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The Anatomy of Addiction
Overcoming the Triggers that Stand in the Way of Recovery
By Morteza Khaleghi, Karen Khaleghi
Palgrave Macmillan Copyright © 2011 Morteza Khaleghi Karen Khaleghi
All rights reserved.
Reframing the Vocabulary of Addiction
BLAME AND SHAME
Lewis came to Creative Care as many of our patients do—at the end of his rope, at the very end of hope. He was in his mid-fifties then, an intelligent and gentle man who, in spite of having already "successfully" completed several other traditional in-patient treatment programs, was unable to string together even a few months of sobriety. What he had managed to string together over the years was a series of arrests for driving under the influence and court appearances, along with mounting legal expenses. He was addicted to both alcohol and prescription medications, and he suffered from a chronic knee problem that he used to explain away his ongoing "need" for pain medications.
Lewis lived on the proceeds of a trust fund his family had set up for him through a family business. While the establishment of the fund could be interpreted as a generous act, in truth it was the result of the family giving up on him; neither his elderly parents nor any of his siblings found much of a reason to believe that Lewis would ever be able to support himself. Within his family, Lewis was a joke, and he'd learned over the years to see himself through their eyes; he couldn't take himself seriously, either. In addition to his other problems, Lewis was morbidly obese, but even in his crippling weight condition, he found fodder for jokes on himself: "Just call me 'the Titanic!'" he told us the first time we met him.
We begin with Lewis's story not because it is sensational but because, in many of its particulars, it is all too common. If you or a loved one has struggled with addiction issues, you'll likely recognize yourself in at least parts of Lewis's story: the exasperation of family, friends, and even coworkers; the periodic brushes with the law; the addict's empty promises and justifications, lack of self-esteem and abundance of health problems, repeated relapses, and the steady escalation of the downward spiral. It doesn't matter if the addiction is to alcohol and prescription medications, as in Lewis's case, or to illegal drugs, gambling, sex, food, shopping, Internet porn, or any other compulsive dependence—the results of addiction are heartbreakingly similar. And the relapse rate of addicts who are treated for their problems in traditional rehabilitation programs remains similarly heartbreakingly high—fully 70 to 90 percent of patients who complete a traditional rehabilitation program are likely to relapse within the first year.
Let us put that dry statistic into some flesh-and-blood perspective. According to the National Institutes of Health (NIH), 17.6 million adults in the United States are alcoholics or suffer from alcohol- related problems. According to a report by the Mayo Clinic, an additional 19.5 million Americans over the age of twelve abuse illegal drugs on a regular basis. Two million individuals are compulsive gamblers. The Society for the Advancement of Sexual Health (SASH) estimates that 3 to 5 percent of the U.S. population could meet the criteria for sexual addiction and compulsivity5—that's upward of fifteen million individuals6—and SASH considers that the estimate, based on the number of individuals who seek treatment, is a conservative one. Taking into consideration just these four manifestations of addiction, that's thirty-five to forty-five million real, flesh-and-blood people in the United States alone who continue to suffer, year to year, with an addiction problem. Clearly we need a more effective approach to help these people take control of, and overcome, their addictions.
Dr. K. and I have a combined total of over forty-two years implementing this more effective approach. One of the core reasons that our approach works so well is that we move quickly to relieve our patients—and, importantly, our patients' families—of the concept of "blame" or "fault" that too frequently hampers recovery. Lewis's family, for example, had long been invested in the idea that it was Lewis's weakness that caused him to drink and take drugs. They believed that if Lewis was simply more committed to his recovery and had a greater strength of character he could remain sober. But if a patient were brought into an emergency room with a broken leg, no one would blame the patient for his suffering, would they? Similarly, we do not blame—or shame—the addict for the anguish his disease has wreaked. We start by looking at addiction not from the perspective of the disease but in the context of the individual addict's life and what happened within that life that caused addiction to manifest.
Now, this isn't a revolutionary approach. Most traditional treatment programs revolve around a set of twelve steps on the order of the justly renowned twelve steps of Alcoholics Anonymous (AA). Counselors in these programs help their patients to focus on their subjugation to alcohol, take a fearless inventory of themselves, and seek "through prayer and meditation to improve their conscious contact with God," as each individual understands him or her. And AA, too, approaches addiction with the sort of compassion that is so necessary to healing ("At my own first meeting in 1982, I felt as shy as Boo Radley, having lived for years in the dark basement of my addiction and shame"), helping the addict emerge from the shadow of disgrace and dishonor his disease has likely cast over him and into the forgiving (and self-forgiving) frame of mind in which renewal can happen. This twelve-stepstructure has proved to be so successful that, indeed, it is an essential part of the treatment we provide at Creative Care; it is also our heartiest recommendation for a long-term sobriety strategy to our discharged patients. It provides the patient with a support system in the form of daily meetings and sponsors that can be key to sustained recovery.
