How We Learn to Self-Medicate

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It is said that in any AA or NA meeting 60% of its group members will have experienced some form of abuse (physical, emotional or sexual) as a child. Childhood abuse is a good indicator of later substance abuse and addiction. 

Recently I posted about ACE (Adverse Childhood Experiences) Study which showed that early adverse experiences, or traumas, predict adult physical and mental health problems that ultimately lead to early death. Adult substance abuse is one such consequence, in addition to smoking and obesity.

In this context, I've been thinking a lot of about validation. To validate simply means recognizing another person's experience of an emotion and their reaction.

If a friend is crying because his dog recently died, I would validate by saying something like "I see that you are really sad" or "You are really missing Buster." In my wanting to help, I might instinctively want to problem solve or advise him so he feels less hurt. I will get there, but first and foremost I acknowledge that his sadness is real and valid.

Imagine a little girl falls and scrapes her knee, and she cries. Her mother or caretaker hopefully will say something like "Oh, no, you fell. Come and let me look at it" or "Let me see. I think it's going to be okay." Both statements indirectly validate that an accident has happened and that the little girl's reaction is valid. But, another parent might simply order the child to stop crying, or say something like "I told you not to run" or "This is what happens when you misbehave by running." 

In a dysfunctional or abusive family, a child's feelings and reactions are invalidated, as the latter examples illustrate. It doesn't seem so bad when looking at just one example, but when it is long-established pattern, parental invalidation teaches the child that her feelings, especially negative ones, can't and shouldn't be felt or expressed. 

The same girl might grow to ignore, disregard, deny or avoid her feelings, especially uncomfortable ones like sadness, anger, shame, guilt, boredom, loneliness, even though they are part of every person's experience.

Enter alcohol and drugs, which in the short-term help her avoid unpleasant feelings. Repeat this way of coping and a dependence and addiction develops. And a cycle of self-medication begins: Immediate relief from unpleasant feelings followed by intensification of those feelings, and so on...

The Examined Life

Some books are to be tasted, others to be swallowed,
and some few to be chewed and digested.
Francis Bacon, the philosopher, not the painter.

Sometimes a book can come along and make your life better. Reading it feels as though it was meant to enter your life at that exact time.
And isn’t this why we have a life-long love affair with books?

Books can help us answer questions we haven’t yet to formulate. At their best, they rouse us to carry on an inner dialogue and deepen our self-awareness. And awareness is the first step in the process of change.
Yes, change is possible. It’s a slow-going, subtle shifting of your attitude, first to your self, and, over time, it will manifest outwardly in your interactions with the world.

Stephen Grosz’s The Examined Life is one such book. Grosz is an American psychoanalyst based in London. I love this book because the writing is superb; language is simple and precise, without psychological jargons to showcase the author’s expertise. He writes for an audience interested in living a deeper, more authentic life (don’t we all?). Though I am not a book reviewer, if you are interested the literati love his book!

My clinician self found important lessons in how to be a better therapist, both in technique and in philosophy. And as a general reader, I very much appreciate the clinical cases he presents, because I identify with many of the enduring “issues” that had brought people to his office. Some of these universal themes are: the search for and keeping of loving relationships, forgiveness, resolving the hurts from our imperfect childhoods, loneliness, sexuality, raising children, facing death.

If there were to be a syllabus for therapy The Examined Life would be a required reading. 

Quick note about psychoanalysis: It is a type of psychotherapy I DO NOT practice. However, I hope to start training in it in the near future. Its aim is to affect or change the personality structure of the client over an unspecified period of time. Usually a client brings in a complaint of a non-urgent nature, something that nags her but does not interfere with her overall functioning. Free association is the primary technique used in analysis; it means that the client is encouraged to think out loud, to say whatever comes to her mind. The analyst then interprets what was said, noting patterns or other significant content to which the client was unaware. There is little advice giving, and progress or insights are made by the client on their own.

The work I do is more hands on and goal directed. The issues I deal with tend to exist on the surface of day-to-day life, whereas psychoanalysis deals with issues that are more deeply imbedded.

Who Are These Alcoholics?

Google “alcoholic pictures” and you will find that an alcoholic tends to be an unhappy adult white male who sits in the dark with his head in his hands. He is alone and depressed with only a bottle for company.




