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A Tough Childhood Can Have Lifelong Consequences: Better Understanding Trauma

Trauma by any other name

Think of the word trauma. What comes to mind? I’m guessing that many of you are thinking of combat veterans, sexual assault survivors, or folks who’ve experienced disasters like car accidents, fires, or shootings. You are absolutely correct!

This narrow definition leaves out a lot of people though. Trauma also includes those of you who experienced neglect or divorce, who witnessed violence, substance use, or mental illness, who dealt with the incarceration of a parent, or who survived any kind of abuse or family instability.

If for any reason you ever experienced the world as an unsafe or dangerous place for an extended period, then you have experienced trauma.

Thankfully, most of you came out pretty much unscathed, maybe even stronger because of it. You might even be able to laugh about some of the things that happened to you.

Some of you, however, continue to experience life as an endurance contest. You can’t control your emotions. You’re easily angered or hurt. You’re often sick or just not feeling 100%. You find it hard to take care of yourself. You struggle to maintain healthy and fulfilling relationships.  

Some of you might still experience the world and other people as dangerous or unsafe. You might even secretly view yourself as damaged goods.

Adverse childhood experiences

It wasn’t until the 1980s that physicians and researchers began to examine the connection between so-called adverse childhood experiences (ACEs) and adult health issues. Things like anxiety, depression, substance abuse, obesity, troubled relationships, among others, were correlated to childhood experiences unacknowledged and certainly unexamined.

Even one of the lead ACE researchers, Vincent Felitti, stumbled accidentally on this line of study. He was performing a standard intake with an individual in an obesity program when a Freudian slip launched him into studying the ill-effects of childhood trauma.

Rather than ask the client, “How old were you when you became sexually active?” he mistakenly asked her, “How much did you weigh when you became sexually active?” Her response: forty pounds.

She tearfully revealed that she was raped by her father when she was four years old. His eyes opened, Felitti began connecting the dots: a traumatic childhood correlates to an unhealthy adulthood.[i]

Over time, ACEs have been segmented into 10 buckets:

  • Physical abuse
  • Sexual abuse
  • Emotional abuse
  • Physical neglect
  • Emotional neglect
  • Mother treated violently
  • Household substance abuse
  • Household mental illness
  • Parental separation or divorce
  • Incarcerated household member 

The more commonly cited post-traumatic stress disorder, however, excludes a majority of these ACE categories. PTSD, you see, is only diagnosable in individuals who have experienced actual or threatened death, serious injury, or sexual assault. There currently is no accepted category in which to place individuals grappling with the lingering impact of childhood trauma.  

Only within the last ten years have researchers and clinicians suggested broadening the definition of trauma. The proposal for developmental trauma disorder would include those who have “experienced or witnessed multiple or prolonged adverse events over a period of at least one year beginning in childhood or early adolescence.”[ii]

That’s academic lingo for having a tough childhood. 

If you're interested in learning your ACE score, here is an article from NPR that includes the quiz and information about what it means and doesn't mean to you. 

Trauma lingers on

The emergence of a new understanding of trauma is important for a few reasons. First, adverse experiences impact brain development. Trauma lingers because it literally changes how your brain functions. Because of physical changes resulting from trauma your self-development is changed. Your ability to reason and process information is altered.

From a biological standpoint, trauma affects how your limbic region functions. It modifies how your hypothalamus, pituitary, and adrenal glands regulate cortisol. It also disrupts neurotransmitters associated with arousal and endogenous opioid systems. These can contribute to a lifetime of anxiety, frustration, misunderstanding, fear, isolation, and ill-health.

Human beings are adaptable animals and most of you who live through adverse experiences find healthy and manageable coping strategies. You grow up to lead productive and fulfilling lives. However, humans are individually unique. Not all of you respond in the same way to stress.

Because of individual, genetic, or environmental circumstances you each respond in a singular way. Plus, research has shown that individuals who experience a greater number of ACEs face an increased likelihood of health problems later in life.

Interestingly, even those who exhibit identifiable negative symptoms (depression, emotional instability, substance abuse, etc.) develop coping strategies that help them survive. But a fulfilling life is about more than mere survival.

There is a necessary and vital distinction between merely surviving and thriving.

A focus on sheer physical survival, a largely unconscious process managed by your limbic system, can hinder your emotional, physical, and cognitive abilities. Your brain can help you to cope with adverse experiences, but doing so requires energy.

And energy devoted to survival cannot be diverted to activities associated with living a more fulfilling and thriving life. These might include things like practicing healthy eating habits, enjoying meaningful hobbies, or developing close friendships.

Until you have reprocessed and cleared the lingering impact of trauma there is a greater likelihood that you will not experience the fulfilment of leading a thriving life.

