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

(Re)Defining Justice

  • April 13, 2013 10:48 am

Restorative Justice is a process to involve, to the extent possible, those who have a stake in a specific offense and to collectively identify and address harms, needs, and obligations, in order to heal and put things as right as possible.”

– Howard Zehr, 1990

Restorative (or Reparative) Justice is based on the Native American principle that criminal behaviors are offenses against human relationships and that after these behaviors are committed, there are both dangers and opportunities:

  • The danger is that everyone emerges further alienated, more damaged, disrespected, disempowered, feeling less safe and less cooperative.
  • The opportunity is that injustice is recognized, equality is restored and the future is clarified. So that participants are safer, more respectful, and more empowered and cooperative with each other and society.

Restorative justice is a process designed to try to “make things as right as possible” for everyone involved.  That includes: repairing what has been broken, making society safer, attending to needs related to the behavior, and making amends.

Traditional criminal justice seeks answers to three questions: What laws have been broken? Who did it? and What do the offender(s) deserve? Restorative justice instead asks: Who has been harmed? What are their needs? Whose obligations are these?

Restorative Justice can take place in a diversity of settings, including neighborhood courts, schools, therapy groups, and nations. The 12-step community has also attempted to address the need for restoration through steps 8 and 9: making a list of the persons harmed and making direct amends to such people whenever possible. Making amends is different from an apology – one is simply an acknowledgement and expression of regret, whereas the other attempts to create restoration. Sometimes people also talk about “living” amends, which has to do with choosing to live differently so as to not create more harm.

Restorative Justice, or making amends, doesn’t require forgiveness. Forgiveness is a step that the victim(s) may or may not be able or willing to choose. Instead, Restorative Justice seeks to restore and heal, so that everyone may move forward less broken, and more whole.

Samantha Smithstein, Psy.D.

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

We Admitted We Were Powerless

  • December 3, 2012 4:13 pm

The very first step of every 12-Step program begins with these words – an admission of powerlessness. For many people, that very first step makes participation in a 12-Step program very difficult and with good reason: powerlessness is an uncomfortable feeling and not one that most people seek out or admit to.

In fact, most of us spend a great deal of energy, time, and effort attempting to try to control things and other people in our lives. We work hard to try to create a life of happiness, as we should. However, these efforts often involve trying to gain control over something we don’t have control of, like an addiction. Other times, the efforts involve trying to change or control other people who are in our lives. And understandably, because the people in our lives – their choices and behaviors – affect us; sometimes profoundly.

But when we stop and look at how effective our efforts are to bend others’ actions to our will – when we really examine how well our efforts to control things go – we find that, in fact, we cannot figure out a way to make others be or do what we want. We discover that using all of our efforts to control someone so they don’t cause us pain doesn’t, in fact, protect us. As the program of Alanon says: we don’t cause the behavior of others, we can’t control it, and we can’t “fix” it. Trying to do so simply makes our life feel unmanageable and increases our unhappiness.

Acknowledging that we are powerless is not about acknowledging that we are weak. Instead it acknowledges what is true, and allows us to focus on the things that we can control and the person who we can help: ourselves. Acknowledging the ways we are powerless also allows us to be more accepting of others, and to find a more peaceful way of being in the world and in relationships.

Security is mostly a superstition. It does not exist in nature, nor do the children of men as a whole experience it. Avoiding danger is no safer in the long run than outright exposure. Life is either a daring adventure, or nothing. Helen Keller

Enjoy Your Life

  • September 1, 2012 8:51 am
Sometimes change is simple, even if it’s not easy

Enjoy your life and be happy. Being happy is of the utmost importance. Success in anything is through happiness. More support of nature comes from being happy. Under all circumstances be happy, even if you have to force it a bit to change some long standing habits.

Just think of any negativity that comes at you as a raindrop falling into the ocean of your bliss. You may not always have an ocean of bliss, but think that way anyway and it will help it come. Doubting is not blissful and does not create happiness. Be happy, healthy and let all that love flow through your heart.

— Maharishi Mahesh Yogi

 

To many, this quote by Maharishi Mahesh Yogi may seem trite, or overly simplistic. And indeed, there are times when we need more than this to create happiness—we may to make changes in our lives or our behaviors, we may need insight and/or healing. We may need transformation through meditation, psychotherapy, or relationship before we can apply new ways of thinking effectively.

However, there is a basic truth to the above quote, as evidenced by Cognitive Behavioral Therapy (CBT); a psychotherapeutic approach that addresses dysfunctional emotions, behaviors, and cognitions through a goal-oriented, systemic process. It is also evidenced through programs such as the 12-Step programs, which helps its members transform, in part, through addressing habits of thought. Programs such as this address a basic truth in the same way Maharishi does: habits of thought create an experience in life, and sometimes we have to consciously change those habits in order to create a different experience, one of happiness.