An alcoholic, defined clinically, is someone physically dependent on (addicted to) alcohol and unable to control how much they drink; alcoholic also has cravings and increased tolerance, and goes through withdrawal symptoms when alcohol leaves their system. Comparatively, a problem drinker, or an alcohol abuser, is someone psychologically dependent on alcohol but without the physical dependence (although a hang over is a collection of moderate withdrawal symptoms). For the problem drinker, the issue isn’t alcohol (because they can go without) but the reasons why they drink and what happens after they drink.

National Institute of Health and National Institute of Alcohol and Alcohol Abuse classified U.S. alcoholics into five subtypes. These results are from a 2007 national survey, and it is estimated 14 million Americans qualify as alcoholics.

Young Adult subtype: largest group in the U.S. with 31.5 percent of alcoholics. Low rate of mental illness, drug abuse and history alcoholism in their families. Least likely to seek out help.

Young Antisocial subtype: In their mind-twenties, 21 percent of U.S. alcoholics. Early onset of alcohol use and problems related to alcohol abuse. More than half from families with alcoholics. About half are diagnosed with Antisocial Personality Disorder. Many suffer from the trinity of mental illness (depression, bipolar disorder and anxiety problems). More than 75 percent smoke cigarettes and marijuana, and many have problems with cocaine and opiates. More than a third seek help.

Functional subtype: 19.5 percent of alcoholics. They are mostly middle-aged, well-educated, with stable jobs and families. Third have alcoholism in their family histories, a quarter had major depression at some point in their lives, and nearly half were smokers of tobacco.

Intermediate Familial subtype: 19 percent of American alcoholics, they are middle-aged and half withs familial history of alcoholism. Most smoked, half of them had clinical depression, and 20% have had bipolar disorder. Nearly 20% had problems with cocaine and marijuana. In this group only a quarter get treated.

Chronic subtype: 9 percent of U.S. alcoholics. Middle-aged; began drinking heavily at an early age. High rates of Antisocial Personality Disorder and criminality. Highest rate of mental illness (depression, bipolar disorder, anxiety disorder). High rates of smoking, marijuana, cocaine, and opioid dependence. 2/3 of the group get help (many of them to mandated to treatment making them the most prevalent type found in treatment.


Information, which I summarized here, comes from:

http://www.news-medical.net/news/2007/06/29/27074.aspx?page=2

http://www.alcoholic.org/research/alcoholism-statistics-and-information/

Are you an alcoholic? Find out here. 

In my practice I work to help problem drinkers with their emotional health, in addition to learning how to become a more mindful, moderate drinker.

Addiction, Depression and Antidepressants

I read with great interest this piece on The Fix called The Dumbest Article You'll See About Addiction, and that's about right. The writer, Maia Szalavitz, is responding to a criticism of her original piece, in which she shares how Zoloft had saved her from a deep depression after kicking a serious heroin and cocaine habit she picked up during college. Twenty years later, while still prescribed Zoloft, she describes how it dramatically improved her mood and the way she responded to the world (depressed people, she says, tend to misread other people's facial expressions), that she has had a successful writing career and a very satisfying life. 

The second writer, critiquing on Slate, says that Szalvitz merely replaced one addiction with another, and asks the astoundingly naive question why we are easier on pill poppers than alcoholics. It's difficult to believe that her editor or anyone else on staff, let slide her ignorance and insensitivity to issues of mental health. While it’s true Big Pharma has integrity issues, the fact is anti-depressant medications and other psychopharmaceuticals dramatically improve, if not save, the lives of many, many people.

Be sure to read the many comments on both pages. It's a serious subject matter that affects many people.

Suicides in Spring

I found this article titled “Clues in the Cycle of Suicides” in the New York Times. It dispels a popular belief about suicides: it is during spring and early summer when suicides peak, not winter, which I thought would be the period with the highest number of suicides. Winter’s long stretches of darkness and cold, along with the holidays that tend to intensify loneliness and isolation contribute to increased symptoms of depression. In contrast, spring brings warmth and a promise of hope with another cycle of natural life.

