Not Getting Clean: It’s A Killer

  • May 3, 2013 12:15 pm

In his recent book Clean, author David Sheff writes about addiction treatment and why it fails to help so many addicts. The idea for the book came out of his struggles helping his son with his addiction, which led to further research on the state of addiction treatment in the U.S. In a recent article on Time.com, he started his article by stating that:

“Every year in the U.S., 120,000 people die of addiction. That’s 350 a day.”

He goes on to write that “A growing body of evidence has proved that addiction isn’t a choice subject to willpower but a brain disease that’s chronic, progressive and often fatal.” He then writes that in spite of this, there are a shocking number of treatment programs which do not use techniques that are based on research on effectiveness. He writes that it is crucial that people need to find and utilize these programs which “use therapies that have proved effective in clinical trials, including cognitive-behavioral therapy designed to train addicts to recognize and interrupt the cues that trigger the relapse mechanism; motivational interviewing, a therapy approach widely used to treat many psychological disorders that helps addicts engage in treatment; contingency management, which essentially rewards addicts for clean time; and psychopharmacology.” These treatment programs can also include “alternative” therapies that have been proven effective, such as meditation, acupuncture, and animal-assisted therapy.

Importantly, he goes on to say that “most researchers agree that no single therapy is appropriate for every addict. Often they’re used in concert. An effective treatment regimen may include AA, but only for those patients who are open to it.”

One of the most important points that he makes is about how unregulated rehabilitation is, and how widely the programs vary.  He writes:

Currently there’s a chasm between these and other evidence-based treatments (EBTs) and rehab programs. Every day addicts fall into it, and many never make it out. Most people in need find themselves in the same frustrating position I was in when I was desperate and overwhelmed, shopping for programs and doing the best I could to navigate an unnavigable system that’s also largely unregulated. In many states, anyone can open a rehab program — no licenses or accreditation are required.

This is slowly changing. More people are being educated about the fact that addiction is a disease and therefore requires treatments based on the medical model. The more consumers are educated and demand EBT, the more the billion-dollar rehab industry will adapt and offer it. That is, the industry will adapt or it will die and be replaced. In the meantime, those who need treatment must do the best they can to find programs that offer EBT. The place to start is by receiving an assessment from a psychologist or psychiatrist who is trained in addiction medicine. … A competent doctor can determine the severity of addiction and the presence or lack of co-occurring psychological disorders and prescribe the next step. It may include a brief intervention, therapy, psychopharmacology, an inpatient or outpatient program that offers quality care or a combination of these things.

Sheff’s points are crucial and a matter of life or death for many. For some addiction programs, even “certifications” are simply designed by people who had theories rather than based on research and/or outcome studies. His plea for standard of care for addiction is critical – for the health and well-being, and even life or death, of so many.

Samantha Smithstein, PsyD

Is Sexual Addiction a Real Addiction?

  • March 16, 2013 8:31 am

By M. Deborah Corley, PhD, LMFT, LCDC, LSOTP, CSAT, CMAT
Co-owner/founder of Santé Center for Healing (www.santecenter.com)

The acceptability of a vast range of sexual behaviors in the United States reflects our changing society in which every form of expression of sexual behavior is available to anyone with access to the Internet. But even those who do not use the Internet for viewing sexual materials, engaging in sexual conversations, or arranging meetings for sexual purposes, anyone who has access to mainstream media has been exposed to explicit coverage of sexual behaviors in the news or in prime time television and movies. Strip clubs have moved from the backroom into multimillion dollar establishments and are available in every state in the union. However, engaging in one or several of these types of behaviors does not make someone a sex addict. Sexual addiction like any addiction – it is not so much about the type or amount of behavior, but about the impact the behavior has on someone’s life. For people who are finding it hard to control their sexual impulses, many fear they are sex addicts but are not sure if it is a real addiction or what to do about it.

Although it was in 1980 that a very famous researcher and clinician from Johns Hopkin University, Dr. John Money, proposed that sex addiction existed, it was later in the early 1980’s that Dr. Patrick Carnes really began the conversation about whether sex addiction was a disorder or not. Sex addiction has been used synonymously with sexual compulsivity, sexual dependency, and excessive sexual desire and hypersexual disorder and the discussions about the definition have been ongoing for the past thirty years. In the past year, the American Society of Addiction Medicine (ASAM) took the lead in the debate about whether sexual addiction is really an addiction. ASAM set about to define addiction with a focus on what happens in the brain for an addict and they included what mental health professionals refer to as process or behavioral addictions like sex, gambling, and Internet use.