But the twelve steps, as critical and key as they are, are rarely the answer in and of themselves for most addicts. The problem is—and this problem is made stunningly clear in the indisputably dismal relapse rates—that the examination of a client's emotional history prescribed in the twelve steps does not go deep enough. And, all too frequently, it doesn't even touch upon underlying physiological or psychological issues that, left untreated, will sabotage sobriety as surely as night follows day.
But we don't want to get ahead of our story. In order to help you understand the approach that has proven to be so effective at Creative Care, we need to spend a few pages on the vocabulary of addiction, reframing and reforming the language that most of us have used in the past to define addiction and its treatment. There are three phrases to which we want you to pay particular attention because they represent three key concepts to helping our patients—and your loved ones—become free from addiction: cause and effect, dual diagnosis, and locus of control.
CAUSE AND EFFECT
By the time we make it through the first month or so of first grade, most of us have a pretty keen grasp of what happens if we don't study for our spelling tests. Chickun. Tabel. Perple. In short order, we come to understand that to raise our test scores, we must study. We make the connection between preparation and the big red grade mark at the top of our paper.
Causality is the relationship between one event (a cause) and a subsequent event that is a consequence of the first event (an effect). Although we may not consciously think about our everyday lives in quite this way, we spend much of our time learning about and negotiating the delicate, ongoing balance between cause and effect. The effects of our actions can be positive—you bring your wife a bouquet of her favorite flowers for no reason other than you know it will put a smile on her face. Or, we may do what we do simply to avoid a negative situation—no matter how tired you are when you get home from a day at the office, you make time to take the dog out for a walk because none of us likes to deal with the consequences of a cooped-up canine. Either way, in these simple examples, it's easy—intuitive, really—to grasp the connection between our behaviors and the results we can expect from them.
But what happens when the situation we're talking about becomes more complicated? Say that you're a first-grade teacher who has used up just about all of your patience admonishing a bright student who, if only she'd spare a few minutes every evening on her weekly spelling word list, would absolutely get better grades than the 60s and 70s she has been pulling in. As a teacher, you want to reinforce the connection between effort and result, right? But let's say that you are a teacher who is very good at what you do: You want to know what it is that prevents your bright students from success. What you find out is that the child is unable to spend those few minutes at home in the evenings concentrating on her word list because her parents are fighting all the time, yelling at each other so she hears them even when she retreats to her own room; her home is not a place that's peaceful and conducive to concentration. What is cause and what is effect suddenly becomes just a little more problematic.
Our conventional thought process is linear. It moves as if there is only one direction in which to go: forward—that is, one thing following upon another. If I do Thing A, then Thing B will happen. As a first-grade teacher, you might begin your attempts to help your underachieving student by thinking in a conventionally linear way about the student's poor spelling-test results—and there's nothing inherently wrong with that. It's clear, linear thinking that gets us through most of our ordinary daily routines—it allows us to, say, recognize that if we don't fill up the gas tank in our car before we head out on a long road trip on I-90 (Thing A), then eventually we'll be stuck sitting on the side of the highway waiting for a tow truck (Thing B).
But a smart teacher will quickly recognize that she began her analysis with the wrong Thing A. It wasn't the lack of good study habits that led to her student's dismal spelling-test grades; it was the lack of a favorable home environment that kept the student from being able to study, which then led to the student's failing marks. That is, the lack of studying wasn't thecause of the student's bad grades—it was the effect of a traumatic situation in the student's home. Now—here is the crucial part—the teacher could have cajoled, insisted, and warned the student to study until her voice was hoarse, but if the home situation wasn't addressed and altered, the student would likely have fallen further and further behind because she wouldn't ever have had the opportunity to sit peacefully with her homework assignments.
The teacher in our example was able, through training and experience, to alter her thinking pattern and drill deeper into the situation in order to be of real help to her student. But the conventional thinking about addiction is often haplessly, stubbornly linear—and nearly always starts off at the wrong Thing A.
