Last night my wife and I went to a lecture by Joseph LeDoux, the author of The Emotional Brain and the Synaptic Self. His research has primarily focused on understanding the emotions of fear and anxiety through animal models, and how these emotions impact memory. One of my favorite chapters in the Emotional Brain is titled “Where the wild things are”  which describes the link between what he has learned about the amygdala, hippocampus, and common emotional problems. There were many take home gems from his talk, but the ones that have stayed with me the most are:

• There is evidence that early traumas, even those that occur right after birth, get seared into the amygdala (emotional memory) and stay with us for life. Even though our ability to remember a trauma requires some development of the hippocampus, and likely does not begin until around the age of three, we can still react emotionally to particular triggers that we were exposed to prior to the age of three even if we have no memory of what happened.
• Trauma changes the physical brain and how it operates, and in so doing, influences the behavior of the person. People respond very differently to trauma, even when exposed to the same traumatic events.
• We are hard-wired to respond to threatening situations behaviorally before our rational brain evaluates a situation and makes a determination of whether something is dangerous. This is why we jump back when we see someting squiggly on the ground. It is an evolutionary, survival response. And if the squiggly thing is a killer snake, then good thing we jumped before we thought about it.
• Traditional anatomy and physiology texts teach that our emotions come from the limbic system. LeDoux’s work has shown that emotions like fear involve many parts of the brain that extend beyond how we understand the limbic system. So…he believes we should do away with the limbic system - it does’nt exist.
• The work of psychotherapy is about our neocortex  learning to exercise control over the evolutionary old emotional systems – over the amygdala.

So, translation for those who struggle with addiction. Addictive behavior can be understood as an unhealthy coping strategy to an amygdala that likely has some emotional wounds. This is why so many relapse prevention programs focus on mindfulness and CBT strategies for behavioral self-regulation. I continue to believe that all who struggle with addiction can benefit from trauma resolution work.

I understand why Beautiful Boy is a #1 New York Times bestseller. It’s a very moving and insightful account of one father’s journey through his son’s addiction, a journey millions of parents have made. David (the author) does not hold back. His writing is powerful, emotional, lucid, and honest. He loves his son Nic to the ends of the earth, there is no doubt about that. Nic is more than just a beautiful boy, he is everything to David. And why wouldn’t he be, he is his son, even when high on methamphetamine and other drugs. At times I laughed, other times I cried. I did not want to be reminded that as a parent there are limits to my ability to protect my son. But it is one of the gifts of the book.

It is often overwhelming reading David’s account of his son’s addiction, and his tireless pursuit to save him. At one point in the book he asks the question: What would you do if a family member were addicted to this drug? He receives many answers from addiction researchers, drug abuse counselors, interventionists, friends, teachers, and members of Al-anon. He leaves few stones unturned, and in the end, realizes that no one person has all the answers. He must decide for himself how to deal with his son’s addiction (and his own addiction to his son’s addiction). I could not agree more. At the same time, I could not help but get frustrated by some of what he was told, and even more, by what he was not told. Here is my answer to David’s question.

Help for David

• I would utilize the Community Reinforcement and Family Training (CRAFT) approach for dealing with Nic and his addiction. When compared to the two approaches most discussed in the book (Al-Anon and doing an Intervention), CRAFT has been shown in clinical trials to be significantly more effective. In one trial, CRAFT resulted in 64.4 percent of addicts entering treatment compared to 22.5  for Interventions and 13.6  for Al-Anon. I would add that if it were me, I would likely skip Interventions, but utilize Al-Anon with CRAFT since there are many positive benefits to connecting with others who are going through similar challenges.
• For family members and friends trying to help an addicted loved one, the end result is most often perpetual trauma. David at one point says, “I have been so traumatized by his addiction that the surreal and the real have become one and the same.” There are many references throughout the book that support the painful fact that trauma pervades not only Nic’s life as an addict, but his father, family, and likely some friends. It is also a sad truth that good trauma therapy is hard to find, and rarely done to any significant degree in substance abuse treatment. For David, who clearly has engaged in a lot of therapy, I would want to explore the degree to which these therapies sufficiently addressed trauma. I have explored this topic in a paper I wrote about treating trauma, as well as in a section about core issues. Understanding trauma and its treatments are as complex as addiction, if not more so. One of my favorite trauma authors recently came out with a new book that I believe should be read by anyone who has experienced trauma, and in my book, that includes us all: 8 Keys to Safe Trauma Recovery. This is tough work, not for the faint of heart. But something tells me that after what David has been through with his son, trauma work would be a walk in the park.