ASAM defines addiction as a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by an inability to consistently abstain, impairment in behavioral control, and craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. (ASAM, 2012)

The criteria most recently proposed for the DSM-V (Diagnostic and Statistical Manual, sort of the psychiatrist’s encyclopedia of mental health disorders) contains aspects of the criteria mental health professionals have been using for some time now in addiction treatment center sand private practices all over the United States. Basically, criteria requires the behavior must be occurring over a period of at least six months – so it is not about just an affair or two, or two weeks of looking at pornography on the Internet. There is a persistent and pervasive pattern of behavior in which a person is not able to control their sexual fantasies, urges, and/or behaviors despite negative consequences to self or others. The person spends excessive amounts of time seeking or engaging or recovering from the sexual activity and generally uses the behavior as away to cope with anxiety, depression, or emotionally distressing situations. And the behavior can’t be the result of drug use or another medical condition like a brain injury. (APA, 2010)

Most people report that the behavior started in adolescence. Women sex and love addicts report more sexual abuse as children than do men but more men have the disorder than women.In a recent study of women sex and love addicts, exposure to pornography as a child was the greatest predictor of sexual addiction, even more than sexual abuse. The most common behaviors reported in studies of sexual addicts includes masturbation with the use of pornography, followed by sex with a consenting adult, and then cybersex activities on the Internet.

Studies done in the recent past have identified how both women and men put themselves and others in harm’s way. Women sex addicts also tend to stay in relationships after they become abusive as compared to other women. Women sex and love addicts report higher numbers of unplanned pregnancies, terminated pregnancies, depression, suicide attempts, and infertility problems than do non-addicted women. Both women and men report an average of 15 different sex partners in a year, unprotected sexual encounters, and higher rates of sexually transmitted infections than non-addict groups so in many ways sex addiction is also a public health problem. Other behaviors often reported by sex addicts that have caused a variety of negative consequences includes use of prostitutes, multiple affairs, viewing pornography on Internet at work, having sex with employees, and heterosexual men having sex with other men.

The good news is that sexual addiction can be treated. There are several screening tests that can be used to help identify people that meet the criteria for sexual addiction (see list at end of article.) People in the early stages of the disorder have had success by attending 12-step meetings for sex addicts or group therapy specifically for sexual addiction. (Individual therapy can be very helpful however, group therapy lets an addict be with peers who are dealing with the same issues and thereby has access to others who can be supportive as well as hold the addict accountable for his or her actions.) When people have combined other addictive behavior like alcohol or other drug use with sexual addiction or have had the disorder for a long time and have a long history of secret keeping or trying without success to stop, more intense therapy is often needed like that offered in intensive outpatient programs or in a residential setting where a safe environment helps the addict have enough time in therapy, support, and accountability to learn other ways to manage emotional distress and life’s challenges.

Some behaviors that have severe negative consequences include illegal behaviors. Sexual offenses are beyond the scope of this article, but the addiction model has also been found useful for those who have engaged in sexual offending behaviors. Family therapy is an important component to any addiction treatment. Family members, especially spouses/partners have been betrayed by the addict through his/her behavior. Support of a family member can be significant in an addict’s path to recovery. Yet being supportive when a person has been betrayed is difficult, so everyone in the addict’s immediate support system needs a chance to heal and learn to respond in a healthy way to the addict’s behaviors. Therapy and mutual help groups are also beneficial for family members.

Sexual addiction is a complicated disorder that deserves additional research to clarify
who is most at risk and the most effective treatments. This will take time. As we learn more, it is
important to see that people who suffer from this disorder get the help that is needed. If you have questions about sexual addiction, the Pathways Institute would be happy to answer them for you. Additionally, SASH (Society for the Advancement of Sexual Health) is a national organization devoted to helping sexual addicts and their families find help (www.sash.net). For other assessment, treatment information, referrals, or copies of recent research articles, you can contact www.santecenter.com.

Screening tests:
Sexual Compulsivity Scale (Kalichman & Rompe, 1995. Available at www.santecenter.com)
W-Sexual Addict Screening Test (www.sexhelp.com) (for women)
Hypersexual Behavior Inventory (RReid@mednet.ucla.edu)
Internet Sex Screening Test (Delmonico@duq.edu)

M. Deborah Corley, PhD, LMFT, LCDC, LSOTP, CSAT, CMAT is co-founder and co-owner of Santé Center for Healing, a residential treatment center for addictions near Denton, Texas. She serves as clinical consultant to the Santé treatment team. She won the 2008 Merit Award from Society of the Advancement for Sexual Health (SASH), the 1999 Carnes Award for outstanding achievement in the field of sex addiction and was the co-recipient with Dr. Schneider of the Clinician’s Most Valuable Article Award by the American Foundation for Addiction Research in 2003 for their work on disclosure. She is the past president of the Board for SASH and a clinical member of the American Association of Marriage and Family Therapists. Licensed both as an addiction treatment specialist and marriage and family therapist, Deb has over 30 years of experience working with and conducting research on addictive disorders and high risk families. As an international speaker in the US and Canada, her focus on treatment of addictions, trauma resolution, disclosure, interpersonal neurobiology and meeting attachment needs is well received. In addition to Disclosing Secrets and Surviving Disclosure, she is co-author of Making Advances: A Comprehensive Guide to Treatment of Female Sex and Love Addicts.