Thankfully, trauma is a treatable condition. In fact, there is increasing anecdotal evidence that working through trauma leads to what is known as post-traumatic growth. The rewards of working through the darkness of trauma far outweigh the reality of merely surviving another day.

In my next post, I will explore some of the ways that childhood trauma affects you in adulthood.   

[i] http://www.huffingtonpost.com/jane-ellen-stevens/the-adverse-childhood-exp_1_b_1943647.html, as viewed on July 13, 2017.

[ii] Bessel van der Kolk, MD, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, Viking, 2014.

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In-Betweenness

The actor Stephen Tobolowsky, whom you might remember as Ned Ryerson from Groundhog Day, remarked during a recent interview that he believes humans “don’t look for happiness in life.” Instead, he believes, we want to feel complete. This rang true for me.

Moments of completeness are joyous and painful, and everything in between, and they always feel accurate to my lived experience. However, these moments are, as is their nature, transitory. They end and humans invariably seek ways to sustain them, even if those strategies sometimes are unhealthy.

At the same time, the feeling of incompleteness we seek to avoid or change also is temporary. In other words, we exist in a state of in-betweenness: between thought and action, between yes and no, between cultures we adopt and those we are born into, between yesterday and tomorrow. We are always coming or going, almost always never arriving, a dizzying experience to be sure.

With practice, however, it is possible to gain one’s footing. Awareness of this in-betweenness and reflection upon it leads towards something resembling acceptance or better yet, equanimity: a calmness during difficulty. I can’t know everything. I can’t do everything. I can’t be everything. And thank goodness for that!

There are moments when action is required and moments when it is necessary simply to be, and most of our time is spent somewhere in-between. The desire to feel complete might be innate, as I think Tobolowsky believes, or not, I just don’t know. What I do know is that the tension emerging between completeness and incompleteness is what propels us forward in our lives.

It is the pulled string on a bow that pushes the arrow forward. It is the equanimity of the bowstave that allows for this action to occur. The arrow does not know the difference, nor does it care. It simply needs both to begin and end its journey.

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Trauma and The Perks of Being a Wallflower

The Perks of Being a Wallflower was published in 1999 and released as a film in 2012. I am fond of coming of age films so this was a perfect choice for some solo movie-watching while my wife was out of town this past weekend. The movie had been recommended to me before and I’m happy I finally watched it.

Emma Watson’s barely passable American accent aside, the movie worked for me as a nostalgia vehicle. Funny, sweet, revealing, honest, dramatic without being too serious or dogmatic, and all under 2 hours: perfect for a night at home with the dogs.

After watching it, I jotted down some of the human needs the film highlights. These are universal needs, I believe, but some are specifically necessary for the journey one begins when healing from trauma. I thought I would share with you some of my thoughts.

To Need is Human

The film focuses on a group of well to do misfits who band together in a nearly adultless world of wealthy Pittsburgh. The protagonist is Charlie, a high school freshman not looking forward to high school. The viewer is made aware of some unknown traumas in Charlie’s life, but nothing is made clear until the film’s conclusion.

The first thing I appreciated about the film was Perks’ insistence on the need for connection. To survive and be our best selves we need others. Relatedly, we need understanding and unconditional positive regard. The film’s kids press against the boundaries of their lives to assure themselves of their support for one another. Charlie, in particular, begins his healing journey by finally having these needs met.   

We also need novelty, especially when we’re teenagers. Even more than that, as kids we need to take risks. The Wallflowers take chances that rightly should be frowned upon by adults; that’s part of our job description! Yet, risks help adolescents feel alive as individuals and as a group member.

The Wallflowers exist within a world of self-acceptance and acceptance of difference. Supporting one another as they try to make sense of their world, these kids create fertile ground for personal growth. We cannot go it alone in this world. We need support.

Adults in the film, like any good teen flick, are ancillary. And yet, they are integral to these kids’ lives, particularly Charlie’s. Perks confirms that we need attention from our elders even as we seek, as teens, to distance ourselves from that attention.

The English lit teacher who feeds Charlie classic texts is necessary to his development of future goals, yes, but he’s more than that. He confirms Charlie’s presence. He witnesses Charlie’s uniqueness. We need to be seen. We need to be noticed even if that attention is negative, a strategy sometimes employed by those who experience neglect.

Trauma’s Demands

Looking specifically at Charlie’s trauma, the film underscores a few key healing ingredients. First, we need to share our pain. Details are not necessary. We do not need to relive trauma. We just need to know that when reaching for comfort there is someone there for us.

This also underscores a vital component of trauma work: we need to be believed. Perks did a nice job of this. Charlie’s admission of need was belated, as it so often is for trauma survivors, but when he finally revealed his hurt he was believed by his friends and his family. To be believed makes connection more likely.