Help For Nic

• David says towards the end of the book, “rehab isn’t perfect, but it’s the best we have.” I am not surprised he reached this conclusion given that when you go searching for help, it is really the only answer. Treatment works. Research says it does, even if you have to go multiple times. And Nic is a testament to this outcome: he goes to many residential (and outpatient) programs and does well for sustained periods of time following treatment before he relapses. I too believe in treatment, but also believe strongly that current treatment practices fall short of what is possible and necessary for long-term success.
• This entire website is dedicated to helping you understand the solution to addiction. My answer for Nic (and David) is summarized in the top five things you should know about addiction and the solution to addiction. David is right when he says in the book that there is no one right path for anyone, but there are specific things that can make a difference in whether a person continues to go through life cycling in and out of treatment, or progresses beyond their addiction.
• For Nic, among the most significant factors that will likely influence his future outcomes is the degree to which his developmental deficits and constrictions are addressed. Among the best frameworks for understanding how to assess development is Stanley Greenspan’s six developmental levels (or stages) of the mind. The deficits and constrictions resulting from early traumas, as well as drug abuse, can be healed over time utilizing developmentally-based psychotherapies. Although meth and other drugs of abuse can result is significant brain changes that impact emotional development, this type of therapy is really the best we have. Unfortunately, in my experience, it is not taught in graduate schools, is completely unknown in residential treatment facilities (and even if it was known, the therapy is done over years, not months or 28 days), and requires significant skill in delivery. It also is the right therapy following trauma resolution work. The good news is that there are some gifted therapists in most places that can do it, it just may require some effort finding them.
• David correctly writes that his son has a chronic, relapsing medical condition that will require long-term care. Yet sadly, it appears that Nic’s care has suffered from our treatment system being a patchwork of acute-based programs, where aftercare is self-help meetings and ”working a program.” Nic needs to stop going in and out of treatment, and instead engage in treatment for many years. The evidence is in the book. When he is in treatment and working his program he does very well, until he stops working his program and relapses. “Working a program” is a 12-step construct that does not include the work I believe is critical to long-term success (see previous bullet point). Staying in treatment for years makes sense when you understand that it is outpatient (not residential), involves resolving underlying drivers of addiction like trauma, is adapted to changes in development over time, and includes the exploration of more than just pathology, like the idea of Me to We. If we are to successfully help people move beyond addiction, we must get outside the black box of traditional addiction treatment and utilize what we know from a variety of fields (e.g., systems science, positive psychology, ecopsychology, education). We can and we must do better, for Nic, and everyone else that suffers.

I want to add that Nic published his own book about his experiences abusing methamphetamine and other drugs, called Tweak. I look forward to reading it in the near future, and hearing his side of the story.

One final comment is related to how David ends the book. He says “I believe we need an all-out war on addiction modeled on the war on cancer.” He goes on to suggest what such a campaign would look like, the funding it would require, and the benefits it could bring. He adds that a research network like that set-up for cancer could test out many promising addiction interventions, including new medications. The good news is that it has been done, and has been bridging the gap between practice and research for many years now. It is the National Drug Abuse Treatment Clinical Trials Network. Check it out.

A comment from a previous post suggested I watch a documentary titled “Cracked Not Broken” by independent film maker Paul Perrier. It was time well spent. In short, the film is about a woman named Lisa who is addicted to cocaine and works as a prostitute to support her habit. Much of the film is an interview with Lisa in a hotel room, where she honestly and openly talks about various aspects of her life on the edge – or as she calls it “the game.” I love how the film goes from black and white to color as she feels the effects of the cocaine she has just injected into her body (yes, there are some graphic scenes). It also shows that despite a number of treatment espisodes, Lisa continues to struggle with relapse hitting home how we understand addiction today – a chronic, relapsing brain disease.