To explain the connection between spring and suicides, article summarizes very interesting recent research concerning the relationship between inflammation and depression, and the decreased production of melatonin to the spike of symptoms of agitation and mania for those diagnosed with bipolar disorder and depression, raising the point that genetics (nature) contributes to development and symptoms of mental illness.

What I found most fascinating was the concept of the “broken promise” syndrome, which I interpret as the feeling of being let down because spring did not eliminate their despair. Maybe the bright cheeriness of spring made despair seem even darker – hopelessness worsened because spring’s promise of hope and renewal did not apply to them, unlike rest of the natural world. Not feeling better in spring became yet another indicator of their emotional and spiritual alienation.

When thinking about it this way, I realize I am only beginning to grasp the enormity of human despair and suffering and the interplay between nature and nurture. But rather than feeling overwhelmed by it I feel emboldened to meeting the challenge of helping people reconnect to themselves and to help them understand that nature does indifferently work against them. In my experience working with clients, understanding the genetics component can help ease the stigma that often comes with a diagnosis and help them take steps toward self-acceptance.

Fatherless on Father's Day

Fatherless on Father's Day. Some thoughts.

Holidays, even Hallmark holidays like Mother’s Day and Father’s Day, can be difficult for those of us with atypical childhoods. Rather than a celebration these "holidays" can, if not downright depressing, be a reminder that you are missing out on something, that you aren’t quite normal. This is how it feels. However, if you look at statistics, father-absent households in the US are quite common (one in three children). Still, if you have lost your father or never had a father to begin with statistics will not soothe how you feel.

Loss is part of everyone’s experience. At times, especially like today, Father’s Day, your loss can feel significant. You feel life has treated you unjustly. You may even feel resentment towards others who appear to have it all (like a loving, caring and strong father). 

The following are some points to reflect on to gain some perspective.

1. Be grateful for what you have. 

This may be difficult, if you’ve had a very difficult history with your father or with your family. There are many of us who have suffered sexual, emotional or physical abuse by our fathers, and the scars will forever haunt us. But the fact is you have survived it, and there is help to undo some of the damage. Remind yourself that you are not alone, and many of us have overcome our traumatic histories. Also, the miracle of being alive means accepting its unpredictability and our humanity – we are capable of great love, but we also have the potential to cause great pain to others, even our children. 

2. Acknowledge the feelings of loss, sadness, anger and pain.

Emotions, like energy, is in a state of entropy. This means unconsciously we are trying to achieve a state of equilibrium, a state of emotional balance. Physical pain is avoidable and something we can manage. But psychic or emotional pain – a defining feature of human experience and therefore unavoidable – must be felt and accepted. It cannot be stuffed away. This would upset the natural course of emotions. Unprocessed emotions will surface down the road, and often it will be more troublesome.

Practically, it means reaching out to someone on a difficult day (Father’s Day, anniversaries, etc.) and talking about how you feel. You will still feel blue afterwards, but you will find comfort. And if your history contains significant loss or trauma, psychotherapy or talk therapy is something you should seriously consider. Avoidance and denial can contain our pain only to a point. Pain needs to have light shined upon it so that it can’t fester in the darkness of memory.

3. Step back from yourself. 

If you are reading this chances are you live in the “developed” world. When we become absorbed in our pain and confuse it with physical pain, the primacy of our feelings can skew our perspective. The fact that you are reading this on a computer (whether it’s your own or shared) you are part of the fortunate minority. We have in common a standard of life and freedoms that most people in the globe can’t take for granted. We can bitch about our own lives, the politics of our imperfect countries, but the fact is our lives could be intensely more difficult. This does not mean your private sorrows, losses, and painful biographical facts are meaningless. But, it means recognizing that you are not alone in the world who is suffering. Emotional pain is one thing, but consider what it might be like to lack adequate shelter, access to health care and education, and food and water.

Practically, this might mean paying more attention to world affairs, for instance getting a more global perspective from news sources that are more international in scope, reading books on public health,  volunteering, and donating money to organizations. 

How Do You Know If You Have a Problem with Alcohol?

Check out the clip below on detecting alcoholism in yourself and/or others.

Rethinking How and Why You Drink

I’ve tried to define risky or heavy drinking in a prior post. Naturally, a post on why one may want to consider cutting back or drink moderately follows.