Charlie initially denied his truths, a rational defense against the pain created by them. Ultimately, however, he realized that the effort and energy it takes to live in denial exacts too great a price. Why not find others who are willing to hold it with you? Charlie was lucky because he did find others he could turn to, hold onto, and rely upon. Not all of us are so lucky.

Also important in trauma work is normalizing one’s experience. Put another way, we need to identify with others. Believing that we are ok precisely because we are similar to others is crucial for all of us, but particularly important to those who have experienced trauma.   

The film also affirms the importance of art and its ability to connect us to something bigger than ourselves. To fully heal, we need to transcend our limited and limiting experiences. The paradox, of course, is that we can more fully accept our finitude when facing the sublime. As Charlie reveals in a voice-over, when in the presence of beauty and communion with his chosen family, “And in this moment, I swear, we are infinite.”  

We Can Be Heroes

Finally, Perks drives home one final point worth mentioning: we need heroes. The film is not subtle in this point, but neither is adolescence. The so-called tunnel song, which these hip kids (unbelievably) don’t know is David Bowie’s “Heroes,” is a song that addresses the powerful and limited nature of our historical existence.

We don’t have forever, but we can find pathways connecting us to something bigger than ourselves even, or especially, during turbulent moments in time. Under threat – and adolescence sometimes feels like an extended trial of existential threats – we can reveal ourselves and be fully present with Others.

Vulnerability is scary, but it takes guts to reveal ourselves to others. Heroes succeed because of their vulnerability, not in spite of it. And it’s important to remember that heroes don’t need to be superhuman. Heroes are our friends, family members, loved ones, elders, and sometimes even strangers. The most heroic among us also are the most human.  

The infinite, revealing nature of connection – whether with others, with art, or with our own experience – it turns out, is a perk of being human. We can rise above shame and uncertainty when we feel connected, when we feel seen, believed, and understood. In connection, we can become the heroes we and others need in this world. “We can be heroes, just for one day.”

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Holiday Tips for the Lion's Den

The holidays are upon us. That time of year when personal, familial, and cultural expectations collide.

An earlier post explored the topic of expectations as a thread connecting holiday stress and unhappiness. So, this year I thought I would focus on a short simple list of things to keep in mind as many of us migrate homeward.

This year might be particularly tricky for some us because of the recently ended presidential election. I would like to believe that family and friends always will respect and honor everyone’s current circumstance. Alas, we do not live in such a rarefied world.

For those of you walking into the lion’s den this holiday season I submit the following short list of suggestions to consider:

1) It’s ok to change the subject if you are uncomfortable with a conversation. Even if you have a strong and well-reasoned opinion, the holidays might not be the best time for its unveiling. Deciphering the direction of a conversation is difficult, but here are three approaches that might be helpful:

a) Pay attention to your body. Is your heartrate increasing? Are you starting to sweat? Are you noticing specific physical sensations (e.g., tightness, numbness, tingling, pain, etc.)? Are you beginning to fidget and move around?  

b) Pay attention to your thoughts. Are you thinking only of your response? Are you thinking of ways to humiliate someone? Is your mind racing? Are you thinking of historical hurts? Are you thinking that your relatives “always” do this to you?

c) Pay attention to your emotions. Are you getting angry? Are you experiencing sadness? Do you want to cry or scream? Are you feeling overwhelmed? Are you flooded with a symphony of contradictory emotions?

If you find yourself answering yes to any of these questions, it might be time to talk about sports or the weather!

2) It’s ok to disengage and/or detach for the moment if you are experiencing discomfort and your attempts to change the subject are not working. You also can feel free to disengage or detach if you simply decide it’s unsafe to do anything else.

Disengagement can take many forms: not participating in a conversation, leaving the room, playing with a pet or any children that might be in attendance, or taking a walk. A favorite of mine is volunteering to help someone. Don’t just sit there, do something!

In some cases, simply declining an invitation to attend an event might be the best strategy.

3) It's ok to prioritize your needs if you believe that others will not respect you or your opinions. Some of us come from families in which gaslighting or bomb-throwing are par for the course. In these instances, it might be necessary to honor your health and well-being by surrounding yourself only with loved ones who support you, no matter what.

Prioritizing your needs could mean missing a family event or double-booking yourself. It might mean verbalizing your decision to not engage in a difficult encounter. In my opinion, anything that allows you to focus on your own well-being, and does not harm others, is justified in moments of stress.

Does it need to be said?

Finally, I’ll offer one more simple suggestion. If you find yourself in a hairy situation with no means of escape and you’re considering jumping into the drama at the risk of your own sanity, ask yourself these three questions: Does it need to be said? Does it need to be said now? Does it need to be said by me?

I learned these questions from friends in Al-Anon as a strategy for maintaining emotional sobriety. Luckily, they are questions that are invaluable for anyone and everyone. Reflecting on the questions allows you to distance yourself from the scrum. The answers sometimes are secondary.  

