from your relapses that have been helpful?
Recently I have been getting a lot of calls from men wanting to get in counseling to address their sex addiction. So what is sex addiction really?
Sex addiction, like other addictions, is a maladaptive pattern of behavior, which involves persistent dependence on various forms of sexual expression, often in order to cope with the stresses of life but not necessarily. Like other addictions, there is a cyclical pattern of behavior, involving urges and cravings to engage in the behavior, a ritualistic way of planning and acting out the behavior, and a sense of relief and elation on engaging in the behavior, followed by a period of withdrawal and repeated cravings.
What makes sex addiction an addiction, as opposed to some other sexual problem, is this repetitive pattern of thought processes and behaviors, which continues despite negative consequences for the addict, and in some cases, for other people. The addictive behavior continues over an extended period of time, and once consequences become obvious and the addicted person is unable to stop the behavior, they feel they are losing control.
Here’s one definition I particularly like “Sexual addiction is best described as a progressive intimacy disorder characterized by compulsive sexual thoughts and acts.”
In the words of one of my clients “The thought of spending the rest of my life with only one person scares me to death.”
Maybe these men are simply afraid of intimacy.
According to Dr. Kal Heller “Intimacy is very risky because it requires making such a serious commitment to the relationship that each person will experience a sense of dependency on the other. To admit to needing someone else is to risk loss and deep hurt. This is difficult for all of us. Dependency is a negative concept in our society. Men, especially, are taught to strive for independence. The joke about men not asking for directions is not really very funny when you realize it is imbedded into the training of most males not to admit to needing help. Dependency has been feminized over the years and inappropriately labeled as a weakness. This is part of how society’s messages affects its members.
Intimacy is more than admitting to needing others. It also requires a sharing of one’s fears and dreams, a process that contributes to a strong feeling of vulnerability. Each of us carries enough self-doubt, guilt, and shame to make the process of sharing our private worlds scary. It is hard for most of us to believe that if someone else REALLY knows us, they will still love us. The very nature of falling in love contributes significantly to this problem. We idealize our partner when our hearts shape our visions and expectations of this special person. Ultimately we become trapped in the curse of not being able to live up to those unrealistic expectations. In this context, it is even more difficult to admit to our failings and fears.”
This makes sense. But I’m not fully convinced.
In fact, I’ve been thinking, is monogomay really natural? Peggy Vaughan in The Mongamy Myth said “The Monogamy Myth is the belief that monogamy is the norm in our society and that it is supported by society as a whole. The effect of believing that most marriages or committed relationships are monogamous is that if an affair happens, it’s seen strictly as a personal failure of the people involved. This leads to personal blame, personal shame, wounded pride, and almost universal feelings of devastation. The reality is that monogamy is not the norm, not by today’s standards, anyway.”
What if Peggy’s husband had a sex addiction problem?
In a previous post, I talk about addictions as humans way of cheating death. I say “Addictive behaviors are human’s way of cheating death. And not just because they satisfy our innermost primitive pleasure instinct (also known as the life instinct) but also because every time we pick up after we quit we exercise a superhuman power of reviving our love (our addiction) from the dead. And isn’t that the oldest, most universal fantasy of our species? When we lose someone in our life to death we know they are not coming back. Death is irreversible and leaves us powerless in despair. A lot of our behaviors go back to our attempts to deal with the permanency of our mortality and addiction can be a very effective cheating system for a while.”
I wonder, what would Freud say?
What do people want? Mostly to be happy. And proud, accomplished, popular, the list goes on. Some people just want to change. Yesterday I talked about resisting change. But what if you weren’t resistant at all? What if you really wanted to change but didn’t know how? What if you want to change so badly but it’s so darn hard and you have no clue where to begin? You have been contemplating change for a long time, maybe years have gone by and you still have this nagging feeling that you should be doing something different with your life or simply conquer a fear?
If you have been reading my blog you know by now that I like to talk about myself. It’s not an egocentric thing. I want everyone to know that being a therapist doesn’t exempt me from human suffering and struggles. May is the one year anniversary of one of the biggest changes I have made in my life in 32 years. And I like honoring anniversaries. This one is HUGE. I was so overcome with fear about making this change that I became paralyzed for years. I had put it off, made excuses about not changing, contemplated it but never thought I could do it, settled for the idea of never trying and even told myself and everybody else a pretty good story titled “I don’t drive”. Yes, you read it right. The change I had been wanting to make but wasn’t able to was to learn how to drive. Before you judge this as an insignificant matter, think of something that has been hard for you to accomplish. Further more try to imagine this. Imagine the fear, challenge and amount of adaptation it would take to move to a foreign country 6000 miles away from everyone and everything you know. Are you imagining? Are you there? Good. Now, multiply it by 100. That was the amount of fear and challenge learning how to drive represented for me. It’s been a year today since I got my driver’s license and I can say the story has changed significantly. The story now goes “I am a new driver”.