Addiction or Excuse?

  • September 1, 2012 8:47 am
Public shaming is counterproductive and simply wrong.

Whether it’s food, alcohol, or sex, there are a number of people who react strongly to hearing that someone has engaged in self-destructive behaviors because they are an addict by saying, “Don’t use addiction as an excuse for your behavior! Take responsibility!”

This concept of an “addiction excuse” is relatively new, and while it captures the imagination of those who are hurt, angry, or frustrated by the behavior of an addict, or by someone who lacks basic understanding of addiction, it simply doesn’t hold water for people who are addicts or those who work with people who struggle with addiction. People who speak about addiction as a “convenient excuse for bad behavior” or a “way to not take responsibility,” don’t comprehend what addiction is, and what the experience is like for the person who struggles with it.

Addiction is a psychological and physiological disorder. Even for “process addictions” such as those related to eating, sugar, sex, gambling, and stealing, there is strong scientific evidence that the neurological pathways related to dopamine are activated similarly to an addiction to cocaine. So addiction is not something made up by people to explain something away, it is a real condition, with both biological and psychological underpinnings.

For the vast majority of people who suffer from an addiction or impulse control disorder, acknowledging an addiction is one of the most difficult steps they will ever take. Most are in denial for years, believing in the “free will” that addiction naysayers speak about; addicts want to believe they are in control, and can stop any time they want. Many struggle for years to gain that control and feel deep shame when they fail, again and again.

Acknowledging an addiction, therefore, is an incredibly important first step. No problem can be solved if the problem is not acknowledged. Until someone admits, “I have lost control of this situation and can’t stop myself,” they cannot possibly be open to learning and working on the steps it takes to change their behavior. To the addict, acknowledging an addiction may be the most difficult, shameful, and scary step they take … but is also a crucial first step in saving his or her life. In fact, rather than being about shirking responsibility, acknowledging an addiction is the first step to taking responsibility.

As a society, we must stop shaming them further by telling them that acknowledging their addiction is an “excuse” and that they should “take responsibility for acting badly” and just feel ashamed. Instead, addicts must be supported in their first step and invited to take the many steps— psychological, physiological, spiritual, and emotional—that must take place for them to become well.

It may be that part of what people are reacting to is the overwhelming list of addictions that we hear about these days. People have begun to feel as if it is an overused term, and that there simply can’t be so many people in our society addicted to so many different things. Sadly, this is also not something that is made up. It doesn’t take much work to look around and see the sheer numbers of people who are addicted to food, shopping, electronics, alcohol, drugs, gambling, sex, and the myriad of ways available to us to avoid the profoundly beautiful but sometimes acutely painful process of being human.

Samantha Smithstein, Psy.D.

(Re)defining Infidelity

  • June 23, 2011 7:09 am

in·fi·del·i·ty

n.pl. in·fi·del·i·ties

1. a. Unfaithfulness to a sexual partner, especially a spouse.

b. An act of sexual unfaithfulness.

2. Lack of fidelity or loyalty.

3. Lack of religious belief.

(The American Heritage® Dictionary of the English Language, Fourth Edition copyright ©2000 by Houghton Mifflin Company. Updated in 2009. Published by Houghton Mifflin Company. All rights reserved.)

 

There has always been a “gray zone” when it comes to defining infidelity and monogamy. Certainly, most people would agree that having sex with someone else would constitute infidelity.  But what about a coworker you regularly flirt with?  How about that person at the gym that you frequently fantasize about?  And what about pornography use?

 

With the internet, that “gray zone” has become a lot larger and a lot grayer. While the above examples still exist, there are plethoras of new ways people are connecting sexually.  Old college friends reconnect through Facebook and find themselves re-igniting an old flame through intimate emails.  Avatars in online fantasy worlds kiss, date, and even marry.  Sexting (sending sexually explicit messages or photographs between cell phones), direct message Tweeting (ala Rep.Weiner), cybersex chat rooms, and hot IMs (instant messaging) are just a few of the ways that people are engaged in “virtual” sexual contact with each other.

 

When Rep. Weiner acknowledged his behavior, he stated that while he had engaged in sexual tweeting with several women, he never had the desire to actually meet any of them in person.  What, then, was he after when he engaged in this behavior?  And if he didn’t really want a real relationship with them, what did he want?  And if it was not actual sexual involvement, does this behavior constitute “infidelity?”

 

Part of why it may be difficult to figure out the answer to these questions may be because sex, itself, is difficult to figure out. The origins of desire, lust, and fantasy are often complex and mysterious, and can range from physiological urges, to emotions and needs that have little to do with sex.  Additionally, the answers become further difficult to reach because we often don’t understand the principles that underlie monogamy.  In other words, monogamy is often a reflexive and emotional choice without having a deeper spiritual and/or psychological understanding of the purpose.  If this were understood, it might be easier to see clearly when lines were being crossed – indeed, it might be easier to make the choice not to cross the lines.