And if all else fails, simply remember that all of us make mistakes over and over again. That’s how we move towards change. David Bowie’s 1977 song, “Always Crashing in the Same Car” is a moody song celebrating this all-too-human foible. Have a listen and remember that even David Bowie wasn’t perfect, close, but not perfect. 

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The Power of Paying Attention

“Pay attention to that.”

I often say this to my clients. It’s a helpful strategy if practiced with consistency and patience. It can provide valuable information for accessing strength and clarity.  

Paying attention can aid in decreasing one’s anxiety or the impact of depression. It can help improve one’s relationships and introduce a way to tolerate the discomfort of stress. It can provide the space for an addict or alcoholic to make healthy choices. 

You’ve Got Skills

As soon as we take our first breath, we have attentional skills. We have an innate ability to turn towards care and to cry when we need nurturance. Growing up, we can laugh and play with wild abandon and know when to move away from scary situations. We can access protective rage in dire situations and bring focus to our loved ones during intimate moments.

These emotional systems provide us with automatic survival tools. Instructions are not included because, if all goes well enough, these skills just flow. However, many of us lose contact with these inner reserves too early in our lives. This can be the result of genetics, personal physiology, or unhealthy environments.

In time, just about all of us grow alienated from or uncomfortable with some of these inborn skills. We turn away from “simple” things and focus on the uniquely modern needs that require higher order rational thinking: school, careers, relationships, family, communities, health.

We learn how to pay attention to external factors with our executive functioning, but forget to check-in with ourselves to see if what we’re doing is a good fit for us. Thankfully, we can change our behavior.

By turning towards what matters most to us we can grow stronger. Our cognitive abilities, the very same ones that can lead towards obsessions with success and power, can help us to be more mindful. We can choose to tune into our sensations, our thoughts, our beliefs, our actions, and our feelings.

With intentional practice, we can deepen our connection to ourselves and the world around us. We can reconnect with those always flowing emotional systems simply by reminding ourselves they exist. We can do this simply through paying attention.  

How to Pay Attention

When I encourage clients to pay attention I’m not asking them to spend hours each week meditating on an issue. In fact, my suggestion sometimes is made in passing. I simply want to draw awareness towards an action, a feeling, or a thought that might otherwise be rote or unconscious. 

I want my clients to be curious about their own lives. I also want them be more tolerant of the distress that is part and parcel of the human condition.

The practice of paying attention can begin simply. In a moment of your choosing, simply notice the sensations you’re experiencing, the thoughts or images popping into your mind, or the feelings arising in you. This three-part approach (sensations, thoughts/images, feelings) is simple, but complex.

A client might notice that she consistently tightens her shoulders when we discuss her family of origin. Normally, this movement would go unnoticed. From this one simple observation, it’s possible then to focus on the thoughts connecting this movement and this topic.

Identifying emotions can be daunting, but exploring one’s thoughts is a fantastic way to move closer to an emotional experience. I’m always aiming for emotion because I find this experiential approach transformative for clients.

Otherwise Known as Mindfulness

Being conscious of sensations, thoughts, and feelings is necessary for becoming more mindful. These data provide an object on which to focus one’s subjective attention. With sustained and intentional focus, we are better able to understand our motivations and formulate thoughtful actions.

I use the phrase “pay attention” for two reasons. First, because while paying attention is being mindful, mindfulness is more than simply paying attention. Second, I just find the phrase itself to be more inviting.

Imagine you’re nearing the end of a session and you mention something important to me. Which would you rather hear, “pay attention to that” or “be mindful of that”? Personally, I’m more drawn to, and less intimidated by the former.

Whatever label we apply, the goal is same: becoming more aware of ourselves as intentional creatures. 

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Addiction: Just Problems

Thus far, I have explored the topic of addiction and broken it down into (hopefully!) understandable stages, Fun and Fun with Problems. In the final post of my addiction series I will review the stage I like to call, Just Problems.

When the only thing you can count on is trouble it might be time to pay closer attention and take stock of your circumstances. When the fun stops, the end is nigh.  

Mission: Possible

The occasional headaches resulting from problematic substance use are controllable. Given enough rope though an individual with a substance use disorder will cross that invisible line into addiction. And to survive, she will circumscribe her world into ever smaller and unhealthy compartments.

As a result, individuals in the throes of substance abuse lose things that are known to contribute to a fulfilling life: friends, family, freedom, meaning, economic security, physical health, self-respect.

These losses are mourned, but easily rationalized away. “I never liked that job anyway.” “He didn’t love me the way I wanted him to.” “Everyone in my family has liver problems.” “I needed to lose some weight anyway.” 