Before you go off reminiscing about old times when you learned how to drive, stop! This post isn’t about driving. It’s about how to conquer your fears and make significant changes in your life. My driving is just a story. And I like telling stories. So forgive me if I use it to illustrate the points I’m about to make. This post is about change. Real change. Change that transforms you in such a powerful way, that it sends waves to everyone around you. Change that redefines who you are, what you do, how you do things and what you are capable of. Change you have putting off for a while. There is no better time to change than now.
Believe it or not you have to start with giving up. Whenever you make a change you have to give up something old to make room for something new. This is how the universe works (I believe), constantly seeking balance and equilibrium. If you want to stop drinking or drugging you have to give up something you love or something that has been your friend for a long time. If you want to leave your partner, you have to give them up knowing you may lose them for life. If you want to change your job you have to give up on the feeling of safety and security and on the belief that dreaming big is foolish. If you want to learn how to drive at 31 you have to give up the false security that taking the bus will protect you from human’s common fate: dying. Give up. Whatever it is you’ve been holding on to isn’t working. It’s time to try something new.
Fear of failing
Do you remember failing when you were a kid? What was the reaction of the adults around you? How did your parents respond? How did you feel and what lessons did you learn? If you are like most people, you learned failing isn’t fun. Making mistakes means there is something wrong with us. So we try very hard to avoid failure. And sometimes this leads us to success. But sometimes this leads us to avoid trying anything new. So let me ask you this? Are you not failing already? I had to take 2 buses to get to work. A normally 20 min commute would take me an hour and a half, each way everyday. I did this for 3 years. And every day for 3 years, even in the face of justification and rationalization (“I’m doing something good for the environment”, “I like the bus, I can read” etc etc) there wasn’t a day I didn’t feel like a loser.
We are creatures of habit. We are slaves to habits and rituals. They provide us with a sense of structure, safety, security, control and predictability. We love our habits. They make us who we are. Until they get in the way of who REALLY are. When people asked me how did I do it, taking the bus everyday, I would say “I’m used to it”. Do we even know we’re doing something simply out of habit? Where did we pick up the habit? Why did it stick with us? We are amazing learning machines. Repetition is powerful for human learning. Do something often enough and it will become second nature. But is it really natural? And if you learned it somewhere, shouldn’t you be able to unlearn it? The answer is yes. If we put as much effort into unlearning a habit as we do into stubbornly repeating it, change happens. If you chase recovery with the same passion that you chase drugs, healing happens.
We need the right tools.
During tax season there was this H&R Block commercial where they were trying to demolish a brick building using a giant stuffed bunny. And a bystander says “That’s not gonna work”. Very funny. Brilliant too. You can not succeed in change using the wrong tools. In the mental health and addiction field we have a saying “The definition of insanity is doing the same thing over and over again expecting different results.” If you want different results you have to employ a different strategy using different tools.
Befriend the change you want to make.
I know it’s scary. I know it’s hard. I know there are obstacles. One way to soothe your fears about something unknown is to familiarize yourself with it. They say you can’t learn to swim unless you go in the water. It turns out you can’t learn to drive from the passenger’s seat. I took 2 driver’s ed classes. The first teacher was OK but she didn’t challenge me. She catered to my fear by rarely taking me into high traffic areas. The second instructor tricked me into getting on the highway the second day. I freaked out completely. I thought I was going to have a panic attack. But he was very calm and confident. And against all odds, I survived. Nothing happened. Actually, something did happen. I became my fear’s friend. Wanting to get to know it better. My instructor taught me the laws of the road, helped me break things down so I could understand them better. When thing makes sense they are not so scary anymore.
The power of mental imagery
This is a little embarrassing but for the first 3 months after I started driving I would lay in bed and imagine my route to work the next morning. Granted a lot of this was fueled by worry and fear and some sort of obsessive thinking so I would caution you not to do this without some professional help. This is what a phobia expert would teach you in therapy. But I think imagining yourself changed, picturing the change, how it looks, how it feels, how it makes you feel, may actually be helpful. And the cool thing is it stays in your brain. No one ever has to know (unless of course you blog about it). Your brain is powerful. Use it.
Going from “I can’t” to “I can”
Our brain is powerful. But it is also a trickster. It is constantly thinking. And some of it’s thoughts are irrational. You can change these thoughts. A professional counselor using Cognitive Behavioral Therapy can do this with you. If you want to try this on your own, do it to others first. Notice an irrational thought they have and challenge it. Then try doing it with your own thoughts. Thoughts are not facts. Take them with a grain of salt. You may think you can’t change, but that’s just a thought. It’s not a fact. Going from “can’t” to “can” needs to start in your head.
I apologize for the length of this post and I hope you’re still with me because I’m about to take it one step deeper. Stay with me!