First, I’d like to distinguish alcoholism from alcohol abuse,
i.e. risky/heavy drinking, by making the distinction between physical dependence on alcohol from psychological dependence.

I am primarily concerned with psychological dependence and its relationship to emotional health. 

The following are the most common reasons/beliefs why people say they drink:

1. Alcohol makes me feel less shy and more social
2. Drinking alcohol makes socializing more fun
3. I am more interesting and fun to be with when I am drinking
4. I am more myself when I am drinking
5. Alcohol relaxes me
6. Alcohol unwinds me from stresses of life
7. Drinking makes me forget my troubles
8. I am more creative when I am drinking

These reasons, for the most part, are valid and supported by the fact that alcohol has been around just as long as we have. There is no denying that ethyl alcohol, the active chemical compound in alcohol, does relax the brain and body, initially.

One possible explanation for how drinking becomes problematic maybe because of habits. Once we hold an idea of ourselves to be true – I am more social and friendly after a couple of beers or alcohol helps me to relax – the repetition of the behavior, or the habit, reinforces the belief which first initiated the behavior. We begin to believe that drinking alcohol is the ONLY way we can be relaxed, be more social and have fun in a social setting. In a sense, we become trapped by the beliefs we have about ourselves. We become the person who we believe we are.

But we can’t be sure this is true, even though it may have been true in high school or college when we first started drinking. But, we can discover new parts of ourselves by doing the same things differently or trying new things.

By questioning established beliefs or behaviors and trying new ideas, we learn new aspects of our personalities, expanding our idea of who we are. As our self-image or self-concept expands, so does our self-esteem, which makes incorporating new ways of thinking and behaving easier.

Practical application of this theory to problem drinking would be to see how it feels to go out and not drink or limit how much you drink so that you don’t go beyond the threshold where alcohol influences your ability to make decisions. 

I recommend to my clients who have identified heavy drinking as a problem to abstain from alcohol for 30 days. During these 30 days, they are encouraged to think deeply about their relationship to alcohol and decide how they might go about changing it. They may decide to stop drinking all together or try to moderate their drinking.

This period of self reflection is not an easy one. Many people will give up, because it would mean dealing with their anxiety and depression. It is demanding work, and change does not take place over night.

To be continued...

Sort of a Film Review: Silver Linings Playbook

http://www.kentuckytheater.com

Initially, I was skeptical about Silver Linings Playbook, but it disabused me of the misconception that all rom-coms are silly affairs in which an attractive young woman and man fall in love after overcoming a series of obstacles. SLP, like other movies of the genre, shows us that the quest for love is universal. Its two protagonists, played by Bradley Cooper and Jennifer Lawrence, are very pretty, as you would expect. I had dismissed Bradley Cooper as an exceptionally good-looking comic actor, and I wasn't familiar with Jennifer Lawrence. However, she won me over as the wounded yet feisty and self-aware young woman; I found her character so intriguing I forgave her being so young, talented and beautiful. And, I gained an appreciation for Bradley Cooper as a man with bipolar disorder just released from a long stay in a psychiatric hospital. His performance did not embarrass; he didn’t simply play “crazy.” Instead, he played a man whose capacity for suffering emotional pain was monumentally greater than most people’s because of the illness. 

As a mental health professional, I appreciated how the film treated mental illness with depth, humour and fairness; I am hoping that it can lift the some of the stigma that keeps people from accessing mental health services. 

These are some of the reasons why I recommend Silver Linings Playbook:

1. By no means should Cooper’s character be mistaken for a clinical case study of bipolar disorder, but it portrayed BD's main features in a believable way. Also, his father's (played by Robert DeNiro) compulsive and superstitious dependence on numbers was a lighthearted look at OCD-like behavior, perhaps to suggest that predisposition to mental illness can be hereditary. 

2. The movie shows that character's bizarre behavior of Bradley Cooper's character did not come about in a vacuum (it's important to note that he did not have delusions or hallucinations, symptoms of psychosis). The distress of catching his wife with another man had triggered his hypersensitivity to a full-blown episode of mania and depression (although we did not see his depressive symptoms). His reaction went above and beyond the "functional range" of emotional response, and, as a result, he was hospitalized. Symptoms of mental illness, especially mood disorders, are extreme (pathological) reactions to life’s inevitable ups and downs, and they are disruptive and upsetting to the sufferer and their family and friends. But, the point is that everyone of us have experienced these symptoms to some degree, because this is what it means to be human. 