However, and this is part of the insidious nature of substance abuse, as losses mount there is always a panacea to offset them. Addiction is an infinity loop that veers wildly between extreme highs and lows. When you’re in it though, it’s hard to see any other reality.

To an outside observer this is crazy. Just say no! But to an addict the mission is simple, straightforward, and obtainable: get high no matter what.

What Problem?

At this stage of the game, as discussed in an earlier post, an individual’s substance use is no longer simply a conscious choice. The brain’s short-cut, it’s “chunk” of time- and energy-saving efficiency is in full control: I don’t like how I feel…When I don’t like how I feel, I use…When I use I feel better… Problem solved!

An addict’s “better,” of course, is a relative term that describes only feeling different than she did when her craving was cued. And craving is triggered by just about any cue, good or bad, at this stage. If gone unchecked, the once perfect solution, the once unassailable resolution to any uncertainty or conflict delivers the addict further into the final stage of addiction and for too many people, closer to death.  

What starts out as a novel way to kill time and hang out with friends becomes a means to address something else entirely, an unquenchable craving that appears to have only one answer: more! The paradox of addiction is that this reward-seeking behavior, a once rational attempt to change how we feel, can kill us if gone unchecked.

For those who enter this late stage of addiction life is unbearable, both for the addict and those around her. Nothing goes right. Everything is wrong. The losses outnumber the wins, but the brain is focused only on earning its reward and easing the pain associated with not using.

Addiction in its final stage is like Kevin Bacon’s character in the film Animal House trying to reassure the panicked homecoming parade attendees that all is well. No matter how sincere is our attempt to put on a game face, sometimes we’re just gonna to be flattened.

Why does this happen?

Addiction in my experience is iatrogenic in nature, an illness caused by the treatment of another affliction. Iatrogenic addiction normally refers only to that caused by healthcare professionals. The classic example being opioid addiction resulting from pain management.

In my experience, however, only in rare instances is substance abuse disorder the sole presenting issue. It more often than not is comorbid with another mental health concern such as anxiety, depression, traumatic stress, unresolved grief, schizophrenia, etc.

Individuals who find relief of some kind through substance use are not just looking for a good time. They are self-medicating.

Substances that once introduced you to awesome experiences and saved you from unacknowledged demons could be the thing that kills you in the end. This is dramatic language, but struggling with an untreated mental health issue can be unbearable even before adding drugs and alcohol into the mix.

Substance use might allow you to bear it for a brief time, but the cost is steep and the payback fleeting. Surprisingly, the causes of addiction are not germane to the brute phenomenon that is addiction. Origin stories are interesting, sure, and also pointless when helping someone regain control of their life.   

Here’s what is important to know: substance use patterns and the ability to control usage change over time. Cues to use creep from conscious choice to something more ingrained, involuntary, and unconscious. Life becomes smaller and less enjoyable. The only thing that provides escape is the very thing that might be killing you.

Recovery From a Hopeless State of Mind and Body

How then do you address the intractable state of being that is addiction? Recovery from a hopeless state of mind and body should be a no-brainer, right? If only that were true.

For those of us with personal experience of it, addiction is a killer, yes, and it's also a pain in the ass. Relapse, manipulation, illness, chaos, loneliness: it’s messy and recovery rates are abysmal.

Despite this reality, recovery is possible. In fact, if an individual is willing to be honest with herself recovery is entirely probable.

There are many recovery paths, from abstinence to harm reduction/moderation management. For anyone who has entered the final stage of addiction I personally believe that abstinence is the best choice. For those not as advanced in their addiction, harm reduction can be a plausible and logical approach.

For now, suffice it to say that there is a solution for everyone, even if that solution is different for everyone. Two necessary threads that characterize successful recovery of any type are honesty and connection with others. Humans, after all, are social creatures.

In order to heal from a condition that isolates us and lies to us it’s necessary to replace separation with relation. White-knuckling it alone at home is not worth the trouble. It’s one reason why too many in recovery return to substance use.

Recovery cannot be focused solely on losing a relationship with a substance though. Recovery must be about living life to the fullest. It must be about tolerating the stress of daily life and paying attention to what really matters to us. It must be about accepting ourselves and others, no matter what.  

To highlight the seductive power of addiction I’ll leave you with the song, “Golden Brown,” by The Stranglers, a song that sweeps you away however you interpret it. 

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Addiction: Fun with Problems

In parts 1 and 2 of my addiction series I explored the broad concept of addiction and the early stage that I called simply, Stage Fun. Both posts included descriptions of the negative consequences of substance use and addiction.

Below, I discuss other kinds of problems and how they emerge as one progresses further along the addiction continuum.

What is Choice?

A common client refrain in the addiction field is that substance use is a choice. I agree. Yet there is more to the story than a rational yay or nay. Choice is in play during one’s early use, but over time dopamine plays a starring role in influencing choice. This is because of the jolt it delivers to the human brain as a result of substance use.