References:
Corley, M. D., & Delmonico, D. (2011). Closing the gap: Results from the women’s sexuality
survey on female sex and love addicts. Presentation at Society for the Advancement of
Sexual Health Conference, LaJolla, CA.
Corley, M. D. & Hook, J. N. (2012). Women, female sex and love addicts, and use of the
Internet. Sexual Addiction and Compulsivity, 19, 53-76.
Corley, M.D. & Schneider, J.P. (2012). Disclosing secrets: An addicts guide to when, to whom,
and how to much to reveal. Tucson, AZ: Recovery Resources Press. Available at
www.amazon.com.
Langstrom, N. & Hanson, R. (2006). High rates of sexual behavior in the general population:
Correlates and predictors. Archives of Sexual Behavior, 35, 37-52.
Reid, R., Carpenter, B. & Lloyd, T. (2009). Assessing psychological symptom patterns of
patients seeking help for hypersexual behavior. Sexual and Relationship Therapy, 24, 47-
63.
Reid, R. et al. (2012). Report of findings in a DSM-5 trial for hypersexual disorder. Journal of
Sexual Medicine,
Reid, R., Garos, S., & Carpenter, B. N. (2011). Reliability, validity, and psychometric
development of the hypersexual behavior inventory in an outpatient sample of men.
Journal of Sexual Addiction and Compulsivity, 18(1), 30-51.
Schneider, J. P. & Corley, M. D. (2012). Surviving disclosure: A part

This is your brain on dope(amine)

  • January 25, 2013 11:32 am

Dopamine is a neurotransmitter responsible for movement, pleasure, motivation, and cognitive processes, such as learning. For the purposes of understanding its role in addiction, let’s concentrate on pleasure and motivation.

Whenever we do something that propagates the advancement of our species, dopamine is released in order to motivate repetition of the action. When we sleep, eat, and have sex dopamine is released in our brain and the message is, “That was great, do it again!” We also release dopamine whenever we find something pleasurable. Be it 18th century poetry, heroin, or Radiohead, our brain will release dopamine to encode the stimulus as something that brings us pleasure.

Dopamine not only serves to categorize the good things we encounter in life, it also programs our pre-frontal cortex (the part of the brain involved in judgement and decision making) to alert us when the pleasurable stimulus is available. If your brain cells could talk, it might sound something like, “OMG! There’s a flyer on that lamppost for a Radiohead concert. Go look at it!” In other words, we become hyperaware of opportunities for engaging in behaviors that bring us pleasure. In fact, a study on people with alcoholism found they were more likely to spot alcoholic beverages in a busy photograph than people who don’t have problems with alcohol.

When we consume substances, it makes us feel good because our brains release dopamine, but drugs elicit a higher amount of dopamine release than is necessary. This is part of what causes experiences of euphoria and feeling high. Sometimes the amount of dopamine released is so great, the chemicals in our brain become unbalanced and we may experience hangover or withdrawal. In time, our brain regains chemical equilibrium. However, if one abuses substances, the brain may develop a tolerance (meaning the person needs to use greater amounts to get high) or dependence on the substance as a source of dopamine. If one becomes dependent on a drug, it may take some time for the brain to regain equilibrium and the person may experience extreme physical discomfort and emotional distress when they aren’t using. The period of re-calibration depends on the amount, type, and frequency of the drug used. For this reason, it’s always a good idea to be under medical supervision and receive support from friends, family, and a mental health professional if you’re dependent on a drug and want to stop or decrease your use.

The mechanism of tolerance is also evident in impulse control disorders, such as sex addiction, kleptomania, and compulsive gambling. Although it doesn’t appear that persons with an impulse control disorder undergo the same intensity of withdrawal that persons addicted to substances experience, there can certainly be a period of re-calibration of dopamine receptors during which a person feels irritable and agitated after stopping a behavior.

Based on the information presented here, we can conclude that we are all hard-wired to potentially become addicts and you may be asking yourself, “If this is true, why do some people become addicted and others don’t?” This is a really good question and the answer is “We don’t really know.” We can predict the likelihood of someone becoming an addict based on factors such as first age of substance use and family history of addiction, and we know that a lack of social support and coping strategies (especially when coupled with mental illness) can also lead to addiction, but there is no conclusive answer to date.

The best ways to prevent addiction are to educate yourself about the substances you use (or to abstain from substance use altogether) and to be mindful about the choices you make. If you have a mental illness, ensuring that you are getting appropriate treatment and maintaining social support are good preventative measures.

