Waiting Room Therapy I


“So you go to therapy too huh?”

“Used to. I don’t now, just waiting for my friend.”

“I see. Why did you stop going?”

“I know what my problem is.”

“Do tell.”

“I like change too much.” (pauses) “And I’m too hard on myself.”

“Ah, learned that from the best didn’t you? Who was it, your mom? My dad loved to point out all my mistakes, I could never do anything right, I could never be good enough, no matter how much I tried. He would come to my baseball games and shout from the sidelines what he thought to be encouragement but I was mortified and embarrassed.”

“Ha. I can’t complain about my parents really. They would tell me all the time how proud they were of me and brag to all the family and friends about my accomplishments…I don’t think of those times though when I think back. I think of how one B in 4 years of straight As forever defined me as ALMOST perfect.”

“I wish I was good with change. I’m a creature of habit. I eat the same breakfast everyday, eat lunch and dinner at the same time everyday and I always have a salad with my meals. And a glass of milk before bed. I always wake up at the same time every morning, I like to watch traffic and weather. Be prepared, you know…My mother had Bipolar. She would do crazy things like wake us kids up at the crack of dawn, pack us up in her Impala like sardines and take a road trip to Atlantic City for no reason at all. Or I would come home and she’d be painting my room a bright turquoise. They fought a lot, my parents. You never knew what you were walking into.”

“When I was about 15 my parents were both abroad and my grandmother and brother were in charge. It was summer. I did not leave my house for a month and a half, didn’t talk much to anyone most days. I read a lot. And listened to music. A lot. I ate, slept, sat, stared out the window, you know the normal teenage stuff. For a month and a half in the summer I did not leave the house. And now, the house eats at me. I don’t like to be home. I hate routines too. And silence. I particularly hate silence.”

“That doesn’t really explain why you like change though.”

“Maybe I don’t really like change. Maybe I dislike sitting still.”

“I started drinking heavily after my wife left me. And it dawned on me, it was probably because the house was too quiet. But you see, me drinking wasn’t the problem. My drink was my companion. I could always rely on it. Problem was, I didn’t want to face things changing around me, didn’t want to adapt to losing my job after 15 years, admit to failing my marriage or watch my parents get old and sick. Drinking was the only steady thing. The only thing I could control. Even when everything was falling apart I could drink to perfection. How about that?”

“I hate feeling powerless. It makes me driven to change. Change gives me a goal, something to look forward to. But sometimes it messes with things that aren’t broken, ya know? I have a dilemma as a matter of fact. A puzzle. A problem without a solution. And I have absolutely no idea what to do about it. I mean, I can make the change. That’s easy, I know how to do that. Yet I’m paralyzed. What if this one doesn’t need fixing? What if this a puzzle that will reveal itself slowly, on it’s own time? Will my immobility cost me dearly?”

“There’s gotta be something in between, right? Change when you have to, sit the rest of it out. But then how do you know you’re just being lazy, coming up with excuses?”

“It’s knowing how to tell the difference that is particularly challenging.”

“So what will you do?”

(after a long pause) “I think I’ll sit this one out.”

…to be continued




Love, Drugs and the Primitive Brain: What No One Told You About

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/

Is Alcoholism a Disease?

First let’s define disease: deviation from or interruption of the normal structure or function of any body part, organ, or system that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. Also: A pathological condition of a part, organ, or system of an organism resulting from various causes, such as infection, genetic defect, or environmental stress, and characterized by an identifiable group of signs or symptoms. A condition or tendency, as of society, regarded as abnormal and harmful. Obsolete Lack of ease; trouble. It is very clear to see how alcoholism fits into these definitions. Still, the debate is heated and the jury is still out.

Here’s some facts that support the disease model of Alcoholism:

1. There is a gene that seems to be linked with one’s sensitivity to alcohol. It’s called CYP2E1. The manipulation of this gene may be very helpful in the field of alcohol treatment. You can read about it here.

2. The role of alcohol on brain neurotransmitters is well known and proven. Neurotransmitters are crucial to brain processes and for our purposes here, our mood and behavior patterns. One of them in particular seems to be directly related to happiness: Serotonin. Neurotransmitters are closely linked to mental health and should be considered in addiction treatment and alcohol treatment. You can read more about the effects of alcohol on Serotonin here.

3. Researchers have been focusing on a particular area of the brain that seems to be involved in alcohol relapse. This area is called the nucleus accumbens (NAcb) core which drives motivated, goal-directed behaviors. Researchers studying a new drug that could help in preventing alcohol relapse, Chlorzoxazone, found that decreased calcium-activated potassium channels (SK) and increased excitability in the NAcb core represents a critical mechanism that facilitates motivation to seek alcohol after abstinence. Read more about it here.

There is overwhelming evidence from neuroscience that supports the short-term and long-term effects of alcohol on the brain.

Yet, we are skeptical. We tend to say things like “why can’t you just put it down?!” “why can’t you just quit?” “what’s wrong with you?”

The disease model of addiction and alcoholism does not imply that we are powerless robots incapable of recovery. Information is out there to help us outsmart the disease, help us understand it and inform treatment alternatives. Information should be able to make us less judgmental and more accepting. Somehow it doesn’t. This is another blog topic all together. Also the disease model implies that there are biological, psychological and social factors that determine the course of the disease and recovery. Just like other well-known diseases such as obesity and diabetes. Our biological predisposition, our psychological make-up and our societal influences COMBINED lead to alcoholism.

Which means, if you are a family member, a friend, a primary care doctor, you too affect the course of the disease of addiction as much as the person’s choice to pick up a drink and a drug. The disease model does not intend to strip the individual from any power or responsibility over the disease, it is meant to create a SHARED responsibility and power between the individual and his/her environment.

Ultimately, it is not as important to determine who’s fault it is that one drinks, as it is to collectively help each other live healthier, happier lives.