The brain of a substance user moving along the addiction continuum is like a child who after being spun through the air enthusiastically demands, “One more time!”  

We know that for some the choice to use becomes more automatic. For these individuals it is less than a fully formed rational decision. It begins to resemble something more akin to a knee-jerk reflex.

The choice to use might once have been the end result of mulling options to a straight-forward and innocuous question like, what shall we do this weekend? But over time your brain, being the genius that it is, notices patterns and seeks to simplify whatever process is in play.

The brain is an efficient system and loves shortcuts. It will eliminate conscious decision-making to save energy whenever possible. In time, the decision to use is almost instantaneous and addicts simply assume that a conscious choice was made.

Bad habits are hard to change

Margaret Wehrenberg refers to the brain’s ability to simplify complex operations as “chunking.” A chunk of information is basically a habit, “a complete and automatic set of actions that occur without conscious decision.”

Substance use evolves over time to become a habitual action for too many of us. Information is chunked together without our conscious awareness and we act accordingly. The addict eventually begins to rely on substance use to regulate an ever increasing assortment of life experiences: good, bad, or indifferent.

Most of us like to entertain the fiction that we are the captain of our own ship, that we are intentional and methodical at all times. But as one moves further along the addiction continuum choice is not as simple as saying I will or won’t do something. There are competing and unexamined forces at play.

What begins as fun morphs into an unconscious habitual solution to personal struggles. Given enough time this habit becomes an all-consuming need, a craving that dictates our choices and behaviors.

Phenomenon of craving

Dr. William D. Silkworth, who treated Bill Wilson, co-founder of Alcoholics Anonymous, at Charles B. Towns Hospital in New York City, wrote in “The Doctor’s Opinion,” in Alcoholics Anonymous, that all alcoholics “have one symptom in common: they cannot start drinking without developing the phenomenon of craving.”

Craving, in my opinion, is evidence of the inability to drink or drug safely. When activated, it subsumes all else. Craving is the internal driver that pushes alcoholics and addicts to consume. As the saying goes, “one is too many and a thousand is never enough.”

It can manifest silently or loudly, but one thing is certain, when craving enters the picture we have exited Stage Fun and entered Fun with Problems. We no longer want to enjoy our chosen substance, we need it.

Substance use is characterized by avoiding at all costs the experiences associated with not using. In other words, at a certain point in most addicts’ stories, use is no longer simply about getting loaded. Instead, the urge or craving to use is rooted in the avoidance of negative psychological and physiological consequences that emerge when one chooses not to use.

Our brain, once it grows accustomed to the rewards of using drugs and alcohol, learns that throwing a hissy fit (moodiness, impatience, anger, judgement, self-righteousness, etc.)  is a good way to get what it wants: an altered reality (and dopamine!).

Like everything else in addiction, craving is a double-edged sword. It propels one further into addictive processes and therefore is a negative force. Yet by encouraging use, craving protects the addict from experiencing the not so pretty consequences of withdrawal.

99 Problems

Addiction also unleashes real world negative consequences, things like: jail, injury, illness, death. These can happen early for some, but over time the process is fairly predictable. We begin to hurt loved ones, lose friends, suffer professional setbacks, face legal troubles, lose self-respect.

The further one travels into addiction the more one loses. As substances take priority, other things must fall by the wayside.

Some substances have the potential to speed up this process of loss, but the progression is the same despite the timeline. Yes, there is a qualitative difference between some classes of drugs, but just because it can take alcohol decades to destroy a life, does that make it less destructive?

Despite initial losses during Fun with Problems the benefits of use, for addicts, still outweigh the deficits and it’s “easy” to ignore such problems for many years. The brain tricks us into believing that despite the horror around us, substance-induced oblivion is the best option available to us. It provides an identifiably consistent answer to any question asked of it.

Individuals with so-called “high bottoms” are willing to address problems associated with the fun of substance abuse prior to losing as much as others who hit rock bottom. They don’t need to lose everything in order to change course. Thankfully, as addiction education has become more prevalent and substance use is less stigmatized there are more people who fit within this category. I wish the numbers were higher.

So, about that river in Egypt….

Because of the mind’s ability to wield powerful psychological tools like denial it’s easy for addicts to ignore the complex operations at play in their mind. This is especially true as long as substance use continues to provide relief.

We as a culture like to believe in our ability to look beyond appearances, but it’s too easy to assume that if someone looks good, they must feel good. One’s insides always match their outsides, right?  

The term “functional alcoholic” describes individuals who outwardly are meeting society’s markers of success. If major responsibilities are met the psychological or interpersonal consequences of addiction can easily be rationalized away as stress, poor nutrition, lack of exercise, insomnia, or some other real, but wholly inadequate explanation.