Jennifer Fernandez, PhD

The Right of Every Child

  • May 7, 2012 10:50 am

Recently, in anticipation of National Child’s Mental Health Awareness Week, the Directors of Pathways Institute interviewed a colleague who has a daughter with learning and attention differences.  Pathways Institute works therapeutically with people who have learning and attention differences and their families, and helps them to navigate the system to get services.

When did you notice your daughter’s learning differences? 

I was lucky: when my daughter was quite young – a little over one year old – I noticed she didn’t have hand dominance.  I remembered reading an article about hand dominance as a possible early indicator of learning disabilities while I was in graduate school.  At that point I started to pay closer attention to the how she was developing.

What happened next?

In preschool they did a “ready for kindergarten” screening and the occupational therapist conducting the screening noticed a couple of things.  She noticed the lack of hand dominance and the inability to cross the midline, meaning she would start drawing on the left side of the paper with her left hand get to the middle and switch to her right hand.  She alerted us that we might want to have her assessed.  We set that up and discovered a couple of things that surprised us: our daughter had weak core strength and no hand dominance.  The recommendation was she do occupational therapy.  We started it and it was helpful.  She spent two years in OT and at the end was able to cross the midline and the OT felt she chose to be right handed.  At this point she is still quite ambidextrous.

How did she do when she started kindergarten?

This was the beginning of a very difficult time for her and us.  She had a great deal of difficulty learning to write her letters and she was already identified as a child that was unable to pick up the first pieces of reading.  It was recommended to us she do some afterschool work with her kindergarten teacher on phonics.  We signed her up and she did two rounds of 6 weeks.  At the end very little progress was made and when we asked the teacher, who had a masters level degree as a reading specialist, if she thought we were dealing with dyslexia, she wouldn’t answer the question.  I learned later that she wasn’t allowed by the school district to answer.  This will remain forever immoral and unconscionable to me.  Here we had a child who needed help and they refused to tell us, for political reasons.  But in spite of this lack of information, I knew that learning disabilities are genetic, and I have a sister who is dyslexic, so I was now “on the case,” so to speak.

Was the school supportive?

We had to push and push for testing, and finally at the end of second grade she was tested.  But she still somehow managed to fall in the low, low averages which would not qualify her as learning disabled.  The testing showed just a couple areas of significant deficit: in particular, she scored at 2% for short term visual memory processing.  Because she was strong in other areas, she didn’t qualify.

There is an undeniable conflict of interest if the same institutions that have to provide the services are doing the testing.  I know most parents with dyslexic kids are shocked to discover – and the generable public should also know – that the acceptable averages to qualify as learning disabled are so low that kids have to be several grades behind in school before they qualify for services in California.  And even then some don’t.  My kid didn’t.  Most kids that fall that far behind experience depression and anxiety.  This should be unacceptable and people should be outraged.  In essence we didn’t get anywhere with the school district, we had incredible problems trying to get help for our daughter, but that’s a story for another day.  Suffice it to say that sadly schools and educational administrators don’t appear to be interested in why a child isn’t learning.  This should be the mission and mandate of special education, not “does a child simply qualify.”  It is a broken system where everyone ends up demoralized.

What was it like for you to be denied services for your daughter?

Traumatic.  My wife and I were incredibly confused, distraught and angry.  We really didn’t know where to turn or what to do.  And we were both well-educated professionals.   We couldn’t understand why no one seemed to want to talk to us or how could it be that all these education professionals, who must have evaluated hundreds of kids, were acting like they didn’t have clue?  Our daughter’s principle told us, “Why don’t you take her to one of the private schools that specialize in learning disabilities?”  It is hard to know if she was asking us to leave or telling us she couldn’t help or both.

Luckily we had a friend who told us about an amazing organization: Parents Education Network (PEN).  We were introduced to several PEN members, and talking with them was like walking out into the sunlight after being in the dark for years.  They told us to stop talking to parents of kids without learning disorders, stop talking to educators who don’t care or aren’t interested or able to think about your child, and surround yourselves with supportive friends, family and the parents of LD kids who are a few steps ahead, join PEN and get more information and education.  Finally, they said be prepared to sacrifice and invest in your child.  We were lucky that it was possible for us. It isn’t for most people and that is one of the great educational crimes of our time.  PEN saved our sanity and in ways ultimately our family.

What was it like for your daughter?

It’s very painful to recall.  During her K-3 years in school she just went down, down, down emotionally.  Every day she went to school and was frustrated and failing in making the kind of progress her peers were making.  She was a good kid and so she never acted-out in school, although some kids do.  But at home she was angry and in a dark place.  She hated school and didn’t want to be there but went anyway.  She was an incredible trooper as we were intervening with reading specialists and math tutors.  She’d go to school all day and then 4 days a week go to tutoring; she was exhausted.  She was sad.  She wasn’t well received socially; she did have a few friends but I think because she was so insecure and frankly exhausted she could be controlling and inflexible.  It was hard on her friends and hard on her.  Her insecurity stemmed from living in body with neurophysiology that was failing her in school.  I think she was riddled with fear and quite anxious.