What does Lisa need to successfully move forward in her life?

• Healthy intimate relationships. Cocaine and sex have become more important than relationships – more important than her daughter, her friends, her family. Ultimately, for her to heal, she needs deep emotional connections to those she loves and cares about. For her to have sustained, healthy emotionally-fulfilling relationships, will require that treatment and intervention place increased emphasis on helping her understand her emotional world in a safe way, and developmentally addressing her emotional deficits and constrictions .
• Trauma resolution.  Just watching Lisa in the video you can sense the chaos and trauma in her life. The splitting off and not letting herself feel is classic trauma. I have blogged about trauma being the gift that keeps on giving (although it is hardly a gift), and for Lisa to move beyond her addiction will require significant trauma work. Again, this is where traditional drug treatment programs often fail clients. They may diagnose PTSD, but rarely have the resources, time, or expertise to address it sufficiently. For someone like Lisa, this work likely will require many months (or years), but usually never happens because of short treatment stays. 
• Medication. Addiction is a brain disease, and as Eric Nestler (Professor and Chair of Neuroscience at Mt. Sinai) has so aptly put it – one that hijacks the brain with a force almost unheard of in our natural world. As a result, for Lisa to succeed, she will likely need some medication to help her with cravings, depression, anxiety, and other symptoms associated with her long use of cocaine as she slowly engages into a life without drugs and sex. The HBO series on addiction has an excellent segment on relapse from Anna Rose Childress where she explains why the brain is so vulnerable to relapse. Her example in the film is a guy who is addicted to cocaine and reminds me a lot of Lisa. Dr. Childress even talks about an experimental medication for cocaine abusers that dramatically reduces the brain activity associated with craving (baclofen). Lisa would also likely benefit from medications that reduce some of the hypersensitivities around her trauma, allowing the critical therapuetic work to progress more rapidly.
• Creativty. Actually, her willingness to be interviewed for the film, and share her story with others, taps into her creative side. She wants something “good to come from [her] addiction” and long-term success will necessitate that she continue to find ways to make meaning from her prior life experiences. Writing, singing, becoming a counselor, working with youth, helping other woman get off the street – these things become catalysts for turning shame into meaning.

As an afterword, there is a website dedicated to the film where Lisa had a blog – one that ended on 10/20/08 with her having been through treatment and acheiving over a year of abstinence. She said she is going back to school to become a social worker. Since the blog entry, I can find no updates on how she is doing. My hope is that she has connected with a  long-term solution that leads her permanently away from addiction. Godspeed Lisa.

I know it has been far too long since my last post, but I honestly have an excuse – I have had no time recently to blog. Well, this is not really true, because how we spend our time is based on how we prioritize what must get done. So the more correct answer is - I could have blogged, but other things in my life took precedence.

In the recently published book Rapt: Attention and the Focused Life, Winifred Gallagher makes a case that life ultimately adds up to what you choose to pay attention to. This got me thinking about how addiction has evolved (and adapted) to our changing world, and the ways in which we are all more vulnerable to excessive (addictive) behaviors – or at least exposed to far more triggers or precursors of excessive behavior:

• Food: Not long ago I had the pleasure to hear Dr. Kelly Brownell, Director, Rudd Center for Food Policy and Obesity, speak about the link between food and addiction. In brief, his talk was shocking, sad, and made me really mad. He provided a very empirically-based overview of how the food industry, food marketers (guerrilla, viral, stealth), and chemistry explain a great deal of our current epidemic of obesity. Check out slide 71, where pop manufacturers used baby bottles to package soda – absolutely disgusting!
• Drugs: If the 60′s/70′s were about heroin/LSD/etc., the 80′s were about cocaine, the 90′s about methamphetamine, the drug-object of addiction for our current times is prescription drugs. Why? They are readily available, many believe the myth that they are safer than illicit drugs because they are prescribed by a health care professional, anyone can learn about them online, and we currently live in a culture that seeks quick fix solutions to problems.
• Sex: Advancements in multimedia technologies have been led by the porn industry. Today, anyone can act-out their fantasies in cyberspace through avatars in second life, or find their sexual cup of tea online. Sex also sells products today more than ever, and marketeers continue to up the ante in ads of all kinds. And a day does not go by that some celebrity ends up in the news for infidelity (David Letterman, Jude Law, Ethan Hawke, John Edwards, Hugh Grant, Bill Clinton – need I say more?) Is it all bad? The flip side of the coin argues that what we need in our every day lives is sexual intelligence.   
• Reality Television: The evolution of reality television has resulted in many people spending inordinate amounts of time living in illusory worlds. When people lack the development capacities to initiate, form, and maintain healthy relationships, then relationships depicted in reality shows provide an easy out. We can get caught up in the lives of those we find interesting or are attracted too – their relationships, struggles, and triumphs – and then cheat ourselves of real relationships living only vicariously through those on television.
• Social Networking Websites: Facebook, Myspace, Twitter and other social networking sites have fueled a new generation of social interactions, but research into the depth of social networks today reveals a very sad conclusion: We are becoming more and more isolated in our everyday lives. In a well-designed general social survey comparing social networks in 1985 to those in 2004, the number of people saying there is no one with whom they discuss important life matters nearly tripled! Seems like isolation may be a trigger for wanting an escape…
• Trauma: I continue to be amazed at the degree to which news makers will go to grab the attention of an audience. Traumatic, horrific, terrifying events happen every day, but now they are brought right into our living room in graphic detail via YouTube, Internet news sites, and other multimedia channels. Sure 9/11 changed a lot, but stories about children being brutally attacked, tortured, locked away, thrown over bridges and left for dead, or kidnapped, raped and held captive for years – and that is just the tip of the iceberg – how are we to take-in these violent images and stories? How are we to process them? Make sense of them? Or have we just desensitized ourselves to such stories? And how does exposure to this type of media motivate our desire to escape into fantasy?
• Time: I began this post apologizing for not blogging because of a lack of time. Despite all the new time-saving gadgets I utilize, I still don’t seem able to keep up with the pace of our fast moving society. Fast food, twitter, blazing high-speed Internet, sound bite news, packed calendars, energy drinks, and did I mentioned residential treatment for addictions in under five days? In the book In Praise of Slowness, Carl Honore challenges our way of life in the age of speed. I like both the book and his TED talk because they help us understand how the pace of our society promotes our need for quick fixes, quick releases, and quick highs. Perhaps one solution to addiction is just to slow down life.

William James said “My experience is what I agree to attend to”,  but it seems that we are increasingly living in a world where the choice of what to attend to is being made for us.

Long-term success in dealing with addiction requires more than a focus on pathology and problems. It requires time and attention to building a life worth living, where intimate relationships with people play a crucial role in happiness. It also necessitates a deepening sense of humanity, empathy for our fellow human beings, a sense of wonder, engaging our creative natural talents, and perseverance to deal with all that life throws our way. The actor, Robert Downey Jr., when asked about his addiction not long ago, said:

“Life is 70% maintenance. I think of myself as a shopkeeper or bee keeper. I’m learning the business of building a life. Instead of getting instant gratification by getting high, I push my nose as far into the grindstone as I can. The honey, the reward, is the feeling of well-being, the continuity, the sense that I am walking toward the place I want to go.”

Unfortunately, many who struggle with addiction have no idea where they want to go in life, or what they might want to create. If you are an artist or musician creativity comes with the territory, but for the rest of us -  the power of creativity can remain illusive. One reason is that the process of creating is not taught in our educational system, and in fact, Sir Ken Robinson has spoken out strongly on how our current system actually does the opposite (please watch this amazing presentation – you will not be disappointed). But all is not lost…

Recently, I picked-up a book at a bake sale that brilliantly answers the question of what we should create in our life and how to go about making it happen:  Me to We: Finding Meaning in a Material World by Craig and Marc Kielburger. These two Canadian brothers reveal through their own journeys how a focus on gratitude, empathy, and creating community leads to a life of happiness and fulfillment beyond any material possessions. From their personal encounters with Mother Teresa in the slums of Calcutta, to helping those dying of AIDS in Thailand, to creating one of the largest non-profit foundations for children, Free the Children, these guys provide the broad brush strokes for how to create a life more powerful than addiction. The essence of me to we is that by helping others we help ourselves find meaning and purpose in life – and we make the world a better place. What I like most about me to we is that it ultimately is about creating nurturing relationships with people – exactly what needs to happen if we are to move beyond addiction.