When living in the Fun with Problems stage this perception is one of the trickiest knots to undo, even for the addict herself. “I can’t have a problem. I’m still paying my bills. I’ve got friends. My family loves me.” All of these things might be true, but that doesn’t mean there isn’t a problem.

Unfortunately, many of us only become willing to admit to a substance abuse problem when Fun leaves the equation and we only are left with Problems. In my next installment, I’ll explore this final stage of addiction.

For now, here is one of the more devastating songs about addiction, Robbie Fulk’s “Barely Human” from his album Country Love Songs.

 

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Addiction: Stage Fun!

Why do substances like drugs and alcohol work so well? Because as a broad class of consumables they have the ability to meet any need or desire. They are perfect in their chameleon-like ability to match, intensify, or alter one’s state of mind or being.

We can get mellow, relaxed, speedy, intense, spiritual (whatever that means!). We can hallucinate, laugh, lose touch with reality. We can (finally!) enjoy ourselves, let loose, and not worry: about responsibilities, relationships, jobs, money, family, fitting in, anything.

Whatever experience we seek to manufacture, however, there is a straightforward answer to the question of why substances are so effective. Neurologically, the rush of dopamine that accompanies substance use is a fuel that feeds the fire that can become addiction.

Positive Feedback for the Brain

Dopamine is a naturally occurring neurotransmitter that acts within the brain’s reward pathway. We cause its release with just about anything pleasurable: food, laughter, sex, you name it. Drugs and alcohol are uniquely effective because they create an intense spike of dopamine.

This dopamine jolt unfortunately is matched only by more of the same. Nothing else can duplicate the intensity of getting loaded. Nothing.

Even just the thought of getting high can lead to a dopamine spike. In studies of long-time heroin users, for example, it’s been found that dopamine levels actually are highest prior to use. That’s right, the brain’s reward system peaks before heroin even enters the body. Talk about a Pavlovian response!

Unfortunately, this response, compounded by increased tolerance, can contribute to overdoses as users ingest larger amounts of the substance to obtain the desired euphoric secondary effects. The brain may get its fix by simply anticipating a high, but addicts still need to experience a drug’s enveloping embrace to feel satisfied.

Tell Me More About the Fun

I laid out previously the identifiable progression of addiction. Part of that process, I noted, is the undeniable fact that early in one’s relationship with substances, use largely remains in the realm of fun.

For everyone who’s ever ingested drugs and alcohol the reasoning is straightforward, they are an effective means to reach an identifiable, if nebulous, end: happiness.  Thankfully, most people are lucky enough to remain in the fun stage without moving towards addiction.   

But again, drugs and alcohol are popular because they are so darn effective. We choose to use because it’s a blast.

Those of us who move towards harmful and then dependent use recognize early on that drugs and alcohol, in addition to their recreational facility, also are a highly effective coping strategy. They increase the intensity of pleasurable experiences, but over time they more importantly decrease the intensity of painful moments.

Focusing only on the negative aspects of substance use is a familiar “scared straight” strategy. Yet, it’s intellectually dishonest and just not that effective. For many adolescents, who developmentally are wired towards risk-taking and novelty, especially behavior that distinguishes them from their parents, this strategy actually can backfire.

Adults, when confronted only with the negative aspects of substance use reflexively will defend themselves against judgment. If you’re saying I’m wrong, and I don’t like being wrong, nobody likes being wrong!, then my best defensive option is to dig in and not let you win. In the old school, “I know better than you,” autocratic approach, the addict and the moralizer each hold one seemingly irreconcilable side of the ambiguous phenomenon of addiction.

What’s needed is for addicts to hold all parts of their substance use – the good, the bad, and the ugly – within themselves. Addicts need to work out for themselves every aspect of addiction and come to their own conclusions if they wish to change their behavior. (This is something that Motivational Interviewing does very well and one reason why I incorporate it into my practice.)

To only harp on the negative also is a subtle form of shaming that can contribute to an addict’s already refined ability to beat the crap out of her/himself. If someone yells at you, “Are you stupid? Don’t you realize this stuff will kill you?,” and you already are convinced that you’re stupid, well, this tactic merely serves as confirmation of one’s unconsciously ingrained and reality-defining concept of self: I’m a piece of shit.

Finger-wagging simply reinforces a desire to dig in and ups the ante for an addict to find some means of escape from feeling bad.

And there is no better escape than intoxication.

Substance use is a creative means to solving sometimes intractable, often debilitating, and always painful experiences. Substance use initially is not about relinquishing power. It is about feeling better. It is an immediate solution to real, albeit misunderstood, denied, or overwhelming problems.

At first, though, and about this we must be honest, it’s simply a hell of a good time!