Societies at large, as well as addicts themselves, their loved ones, and many of the physicians and therapists who treat them, think of addiction as a cause. Because of a person's addiction, he or she can't keep a job, can't sustain relationships, suffers increasing and/or chronic health problems, and brushes up again and again against the wrong side of the law.
Of course, all of these problems may well be part of an addict's life. In fact, it is rare to find someone who is, for example, an alcoholic or a habitual gambler who enjoys long-term employment, a strong marriage, excellent physical health, and a clean police record. But simply putting an addict through his detox paces in a conventional 28-day rehabilitation program is a recipe for relapse. Assuming that an addict, once free of physiological addiction and well schooled about how harmful addiction is in general, should be able to return to the larger world and acquire all of those elements that we traditionally think of as composing "the good life" is setting him up for failure.
The reason that the relapse rate is a shocking 70 to 90 percent for patients who have completed conventional treatment programs is that most conventional treatment programs view the nature of addiction from an old-fashioned perspective—as a physical condition not unlike heart disease or diabetes. As a result, these programs ask the cause-and-effect questions of addiction in a superficial way. At Creative Care, we turn around the conventional thinking and start our inquiry into a patient's recovery by focusing on her addiction as an effect. We ask what happened prior to the addiction that caused the patient's need to compulsively—self-destructively—self- medicate. Can the addictive behavior be traced to a life trauma—the death of a parent at a young age, perhaps, or combat duty in the military? Both of these traumas can precede a diagnosis of post- traumatic stress disorder (PTSD). Is the addictive behavior the result of—or exacerbated by—a preexisting psychiatric disorder, such as bipolar disorder, depression, or schizophrenia?
Getting to what happened in a patient's life prior to the manifestation of addiction is not simple or easy work. When patients first come to us, they are nearly uniformly fixated on the here and now of their physical pain and are connected with their emotional pain on merely a surface level.
Let us propose an example that will give you insight into the sort of profound disconnect we are talking about. Let's say that you work for a company that uses annual employee evaluations to determine issues of salary and promotion, and you have just received an unexpectedly negative evaluation from your supervisor. How will you handle the negative emotions generated by the bad review from your boss? Will you dig in and redouble your efforts to do the job right? Or will you huff out of her office and into the nearest bar to soothe your hurt feelings with a glass of wine? And, in either case, will you understand the connection between the emotions you're feeling and the manner in which you are reacting to them?
Although your desire for a glass of cabernet in this instance may not in itself indicate an addiction issue, it can serve as a peek into the addict's dilemma. How many times have you said—or heard someone else say—that you "really need" a drink after a hard day at the office? Making such a statement is making a conscious connection between a stressful situation and your need to take action to immediately relieve the pain of it.
Stress relief does not ideally, of course, come in the form of a glass of wine. The iconic commercial tagline, "Calgon, take me away!" is an almost breathless voice-over to accompany the visual of a harried mom slipping gratefully into a bathtub full of bubbles. A bath is a different form of stress relief, but the commercial makes an unmistakable connection between the events of a difficult day and reprieve.
For an addict, the connection between cause and effect, pain and relief, is rarely, if ever, so clear. When a patient first comes to us, he is unable to make the connection between how he feels and how he behaves. He simply knows that he is in pain and that the pain is intolerable. His life's focus has become to mask the pain through drugs, alcohol, or other addictive behaviors. Our job is to help the patient, and his family, connect the dots between the emotions he is feeling—or, even more accurately, has spent a lifetime avoiding—and the behaviors he is exhibiting.
While this work is neither simple nor easy, it is often exactly the work that the patient himself is crying out to do. When Lewis first came to Creative Care, for instance, he had a lot of why s on his mind. Why, even after so many attempts at rehabilitation, had he been unsuccessful at staying sober? Why did he keep hurting himself with alcohol and prescription medication—and food? Why had he been unable to keep the promises he made to his parents, his siblings, and himself? Like many of our patients, Lewis knew intuitively that there were questions that required answers, but he had only a vague notion of what they might be. Like many of our patients, he put the blame for his current family and health and legal problems squarely on his addiction. Our job was to help him see that he was starting with the wrong Thing A and to take him back a bit further on his life's road to uncover the real whys that were tormenting him. (Continues...)
Excerpted from The Anatomy of Addiction by Morteza Khaleghi, Karen Khaleghi. Copyright © 2011 Morteza Khaleghi Karen Khaleghi. Excerpted by permission of Palgrave Macmillan.
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