Estimates of the co-occurrence of trauma and addiction are quite high, and depending on how trauma is defined, one could argue that most who struggle with addiction have experienced some type of trauma in their life. In my clinical work, most patients had histories of traumatic events that shaped their life in significant ways, even if their present symptoms did not meet criteria for PTSD. The problem with trauma is that it is the gift that keeps on giving – but often in very subtle ways.

What I mean by this, is that when a person has experienced trauma, not only do physical changes in the brain take place that increase sensitivities to stress, but psychologically a person becomes vulnearable to future traumatic experiences – often experiences similar to the original trauma. This is because trauma is like unfinished business, it desires resolution or completion – or a way to make sense of what happened. What this looks like in everyday life is that a person will continue to repeat similar experiences: a sexually abused child will hook up with adult partners that continue the abuse, a physically abused child may find themselves in situations where they are physically abused as adults - and so on. Although each situation may appear different, the underlying theme is that unresolved trauma plays a role in perpetuating a painful life. Because reexperiencing trauma in different forms is painful, addiction becomes a powerful antidote. Thus the reason why one cannot expect good outcomes from addiction treatment if underlying trauma issues are not addressed.

As I mentioned in my previous post, the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) will significantly change diagnoses related to alcohol and drugs. No longer will the diagnosis of abuse exist, but instead we will have one category or diagnosis of problematic substance use behavior with varying degrees of severity. At issue is what to call this disorder.

Presently, the term addiction does not appear anywhere in the DSM, but instead the term dependence is used to describe behavior that traditionally invovles compulsive use, loss of control, and continued use despite consequences. Unfortunately, the term also describes a normal process that has nothing to do with problematic behavior or addiction, such as a person who becomes “dependent” on insulin for diabetes, or pain medicines for chronic pain. In these instances, the term dependence describes something entirely different than what is in the DSM. So what to do?

It sounds likely that the upcoming new version of the DSM will use the term addiction and drop dependence because of its dual meaning. Other terms  including appetitive disorders have been thrown around, but this label would require significant public education. Those who are against using the term addiction say: (1) it carries too much stigma, (2) has no clear scientific definition, and (3) is overly identified with drug abuse instead of capturing the full range of excessive behavioral problems (e.g., sex, food, gambling).

In truth, there is no perfect term, but at least addiction is a commonly used term that most understand, even if it presently is not associated with a universally agreed upon definition. I support using the term, but also believe the field needs to evolve its thinking and define addiction more broadly to include the full range of problematic behaviors that go beyond just drugs and alcohol. At CPDD speakers suggested gambling will be included in the new diagnosis, and potentially internet addiction in the near future, but sex and food – perhaps the two most powerful addictions due to their link with our survival – will likely not make the cut.

What does this mean? It means that politics win over science and many folks who need help will not receive it because insurance companies will have a reason not to pay for something if it is not officially in the DSM and/or does not have the right diagnostic codes.

This past week I attended the 71st Annual Scientific Meeting of the College on Problems of Drug Dependence in Reno, Nevada. As usual, many of the world’s leading addiction scientists attended the conference to bat around the latest ideas in the field. One of the most memorable sessions for me was focused on the work group responsible for alcohol and drug diagnostic categories in the upcoming new edition of the Diagnostic Statistics Manual (DSM5) of Mental Disorders.

Presently, problems with alcohol and drugs fall into two general diagnositic categories – abuse and dependence. It turns out that these categories are largely the product of researchers sitting around a table and theorizing, and not so much on sound science. Substantial data now suggests that these categories do not represent distinct diagnoses, but instead should be combined to reflect a unidimensional continuuam of substance-problem severity. In technical terms, factor analysis revealed they load on the same factor and using Item Response Theory suggests the curves all stack on top of each other. What does all this mean?