What help and treatment did you seek?

We went to a very wise child psychologist, who told us to get her out the school, change her environment and put her in a school that specialized teaching kids who are dyslexic.  He told us this wasn’t a parenting problem – we had been told it was a parenting problem at different points by school administrators and unkind people who saw an unhappy kid and blamed us, the parents. He recommended we get her neuropsychological testing which was informative and verified what we knew in our gut: that our daughter had learning and attention disorders, although they failed to give her a diagnosis of dyslexia.  Once she was at the new school with experts they all said, “Your kid is dyslexic”.  As an aside, we were so glad to learn that finally, in the upcoming DSM-V, dyslexia will be included with an understandable and researched-based criteria.  You have no idea how relieving this will be for us and millions of parents and kids who are dyslexic.  An actual criteria worked on by the Shaywitzs, the leading researchers and experts in the field.

Did you feel relief after the neuropsychological evaluation and diagnosis? 

Recently, I saw a clip of an interview with James Redford about his new movie, The D Word.  It is about his son’s journey with dyslexia.  He was asked the same thing.  His answer was something like, “No I wasn’t relieved once there was a diagnosis, my son was functionally illiterate and I was still caught in the fear of wondering how this kid is going to make it in life.”  I nearly broke down in tears when I heard that clip – another parent, a father, that really understands.  I wasn’t relieved either.  I didn’t know how my daughter was going to do.  Would she ever get to a place of acceptance, would she learn to read, would she have the chance to go to college?  Would she plateau at a very low level, would she ever feel secure?  A child’s world and job is school, and when they start out failing the psychological impact is huge.  I knew that kids with LD and ADHD are at high risk for dropping out of school, drugs and other impulse disorders.  I wasn’t relieved I was still terrified.

You have seen a change in your daughter over the past few years.  What’s different now since she has been at the school these last 4 years?

My sister is a psychoanalystand I remember talking to her about my daughter when my daughter was about 7-years-old.  She said, “You know, some day she will need to tell you what is was really like for her.”  I was puzzled, I didn’t really get it because I thought I knew what it was like since I has been through it with her.  My sister said, “She will need to tell you how painful it has been and likely how angry she has been at you, because she is dyslexic and in that way different from you and Lori (my wife).  You and Lori didn’t struggle in school and you don’t struggle with learning now.”  At that time, my daughter would just express anger and shut-down, she never was able to talk about what was happening.  She was obviously young so I couldn’t expect it but was this ever going to happen, this kind of conversation with my daughter?

Even after going to the new school my daughter struggled at first – she saw it as a school for losers.  She was projecting her own insecurity and lack of acceptance on the school and kids.  Gratefully, we were referred to a truly gifted child psychologist who worked with her.  This psychologist really understands LD kids and is so incredibly patient, sensitive to and interested in their amazing minds.  She has helped my daughter accept being dyslexic.  It wasn’t quick, and it wasn’t cheap, but the therapy and the education has been worth every penny, miles of carpool, and thousands of hours of time.

I always hoped the day would come as my sister suggested it might, that my daughter would be able to say to me and my wife the truth about her experience.  That day came about a month ago.  It happened when my daughter was having a brown out (unable to recall from memory knowledge she had the day before) and struggling with homework.  She was tired and frustrated and then just began to weep.  She said to me, “You don’t understand what it’s like.  I have to work so hard and sometimes I just can’t remember or find things in my mind.  And you aren’t dyslexic.  You and mom never have these kinds of problems and you’ll never know what it is like.”  I knew then that she had really begun to develop a place of deep acceptance of herself and that she could now tell me what was so painful, that things were easier for me, that she was different than her mom and me.  It was a deep expression of psychological security and healing.

I still get anxious – currently I worry about next steps as we begin to look at high schools – but I am not as scared.  And when I can sit back and just see what she has accomplished I am filled with the deepest respect and love for her.  I have to keep working on having faith so my own fears don’t get in her way.  I now believe that she is going to have an amazing future.  She is the strongest person I have ever known.

How does your daughter feel about herself today?

Well you’d really have to ask her.  What I see is that my daughter is learning, she values her unique out-of-the-box thinking mind, she wants to be a scientist, she has learned to be quite flexible, and has a full social life of friends.  She is able to laugh and recently just happened to say how she doesn’t feel angry any more.  We owe a great debt to all those who have supported her and us.  Both my wife and I feel that educational advocacy for this population of people will be our life’s work.  Every child and family should have this kind of success, whether they have money or not.  It is the right of every child to learn and grow to their fullest potential.