Rewriting your story
Ultimately, change is about rewriting your story. Eric Berne didn’t say much about addiction but one thing he did say stayed with me. He said “Alcoholics need permission from their mothers to stop drinking.” How fascinating! I have found this to be true in my work, especially the need for permission part. The way I see it, everyone needs permission to be successful. Often from their parents but mostly, as adults, we need to give ourselves permission to succeed. Can we give ourselves permission to change the way the story goes? Can we rewrite the way the story ends? I gave myself permission to rewrite my story. My story was “I don’t drive. I can’t drive. I’m too scared to get in an accident and survive but be crippled for the rest of my life. I’m too scared to screw up”. I won’t get into where I learned that. But I will say I had to break it down and challenge it and rewrite it. So now my story goes like this: “I’m a new driver. I’m cautious when I’m on the road but I can drive. I have made silly mistakes since I started but I chose to see the humor in them. Driving has changed my career, my relationships and my beliefs about what I can accomplish.” Next year this story may be slightly different. Because change is a process not an event.
What will your new story say?
Somehow everything in the past 24 hours has been about pain. As a runner, I have the honor and privilege of experiencing a myriad of physical aliments associated with running on pavement (with the wrong shoes); first bursitis in my hip and now shin splints. Last night, I couldn’t run. My shins hurt so bad they felt like they were on fire. My feet were abnormally swollen, I felt fatigued and run down. And I thought to myself “this is not fun”. So yes, I know I should get better shoes, ice my shins, stretch properly, run less, rest more and watch my sodium intake. But all I kept thinking though was “God I’m turning into my father”. Both my parents suffer from rheumatoid arthritis. I grew up listening to their pain stories. And pain is a sophisticated story teller, more so than any other physical ailment. I started thinking about how my mother’s arthritis flare up put her in a rehab at 19 for 25 days, being pumped with every steroid imaginable and feeling like a water balloon ready to pop. And all of a sudden, my shins started to hurt more, and my heart started to pound and a puddle of embarrassing tears formed silently in my eyes. God, what a bummer!
This morning at the doctor’s office I rated my pain as a 10 from 1 to 10. But then I started thinking, was it really that bad? See, the problem with pain is, it’s very subjective. With all the science advances, we have not been able to come up with a pain “meter”. We rely on the patient’s subjective account of how much it hurts. And I guarantee you, that rating feels correct. My pain felt like a 10. But what makes my experience different from any other runner who has experienced shin splints, is my parent’s story and my fear of having the same painful fate. Fear. Fear is a powerful thing. Fear can propel your pain scale to the sky. Perception of that pain can too. Our minds are powerful; they can fuel our physical pain like oxygen does fire, keeping it alive and roaring. When you are in physical pain, you are in emotional pain too.
This morning I was listening to the Diane Rehm show on NPR as I’m driving to work. It’s on prescription drug abuse, with a focus on the Oxycontin epidemic. Professionally, this is right up my ally. You can listen to it here. As usual Diane has invited an impressive panel of pain doctors, substance abuse experts and a sheriff. The debate is very interesting, informative and important. Then a heroin addict in recovery calls and makes the most important point in the whole show. He’s talking about emotional pain.
Sure, we can do research and come up with telling statistics, sure we can blame Purdue and sue them for producing such an “evil” drug, sure we can talk about prevention, education and ways to decrease abuse and diversion while still helping people who are suffering from chronic pain and NEED these “evil” drugs. But are we talking enough about emotional pain?
In my years of experience working with people addicted to opiates, emotional pain is the one, single, most important aspect of their addiction and recovery. This is simply an observation, but emotional pain is the determining factor in whether or not that temporary prescription your dentist gave you for Hydrocodone is going to be just a pill or is going to turn into your love, you lifeline and ultimately your worst nightmare.
We are a pill popping society. There is no doubt about it. The pharmaceutical companies and pill pushing doctors have perpetuated this “fast food” like culture of making your problems disappear. No one wants to talk about the underlying emotional pain. No. That’s a painful, grueling, long process. We can’t bare feeling exposed, powerless, weak, sad, lonely, fearful. We can’t sit with ourselves. Even when we think we have religion, many times we have lost our spirituality.
Many of my clients would initially talk about how their doctor didn’t warn them enough about the risks of becoming addicted and how a seemingly innocent prescription turned into something they needed to function every day. Even when they didn’t have any of the risk factors to becoming addicted such as biological/family predisposition or prior history of alcoholism or abusing illegal drugs, they became addicted. After a year or so in therapy their real stories start to come out. About how the pills did more than just kill back pain, how they liked the way it made them feel and how that was an escape from their reality. And then, slowly they start to open up about their emotional pain, which is the hardest to talk about. Somehow, physical pain is acceptable but God forbid our heart hurts and our brain feels like it’s going to explode. Somehow we are weak for experiencing that kind of pain. Somehow we should be tougher, stronger, saner. But we are not.
The scary part about this is that we are teaching this to our teenagers who are the most at risk of developing an addiction to pain pills. Yes these pills are more available to them. Yes, people believe they are safer because they are legal and a doctor is prescribing them. Yes, they find these pills in your medicine cabinet. But what else is happening in our families that we are not talking about? Why are we so afraid to expose our demons? Why are we stubborn when it comes to change? What is the larger responsibility that our schools, communities, cultural, political and economical climates have on this epidemic?
And most importantly, why aren’t we in therapy more?