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.

Stealing or Stealing Madness? And Is There A Difference?

  • June 8, 2012 2:37 pm

When most people think about theft they think about criminals who steal possessions of other people in order to resell them and make money. Or the identity theft who is able to steal money out of the bank account of others. The “criminal” who profits from stealing from others rather than working for his or her money. But there is a different kind of stealing – stealing that people do when they don’t “need” to. People who compulsively steal and experience intense urges, obsessive thoughts and elaborate rituals and planning.

Recently a high tech executive was arrested for forging bar codes on Lego toys, purchasing the Lego’s way below value and reselling them on EBay and making thousands of dollars.  When this hit the news he was being called “a man with an obsession” because he couldn’t possibly need the money and could well afford to pay full price.  Maybe it was because he was a highly educated individual and it’s harder to think about those with status and privilege really having a stealing problem, but on the surface he appears to be suffering from kleptomania, or compulsive stealing.

What about the rest of us who are not “criminals” or suffering from compulsive stealing?  Are people such as this executive so different from us? Consider for a moment, you are going on a trip and in order to make reservations and  you need to submit a copy of your passport.  You take your passport into work, make two copies, and mail it in with your application, which you print out while you are there.

Is this stealing?  It depends on what the policy is at the office, but most likely it is, since office equipment and paper was not likely purchased for employee personal use.  Is it something you are likely to get fired for?  Probably not, but it may depend on just how many copies you are making and how strict the workplace is.

The above example represents the myriad of ways that people steal every day, without even thinking about it.  Whether we make copies at work, walk off with a pen we borrowed, use someone’s unsecured wifi, or don’t report the income from a garage sale on our taxes, most of us steal in some form or another during the course of our lifetime and even on a regular basis.  If we do think about the fact that we are stealing, we typically rationalize it, telling ourselves that “a few pieces of paper and a little ink is a drop in the bucket at work” or “I’m only making a few dollars at the garage sale – the government doesn’t need this money as much as I do.”

Why is this important to think about? When most people think about stealing, we think of it as something “I would never do” and hold ourselves as separate from “people who steal” – we assume the person caught stealing is simply greedy and only in it for themselves.   But whether we don’t tell the server they forgot to include a drink in the bill, pocket a pack of gum at the grocery store, or rob a bank, the common thread is the rationalization in our mind that makes it possible.  This distancing may be part of why we are so blind to how commonplace the problem is in our society, or why the field of psychology is not thinking enough about stealing and what the thoughts and behaviors are telling us about the person committing the acts.

Larry came into treatment in order to deal with his stealing issues.  Larry was diagnosed with kleptomania and bulimia (he threw up and over-exercised after over-eating).  He was a well-educated having attended and graduated from a prestigious college prep boarding school and an Ivy League University.  He was under employed, frequently complained of boredom and struggled with personal and professional relationships.  It was difficult for Larry to open up and be honest in therapy. Overtime he began to trust his therapist and group members.  He shared that he felt incredibly out-of-control and ashamed of his obsession with stealing.  He shared that his problem wasn’t only the everyday simple shoplifting it went much deeper.  Over several years he had been going to music stores and large big box store that sold DVDs.  He would purchase the DVDs and then with painstaking care using exacto blades, hot glue guns he would slowly and carefully unpackaged the DVD’s, take them out and upload them to his computer and then repackage them and return them to the store for a full refund.  It took hours upon hours and he expressed that it gave him and incredible high and a tremendous sense of accomplishment and he felt less guilt having returned the merchandise. 

In the example above, as well as the recent case of the executive who stole Lego kits, or an individual who purchases an outfit, wears it to an event, and then returns it, these actions take more planning to execute than simply walking off with a pen.  However, oftentimes these individuals don’t need the money from these transactions, in the same way that you can afford the pen you walk off with (or afford to pay the taxes on the earnings from the garage sale), and so the motive for the stealing, and the subsequent rationalizations, are often complex. But these rationalizations, similar to the distancing, keep us from acknowledging the ways we steal and how commonplace it is in our society – and keep us from being able to effectively help those who steal compulsively and need it.

Samantha Smithstein, Psy.D.

Elizabeth Corsale, MFT

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.

Addiction and harm reduction: come as you are

  • March 17, 2011 7:28 am

In the world of addiction, moderation has traditionally been a dirty word.  Harm reduction has started to change that. Harm reduction is a philosophy that approaches change compassionately.  The aim is to reduce negative consequences associated with the behavior in question and celebrate any positive change, no matter how small.  The motto “Come as you are,” captures harm reduction’s foundation in humanistic and client-centered approaches.

Moderation management for alcohol and drug abuse has gained awareness as an alternative intervention to abstinence, however clinicians who treat process addictions, such as compulsive sexual behavior and kleptomania, have been doing harm reduction by default. For example, most patients who seek sex addiction treatment aren’t looking to abstain from sexual behaviors or activity, but rather to develop healthy sexual behaviors.  Likewise, patients in compulsive shoplifting treatment programs aren’t told to restrict themselves to online shopping, but instead learn why they behave impulsively and create alternative, healthy coping strategies. Furthermore, Harm Reduction Psychotherapy, which addresses both the compulsive behavior and underlying mood or personality disorders, fits process addiction treatment like a custom knit glove. So many patients with process addictions act impulsively as a means of self-medicating depression, anxiety and trauma, much like someone who misuses drugs or alcohol as a way of coping.

So what does this mean for the future of process addiction treatment? If we utilize a harm reduction approach to treatment, we can help the patient reduce negative consequences, increase their self-efficacy and motivation to change.  We do this by celebrating small successes, helping them understand the meaning of their impulsive behavior with the use of integrated psychodynamic, cognitive-behavioral and attachment theories, and reduce the paralyzing shame and guilt that encumbers initiation in treatment by encouraging patients to come as they are.

Jennifer Fernandez, MA

Blindsided by cravings

  • March 10, 2011 12:31 pm

In a previous article, I wrote about dopamine and how intensely pleasurable experiences elevate dopamine in the brain and ultimately can lead to addiction.  Dopamine is a brain chemical linked to reward, motivation, and survival.

Recently, researcher Gene-Jack Wang, a physician at Brookhaven Lab and the Mount Sinai School of Medicine, and his colleagues studied the dopamine levels of people who compulsively overeat and found that the mere sight or smell of triggering foods caused dopamine levels to go up.  This is similar to the findings of people addicted to drugs who experience elevated dopamine levels from viewing photographs of people using the same drug.  When the addictive activity is viewed, dopamine primes the brain for receiving the reward.

This research is key in furthering our understanding of why people have a difficult time resisting binging on foods they associate with pleasure, even when they know it is bad for them and even causes them health problems.  It also can help us to understand why people addicted to other intense pleasurable activities, such as shopping, stealing, romance, and sex, have a hard time turning it down – it is not just a matter of getting away from the activity but viewing particular photos, seeing an item, or seeing a person who fits a particular description can trigger the dopamine response, in turn triggering an intense craving for the pleasure.

This research also helps to validate the power of the addiction for those addicted to a “process” (eating, stealing, sex) rather than a substance.  Just as with a substance addiction, the craving is not just psychological and/or emotional – it is biological as well, and can be triggered suddenly and intensely.  This makes holistic treatment crucial for the process addictions – honoring the “sobering up” that needs to happen on all levels.

Samantha Smithstein, Psy.D.

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