Sex addiction, sexual abuse, and “men behaving badly”

  • June 2, 2011 8:54 am

Recently, as news of Arnold Schwartzenegger’s extramarital affair (and out of wedlock child) and Dominique Strauss-Kahn’s arrest for hit the news together, there have been a spate of articles about the two of them – men in power behaving badly, men in power being psychopathic, etc. – and with that a re-visiting of the sexual behavior of Tiger Woods, John Edwards, and others.

 

While some of this discussion is educational and even important regarding sex addiction, extramarital affairs, sexual assault, power, and culture (and even heterosexual privilege), other aspects of the discussion seem bafflingly over-generalized and damaging. Should all of these men be lumped together and painted with a broad brush?  And furthermore, should their behavior be attributed to power?

 

From years of working with both individuals who have been convicted of sex offenses and individuals suffering from sex addiction, I can assure you that men in power are not the only men who have extramarital affairs or children out of wedlock – and it is not only men. The current accepted estimate is that approximately half of all married men and women will have an affair at some point during their marriage.  In regards to sexual assault, estimates are that each year in the US there are over 200,000 victims of sexual assault.  Certainly some of this behavior is by men in power – and a position of power or wealth can give an individual more power to perpetrate, and perpetrate without getting caught or punished.  But much of it, obviously, was not – it is estimated that 2/3 of the victims were acquainted with their attacker.

 

Furthermore, there are thousands of men in powerful positions who behave with integrity and grace, and never abuse their positions of power. To equate men in power with egregious sexual behavior is a gross disservice to these men, similar to dismissing all priests as child-molesters simply because of the behavior of some.  Certainly, discussing power in relationship with sexual behavior and dynamics is worthwhile and important, but it would behoove us to do it thoughtfully and with sensitivity, and to attempt to avoid stereotyping and perpetuating harmful myths.

 

To give an “armchair diagnosis” of any of these men is simply an irresponsible – and harmful – guess. Often when people seek help for their sexual behavior (or are mandated to treatment for it) it is because it has wreaked havoc in their lives and they are in danger of losing those they love, or already have.  When asked why they engaged in these behaviors, they often don’t have an answer. The answer turns out to be a complex mixture of: personality, physiology, environment, childhood, psychology, drugs and/or alcohol, neurology, and circumstance.  Again, there is something important about discussing the influence of any and all of these factors in order to thoughtfully discuss issues of importance in our culture and society.

 

But to narrow down behavior to simply one of these factors is a disservice – not only to these men, or men in general, but to all of us. It may be convenient and comfortable to create an “us versus them” scenario when regarding the behavior of others that we don’t like or don’t agree with or even find unacceptable.  But ultimately, prevention and change come from embracing the complexity, attempting to understand in a deeply thoughtful way, and even empathy. Through understanding these men, as complex individuals, we grow to a deeper understanding of humanity and even of ourselves, and move to the possibility of prevention and change – as individuals, as a society, and as the world.

Samantha Smithstein, Psy.D.

Drinkin’ and “Stinkin’ Thinkin’”

  • April 24, 2011 2:53 pm

There has long been an accepted link between alcohol abuse and impulse control problems –people with alcohol problems have difficulty choosing large, delayed rewards over smaller but more immediate ones.  Most people immediately attribute this to the instant effect of drinking – alcohol lowers inhibition and thus negatively affects peoples’ ability to make good decisions in the moment.

However, in a study to be published in the July 2011 issue of Alcoholism: Clinical & Experimental Research, Eric D. Claus and his colleagues used brain imaging to study people with alcohol use disorders as they made decisions and tried to delay rewards.  What the researchers found was that people with alcohol use disorders have anomalies in brain regions associated with emotional and cognitive processing and control – the area of the brain where the ability to delay rewards lies.  The researchers also found that the more severe the alcohol problem, the more dysfunction there is in that area of the brain.

What could not be determined is which came first: the neural dysfunction related to impulsivity or the alcohol abuse.  In other words, did people first have brain anomalies which lead to impulsive disorders and alcohol abuse, or does the alcohol abuse cause the brain to malfunction?  This would be an important area for future research.  But whichever came first, they happen together, and that’s important and useful information to have in the treatment of alcohol use disorders as well as impulse disorders.

It seems that part of why people who abuse alcohol impulsively make decisions because their brain has difficulty delaying gratification, not simply because it is more rewarding to do so.  In this way, it is not just a matter of an individual with alcohol abuse/impulse control problems learning to see and account for the rewards of delayed gratification, but also a matter of training the brain to do work that is difficult for them.  This brain work could be helped by specific psychotherapy, but there is research that it could also be helped with alternative therapies, such as meditation, yoga, or acupuncture.