 

Among couples today, cybersex and Internet infidelity are leading causes of divorce.  So while it may feel in the “gray zone” and be experienced as “not real” to the person engaging in the behaviors, it is often experienced as a betrayal and very real to their spouse.  It is worthwhile work, then, for us to gain a deeper understanding of what monogamy, fidelity, and faithfulness look like, what they mean, and why they are there, so that we can catch-up our relationships to the high-speed blossoming of the sexual world of the internet.

Samantha Smithstein, Psy.D.

Infidelity in cyberspace: whose doing it & how great is it really?

  • June 20, 2011 6:44 pm

Recently, in order to explore infidelity on the internet, Kholos Wysocki and Childers placed a survey on a website aimed at married people looking for sexual partners outside their marriage. A total of 5,187 adults answered questions about internet use, sexual behaviors, and feelings about sexual behaviors on the internet. The authors were particularly interested in aspects of sexting, infidelity online, and infidelity in real-life.

 

The survey posted on the “infidelity” website revealed a wide range of results on sexting and infidelity. For example, they found that women were more likely than men to engage in sexting behaviors, and over two-thirds of the respondents had engaged in sexual behavior online while in a serious relationship. Over three-quarters of them had engaged in infidelity in real-life, and both women and men were just as likely to have engaged in sexual behavior with someone other than their partner while in a serious real-life relationship.

 

Of particular interest was that Kholos Wysocki and Childers found that respondents were more interested in finding real-life partners, both for dating and for sexual encounters, than online-only partners. The authors concluded that while the internet and social networking sites are increasingly used for social and sexual contact, our need for physical contact has not lessened.  They state, “While social networking sites are increasingly being used for social contact, people continue to be more interested in real-life partners, rather than online partners. It seems that, at some point in a relationship, we need the physical, face-to-face contact.”

 

While the authors of this study did not suggest it, one could argue that it’s possible that it may be that not only were people more interested, ultimately, in real-life sexual encounters than online encounters, but perhaps the sexual encounters themselves were simply a stand-in for even deeper yearnings.  In other words: perhaps the extra-marital online sex is a poor substitute for real-life sex, but that real-life sex itself may be a poor substitute for other, deeper needs that aren’t getting met.

Samantha Smithstein, Psy.D.

Schwartzenagger, a child out of wedlock & another celebrity scandal: choosing not to follow the story

  • May 17, 2011 12:41 pm

When celebrities confess sexual betrayal it can trigger painful feelings and memories for the partners of sex addicts.  It is hard to look away when it’s all over the news, radio and internet.  You may want to ask yourself a few questions:

Does it help or hurt me to give my attention to this latest scandal or story?  Do I need anymore evidence that sex addiction, betrayal and loss of trust exist and damage relationships?  Would it be better for me to do something affirming for myself and my healing process?  Can I take a media vacation today and not get into any gossip sessions with co-workers, family and friends?  Can I be honest with my partner and those I am close to and tell them the current story triggered painful and angry feelings and I need love and support and understanding?  

Take a break, take a deep breathe and think about how you can have a better day.  

“We either make ourselves happy or miserable. The amount of work is the same.” – Carlos Castaneda

Elizabeth Corsale, MA, MFT

Spotlight: Interview with a woman sex addict

  • May 11, 2011 5:07 pm

The following is an interview with a woman who self-identified as being in recovery from a sex addiction.  She is in her 40′s, professional, and married with children.  She asked to remain anonymous for the sake of her privacy; she used the pseudonym “Nora.”  I asked her about her addiction and about being a woman and sex addict.  I began by asking her to describe her sexual addiction:

Dr. S: How would you describe your sex addiction?

Nora: At this point in my recovery, many previous problematic behaviors have dropped away, leaving only the core of my addiction – which started in early childhood – masturbation with disturbing fantasy.  So in describing my sex addiction, I would say that I have been able to let go of all my problem behaviors without great difficulty but struggled to achieve abstinence with masturbation with those fantasies.  I am currently sober and have been for some time, one day at a time.   My addiction started in early childhood, and later was obscured by the acting-out I was doing with men.  But it was all deeply influenced by the control and rage-based fantasy world which started in my childhood.

 

Dr. S: How did you know it was an addiction?

Nora: I was unable to stop my behaviors on my own.  I would make promises to myself to stop having one-night stands, unprotected sex and falling in desperation (love) with unavailable men.  I would be in one desperate relationship, and cheat on that person, intrigue with other men, or cheat on him in my fantasies, and go from one bad situation to the next – from my teens until my late 20′s.  I started therapy because I was terribly unhappy, and early-on in treatment my therapist told me to go to Al Anon because I had a family history and relationship history being with others who struggled with alcohol and drugs.  I began understanding I was a co-dependent but I wasn’t able to yet accept my own sex and sex and love addiction issues.