3. Medication works. It does not “cure” but, under the care of an able psychiatrist, it can manage and control the symptoms and improve the quality of life for the patient and their family. It enables the patient to work, be in relationships and seek talk therapy to complement the pharmacotherapy, which only addresses brain chemistry. The most effective treatment for mental illness is drug therapy with concurrent psychotherapy. 

4. People diagnosed with mental illness have unique personalities and real lives, and they are capable of great achievements. They are more than their symptoms or diagnosis. One can LIVE with mental illness.

5. Mental health professionals are real people. We have real lives that are sometime messy and have interests outside work that may seem incongruent with what we do professionally. However, I am not a fanatical fan of any sports team.

What Is Problem Drinking?

What is too much drinking? That depends on whom you ask. Some will say, “I drink every day, but I don’t drink during the day.” And, others say, “The only problem I have is that bars close at four, and I have to stop drinking.” Or, “Just as long as I am able to go to work/school and attend to my life, I can drink just as much as I want.” But, it’s difficult to admit that one feels that they do not have control over something outside themselves. So, until something concrete and negative happens, most people learn to live with the vague anxiety of feeling powerless.

I think many people, including myself, were surprised by this guideline from the National Institute on Alcohol and Alcohol Abuse on problem drinking. By their measure most people I know in New York City between the ages of 20 to 50 are problem or binge drinkers. But, most of these people are not alcoholics either. Personally I don’t know anyone who has been to detox or rehab*. I’ve worked as a social worker with many clients who have been in and out of inpatient and outpatient drug and alcohol treatment programs, and so I know what alcoholism and addiction looks like. Most of my peers would fall into the problem or habitual drinker category at some point in their lives, but they would not be classified as alcoholics.

So why is habitual, mindless, heavy or risky drinking a problem? With every behavior there is a consequence, and consequences of unchecked alcohol consumption are very real and can pervade every aspect of life. Common issues are: vague discontent and unhappiness (depression, maybe not in the clinical sense); poor health due to bad diet and excessive alcohol, smoking while drinking and lack of exercise; frequent hangovers; being late or missing work or school; regret over one’s behavior while drunk – being excessively emotional, aggressive or sexual; use of other drugs such as cocaine, further lowering inhibition leading to poor decision making; fighting with partners about drinking or other problems caused by drinking.

As a result of these and other reasons, problem drinkers try to cut back or stop but often without success. Because problem drinkers have difficulty controlling alcohol intake, they may intend to have just a drink or two, but after the two they find themselves not wanting or able to stop. And, happy hour becomes an all-night drinking session or binge. And for problem drinkers, drinking happens most nights of the week, although not heavily every time. 

To be continued…

*Detox takes place in a hospital or medical setting for the duration of a short week. For severe alcoholics medically supervised alcohol withdrawal is necessary as seizures and other serious complications may occur when a body, long immune to the presence of alcohol, is suddenly without it. For this reason, anti-anxiety medications, such as Xanax, Valium and Librium, are often prescribed. The singer Amy Winehouse’s death was probably a result of unsupervised withdrawal.

Rehabs are usually 28 days long, although depending on severity and finances stays can be longer. I’ve worked in a facility that wasn’t much different from jail; many of its clients, mostly former heroine addicts, were mandated to drug treatment in lieu of serving yet another stint in jail for drug-related charges. Most of these clients were Medicaid eligible and stayed anywhere between three months to two years. Private insurance does provide inpatient substance abuse treatment, but they ususally restrict the duration of treatment to 28 days. However, if you are financially able, treatment options are plentiful. After the initial medically supervised withdrawal (what happens in a detox) a treatment team addresses the psychological aspect of addiction. Through group and individual therapy long exploration into the how’s and why's of addiction, in addition to strategies to prevent relapse, are explored These programs are designed to prepare for maintaining abstinence – a life of sobriety. Ideally, this would be just the beginning of psychotherapy, which should continue post-rehab.