Samantha Smithstein, Psy.D.

Sex addiction and sex offending: a growing and dangerous relationship

  • April 4, 2011 7:07 pm

Before the Internet, people were forced to great lengths to commit a sex offense. Sex offenders were typically either compelled by a paraphilia or didn’t give a damn about the laws of society.  People who suffered from a sexual addiction, on the other hand, typically acted-out through legal means, such as having affairs or casual sexual encounters; the most common illegal means being the hiring of prostitutes.

Subsequent to the Internet, there has been an explosion of out-of-control and illegal sexual behavior. Activities such as viewing child pornography, soliciting sex with minors through chat rooms, and others are much more common.  Some of this has to do with the obvious fact that the Internet makes these activities much more available and easy.  However, there are other factors as well, such as an illusion of privacy while doing it, lack of immediate consequences for these actions, an idea that others are doing it to (that makes it feel less taboo), and that the need for new stimulation often leads to widening exploration.

Of course, some people committing sex offenses might have otherwise anyway, and there are still those driven by paraphilias or who are highly antisocial.  But some sex offenders are more aroused to the illicit and forbidden nature of the material or acts than to the actual material or act – it is the taboo that is exciting.  Many people committing sex offenses today are otherwise law-abiding citizens who may not have ever crossed the line to commit illegal sexual acts if it weren’t so easy and if they couldn’t do it from the privacy of their own home, and are truly shocked when they are discovered and/or arrested.

Does all of this make it okay or excusable to commit a sexual offense?  Absolutely not.  A sex offense is a sex offense because there is a potential victim involved – and the possibility that someone is harmed. However, it may be information that is important for us to think about when it comes to sentencing and (ideally) treating an individual who has committed a sexual offense.  Now more than ever we should be thinking about the possibility of a sexual addiction as the driving force of a sex offense, and that the standard treatment models for sex offending may not be a complete model.  Likewise, the sex addiction specialist who is working with a sex offender may not have all of the tools that he or she needs for a comprehensive treatment.

These two areas – sex addiction and sex offending – are increasingly entwined in a growing and dangerous relationship.  And yet the fields of sex offender treatment and sex addiction treatment remain fairly isolated from one another.  Many sex addicts who get caught up in illegal activities and prosecuted end up in sex offender treatment with their addiction untreated.  And many sex offenders who have not yet been caught end up in sex addiction treatment with a provider who has little or no training regarding work with sex offenders.  It would behoove us to create as much dialogue as possible between these fields, so that we may grow to meet the needs of this ever-increasing population of people who need our help – within a society that needs us to help them.

Samantha Smithstein, Psy.D.

Sometimes what you need is hard to swallow

  • December 14, 2010 2:02 pm

Frequently when a therapist suggests that his or her patient might be helped by psychotropic medication the suggestion is met with concern, doubt, or even anger. This is even the case when a patient has been suffering for years from mood, impulse, or attention-related issues. Additionally, often patients try medication, experience relief, and then decide abruptly to stop taking medication without consultation with their therapist and psychiatrist; often while simultaneously self-medicating with illegal drugs, alcohol, or unhealthy behaviors. This can be especially true during the holidays, when the pressure to be happy is intense, the feelings of depression are frequent, and the availability of unhealthy behaviors is high.

No doubt prescribed psychiatric medication is not a perfect science: there are side-effects and sadly medication doesn’t always work and provide the relief of symptoms and quality of life improvement sought by the patient. However, all too often side effects and/or the efficacy of the medication are not the reasons people stop taking helpful medication. Instead, the reason expressed is more likely to be “I just don’t want to be on medication (for the rest of my life).” Why?

Unfortunately, in large part this is because there remains serious stigma, shame and fear of psychiatric medication and psychological treatment. According to NARSAD, the Mental Health Research Association, one in five Americans suffer from mental illness in a given year but only one-third seek treatment. In San Francisco it is estimated that close to ten percent of the population suffers from a serious mental illness. In a recent study, psychiatry residents – those doctors learning to help people with mental illness – acknowledged that while they would tell others about being in psychotherapy, they had not admitted to anyone that they were taking psychotropic medication because of the perceived stigma even amongst their peers and superiors. In a study earlier this year, it was found that even the drug companies that market psychotropic medications to doctors were perpetuating rather than breaking-down the stigma attached to mental health problems.