 

Dr. S.: What made you accept that you were powerless over it/that it was an addiction?

Nora: Accepting my powerlessness has come in stages in my sex addiction recovery.  About a year or so into individual therapy my therapist, who had already told me to go to Al Anon, next told me I needed to go to SAA [Sex Addicts Anonymous].  I was angry and refused.  I am surprised that somehow I didn’t quit therapy.  But later I was a bit more open because I could see my inability to stop acting-out sexually and with love addiction.  I hit bottom.  Prior to my bottom, I was sure I had met the love of my life: a seminary student who was moving out of the country in a week.  I was certain I would be able to convince him to stay and be with me!  When he left and I never heard from him again I came crashing down.  I remember looking around and seeing natural beauty, and happy people, and I was miserable.  I remember thinking that I had to quit these behaviors and get a grip.  I went into to therapy deeply humbled and told my therapist I was going to go to SAA meetings.

 

Dr. S.: What made you feel like you needed recovery?  What did you do for recovery?

Nora: I went to SAA.  Unfortunately I didn’t continue to go to Al Anon.  I didn’t understand at the time the struggle I had with co-dependency was as serious as my sex addiction problem.  I was still confused and thought that now that I was in SAA that would take care of everything.  Of course it didn’t and later I realized a lot of my inability to get completely sober in SAA was because I wasn’t working on my co-dependency.  After a while I returned to Al Anon and remain in both programs now.  I am not in AA but I understand from AA friends who also go to Al Anon they consider themselves “double winners”.  I hope that is true for me as well.

 

Dr. S.: What have you come to understand are the origins of your sex addiction?

Nora: I believe that its origin was in my early childhood.  I was raised by two parents both with significant mental illness.  My mother had a severe anxiety disorder and my father struggled with depression and rage.  There was a tremendous amount of tension, rage, and fear present at all times in my family.  My father had been a war veteran and it was only later in his life that I suspected he likely had PTSD.  He was also a high functioning alcoholic.  He was terribly violent and for some strange reason, I took on the role of standing up to him and often bearing the brunt of his violence while no one in the family stepped-in or defended me from it.  So I was an extremely angry, fearful, and anxious kid.  I think my anger saved me but it became eroticized and the root of my sex addiction.  I had all this anger directed at wanting to save my mother and defeat my father.   I was never going to let a man or anyone have power over me and I was never going to let anyone’s anxiety intrude on me – at least that was my power fantasy, which of course isn’t – and wasn’t – reality.  I wanted to have power over men and women.  And in my mixed up thinking thought I could do that sexually.  Unfortunately my concern about power was not just with men but in all areas of my life and these issues kept me from being close and intimate with family, friends, and my partner.  At its root, I was terrified of intimacy.  My “savior” anger has probably at the same time turned out to be my worst enemy.  It remains a central part of my recovery work today.

 

Dr. S.: What made your recovery different as a woman than it would be for a man?  Why do you think more women don’t get help for their sex addiction?

Nora: I think that some of the differences have been that there are far more men in [SAA] meetings than women.  There have been more women who identify with the “love addiction” side of things and sometimes I feel they don’t recognize that “love addiction” is often eroticized fantasy of power and that has to do with sex as well.  I sometimes feel isolated and alone, and that there still is as much social stigma about women being sex addicts as there has been historically about women being open about having sex.  ”It’s just not done.”  I see all the statistics that show women are becoming addicted to internet porn in larger and larger numbers, but I am not seeing these women in my meetings.  It makes me sad.  I have seen a tremendous increase in attendance in the conference call, women-only meetings but perhaps that still suggests we women are afraid to go to face to face meetings?  I am glad for the support of the conference call meetings.

 

Dr. S.: Have you had any relapses?  How do you think about relapse?

Nora: If you are referring to my inner-circle, or bottom-line behaviors, I have had no slips in areas such as sex outside of my relationship, affairs, and intrigue.  But I have had slips with masturbation and fantasy.  Sometimes I understand the slips and sometimes I have to work to get it.  I have done a fair amount of therapy and work the 12-steps and understand that I have to practice my program, one day at a time.  I don’t believe I can promise never to have a relapse, and that is not about having one foot out the door or making excuses.  But I think with regards to my core sex addiction, if I stop taking care of myself and/or stop working my program, I can find myself in trouble.  Sometimes I feel I am in my addiction even though I am not acting-out.  This is when I have lost my grip on the “here and now,” and I confuse where I am powerless and where I have power.  If I think I can deal with my addiction or stress by myself, then I am in trouble.  I know I am powerless over addiction, so one day at a time makes me more responsible to do everything I can do to stay honest and work the steps and choose to bear the hard stuff that I used to act-out over.

Samantha Smithstein, Psy.D.

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