It means that in the new DSM5 there will be no “abuse diagnosis” and only one diagnositic category with varying degrees of severity. This brings up the loaded topic of what we call this category – an issue I will write about in my next post. But for now, I want to conclude on three points:

• Labels have power, and for years while doing clinical work I labeled folks as having abuse/dependence diagnoses. For many clients these labels took on great meaning – both positive and negative – and may continue to influence their life today. Now I learn that my labeling was likely incorrect at times, and it teaches me that perhaps we need to not forget that labels are socially constructed, even when influenced by science. What we label as a disorder may be entirely normal in another culture or time.
• We diagnose and label people largely because of politics and money. Diagnoses determine what insurance will pay for, who gets treatment, what gets researched, and how as a society we want to understand and talk about specific problems.
• Diagnoses, labels, and categories of behavior are beneficial when they link to specific interventions that have been shown to be scientifically valid.

For more details on this issue, see: Martin CS, Chung T, Langenbucher JW (2008). How should we revise diagnositic criteria for substance use disorders in the DSM-V? J Abnorm Psychol, Aug; 117(3):561-75.

Addiction comes in packages – not the type of packages you want on your birthday or for Christmas, but packages that develop over periods of time and involve excessive behavior with more than one object of addiction. Rarely in my clinical work and research have I experienced patients that struggle with only one addiction. If you abuse methamphetamine or cocaine, chances are good you have struggled with out-of-control sexual behavior. If you gamble, chances are good you also drink or smoke. If you use drugs of any kind, you likely drink and use cannabis as well.

And of course the packages usually include a lot of other issues as well: mental health problems (trauma, depression), physical health problems (chronic pain, diabetes, hypertension), and a wide range of psychosocial problems (relationships, debt, unemployment, legal problems). When we combine all the issues with addiction what we see clinically is a complex mess. What makes treatment so difficult is really understanding how all the issues interact with each other, and where to start with intervention. Many who receive treatment from a private practice clincian rely on what happens in just one hour out of 168 in a given week. Not much time to intervene when so many issues are present.

One of the best descriptions of the “packages” is a chapter written by Patrick Carnes, Robert Murray, and Louis Charpentier titled “Addiction Interaction Disorder” found in the Handbook of Addictive Disorders: a Practical Guide to Diagnosis and Treatment, edited by Robert Coombs (2004). In the chapter, the authors define 11 dimensions in which different addictions interact with each other. For example, masking occurs when “an addict uses one addiction to cover up for another, perhaps more substantive addiction.” Such is the case when a patient says “I did all those sexual things because I was high on methamphetamine.”

The key point of all of this:  to successfully intervene it is necessary to address the package of addictive behavior, and the co-occurring issues that go alone with the addictions as well. We must move away from treatments and interventions that focus exclusively on specific objects of addiction, and learn to think systemically about all of the various issues causing problems. This is why I am not a fan of certifications focused exlusively on drugs, gambling, or sex. What we need are clinicians who can treat the entire package.

Although the common theme these days is to understand addiction as a brain disease with contributing “psychosocial” factors, I believe there is a more useful way to think about this problem that directly links with how we go about solving it. Addictions are about relationships with objects instead of people. Let me explain.

In all my years doing clinical work and research, I have yet to come across anyone who struggles with addiction that does not also struggle in their relationships with people. This is because addiction typically does not happen overnight, and involves multiple reinforcing experiences that basically tell the brain “keep it up.” Unfortunately, as a person invests more time and energy into their relationship with objects (alcohol, food, drugs, porn, video poker, the list goes on) less time is spent engaging with people in healthy human relationships. The result is that important developmental skills necessary to initiate, develop, and maintain intimate human relationships become significantly constricted. In sum, many adults who struggle with addiction are child-like in their ability to be in relationships with other people.

This suggests that our treatments and interventions very often miss the mark. We focus so much energy on stopping the problematic behavior that we miss the importance of helping those who struggle developmentally catch-up. We know well from work with autistic children, trauma victims, and others, that no matter how significant the developmental gaps, we can intervene effectively and help people create intimate, emotionally mature, and nurturing relationships that take the place of object-relationships. This work is not easy, and in future posts I will provide a lot more details about the specific developmental problems we see in those with addictions, and the treatment necessary for healing.