Of course, the ads from the medication companies and fears of the psychiatry residents are simply a reflection of the societal stigma that still exists. And yet medications have given so many people a chance at living a happier, more fulfilled life. Rather than a weakness, character flaw, or sign of a mental deficiency, a psychiatric condition is a medical condition that needs to be treated. Without a doubt, there are many ways to approach psychological problems without medication. This can range from psychotherapy, to meditation and/or yoga, to exercise, to lifestyle interventions, or some combination these interventions. But in some cases, just as with any medical issue, medication can make a tremendous difference. For example, medication can make a profound change in a patient who has been in psychotherapy for years and has made tremendous progress psychologically, emotionally, and in making healthy lifestyle choices, but remains unable to shake a pervasive negativity about herself that makes it very difficult for her to achieve satisfying, intimate relationships. Once on a low dose of anti-depressants, she may find that the negativity has lifted and she is much more healthy psychologically and capable of relationships than she imagined.

Part of the resistance to medication is due to a societal backlash. Pharmaceutical companies make a profit from selling medication and our culture has a tendency to look for the easy answer to problems, sometimes in a pill. Many have turned to medication inappropriately – over-medicating our children or those struggling with mental illness. It has become clear through these experiences and in research that medication is not always the answer and most often not enough as a solution. However, it is also clear that in some cases medication is one tool in the toolbox of interventions that can make a tremendous difference.

Samantha Smithstein, Psy.D. and Elizabeth Corsale, MA, MFT

Diagnostic conundrum part 2: compulsive behavior as an anxiety disorder

  • February 16, 2010 6:55 am

In a previous article, “process addictions” such as addiction to sex, stealing, food, etc. were explored as legitimate disorders and inclusion was called for in the diagnostic manual. One possibility explored in that article was that it be included in the category of “Substance-Related Disorders,” since the experiences of people who feel compelled to repeat these behaviors are often highly similar to the description of the experiences of people dependent on substances (the diagnostic criteria).

There is, however, another category of diagnoses under which process addictions could potentially be included: that of Anxiety Disorders such as Obsessive-Compulsive Disorder. A person with Obsessive-Compulsive Disorder has recurrent and persistent disturbing, intrusive and inappropriate thoughts or impulses that they cannot ignore or suppress. This person then feels driven to perform a behavior in order to reduce the thoughts or impulses. The behavior is either not realistically connected to the thought or is excessive.

Most traditionally, obsessions are related to fears (getting ill) and compulsions are related to simple, common acts such as hand washing, ordering, checking, counting, or repeating words silently. The person may even rationally know that the behavior won’t make the fear/thought go away, but they still feel compelled to action, over and over again.

However, it is possible that some people attempt to quash the intrusive thoughts or fears  by behaviors such as shopping, eating, or masturbating, and that the person feels driven to this behavior in spite of knowing that it will not, ultimately, solve their problems. Often people describe an experience of feeling anxious, alone, or generally “uncomfortable.” They seek out a behavior in an effort to feel better, even as they are aware that when they are done, they will feel even worse.  Sometimes they find themselves repeating the behavior over and over, such as masturbating for hours even after it ceases to feel pleasurable.

This way of thinking about compulsive or “addictive” behaviors is a less common way of conceptualizing it, but for some, it may be exactly what ails them.  And, as in the case of substance dependence, inclusion in the new diagnostic manual could get them the help (and medical coverage) they need.

Samantha Smithstein, Psy.D.

Process “addictions”: a diagnostic conundrum (part 1)

  • February 16, 2010 6:52 am

The diagnostic manual for mental disorders (DSM-IV-TR) doesn’t actually have the word “addiction” in it. Nor does it have a category related to addictions. Instead, it has a category called “Substance-Related Disorders” and lists Dependence, Abuse, Intoxication, and Withdrawal as the four subsets.

This means that when people speak of being “addicted” to things such as sex, gambling, food, stealing, electronic media and gaming, shopping, etc. they are speaking about an experience that does not exist in the realm of diagnoses. This is part of why there is a paucity of good (and necessary) research done with these kinds of “process addictions” (versus substance). This is also why there is no insurance coverage for treatment, and the treatment available has been pieced together by therapists who have co-opted concepts from other areas of psychology, like substance abuse. To talk about addiction is to be in the realm of “pop psychology” versus legitimate psychology.

Part of the rationale for this absence is that the manual is based on psychiatry, and therefore based on a medical model of looking at disorders. In other words, substance dependence (or, in layperson’s terms, substance addiction) is based in part on a physiological dependence to the substance.

But this does not acknowledge that a process addiction can also have a physiological dependence – many people who are addicted to these behaviors report feeling a craving, a high, and then a crash (and withdrawal) afterward. Additionally, they often report a need to raise the stakes to get the same level of high, similar to an increased tolerance of a substance. People report that it interferes with their relationships, they feel compelled to keep doing it in spite of terrible consequences, and they can’t stop. These are all listed as symptoms of Dependence.

There is a lot of discussion right now about the next revision of the manual.  It may be time to re-think this category in the diagnostic manual so that people who feel compelled to repeat behaviors at great expense to their lives can get the treatment they so desperately need.

Samantha Smithstein, Psy.D.

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