Tending Towards Chaos

Unfortunately, drugs and alcohol too quickly can become the answer to almost any question asked of them, especially if asked at a very young age. Fun might be the original intent, but the ultimate impact can be quite the opposite.

Perhaps there is nothing inherently wrong with altering or enhancing one’s reality, but the impact of sustained substance use plays itself out on a longer time frame than just one evening. If given the time and space to unfold, addiction leads to chaos. The process is subtle, however, especially for the addict whose brain simply wants its reward and whose goal is just to feel better, even if only for a moment.

In my next post, I will delve further into addiction by exploring the stage of addiction I’m calling, Fun With Problems. For now, I’ll leave you with Black Flag’s sardonic commentary on the salvific qualities of alcohol, “Six Pack.” 

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What is addiction?

Most of us know someone impacted by addiction. Most of us probably know an addict, whether we, or they, know it or not. But what does it mean to be addicted?

The reasons why people consume mind-altering substances vary: to relax, to have fun, to alter reality, to rebel, to escape, to ritualize important events. But substance use, in my understanding, can be boiled down to one simple idea: I want to change how I feel.

There is nothing inherently wrong with this desire, but herein lies the real danger of drugs and alcohol: they work! Substances are immediate and intense in their ability to alter one’s concept or experience of reality. They’re really good at what they do, perfect in fact.

To be addicted is not simply about (over)consumption of a substance though. Rather, it is a state of being in which one relinquishes power, choice, and control to a substance, or process, that once was beneficial and is no longer.

It is not useful or practical to continue repeating the same actions over and over again. Rightly named, this is compulsive behavior. Psychologically then, addiction can be understood as a compulsion to assuage the obsessive belief that how I feel is insufficient or wrong and should be changed.  

No, seriously, what is addiction?

From a clinical or process oriented perspective, addiction is a conceptual handle by which it is possible to take hold of, explore, and better understand a subtle, ambiguous process that includes both positive (yes, positive!) and negative consequences.

Segmented into stages, or perhaps a continuum, addiction looks something like this:

Experimental use > Social use > Regular use > Harmful use > Dependent use.

The original positive consequences that spurred use – fun! conviviality! connection! – bend towards the negative with increased use. But again, addiction is not merely about consumption. It is about the reasons for use, the patterns of use, the consequences of use, and the denial of the need for change or personal evolution beyond one’s relationship with drugs and alcohol.

Moving from early experimental and social use toward dependent use one’s life is reduced; that is, the components that contribute to a full life are gradually lost: family, friends, freedom, economic security, physical health, self-respect, meaning.

They are replaced over time by an increased reliance on substances to modulate one’s sense of “normal" or happiness. Graphically, this process might look something like this.*

At some point in this process, somewhere between regular use and harmful use, an invisible line is crossed landing one in addiction. It is possible, of course, to stop, examine this process, and implement change. However, the closer one moves to dependent use the harder it is to effect change.

As one’s freedoms are reduced one’s power, choice, and control are eroded and one’s life becomes narrower and narrower. This is characterized by the compulsion to repeat the same behavior over and over again and each time expecting different results. "This time, everything will work out!" And that, my friends, is insane!

To simplify this process even further, I borrow the model of addiction as conceptualized by a friend of mine in Alcoholics Anonymous:

Fun > Fun with problems > Problems.

Over the next few blog posts I will explore each of these stages in order to provide a means of understanding the confusing and all too often deadly path of addiction. For now, I’ll direct you to the song “Underneath the Bottle” from Lou Reed’s 1982 album, Blue Mask. A more perfect description of addiction would be hard to find.

 

*The continuum of addiction model was adapted from Atlanta therapist, Ralph Boynton, my former supervisor at Odyssey Family Counseling Center, and Annie Kelahan, my current supervisor at Therapy Works ATL.

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After Orlando, Love is Not Enough

In the wake of the mass shooting in Orlando, a hate crime that targeted members of the LGBTQ community, a number of published responses have focused on love. People have waxed about the need to love furiously, to love deeply, to love radically, to love defiantly. I value these sentiments.

As a couples’ counselor, I regularly invoke the power of love to soothe a partner’s fear. I call forth love as the antidote to poisonous isolation and loneliness. I introduce love as the necessary balm to heal old, sometimes hidden wounds. Love comforts us and helps us create a secure base from which to act.

But is love the necessary ingredient for systemic change? Reflecting on tragedies brought forth by systemic injustice, systemic inequality, systemic oppression, systemic immorality, I am coming to believe that love is not enough.

Love is necessary, but love is not sufficient.

Love is relational. It is, at minimum, dyadic. It can extend beyond the I-Thou relationship, but it cannot exist without it. Without another, even a conceptual, imagined, dreamed of, or grieved for other, love is conceptual, an abstraction.

Love can inspire individuals to stay connected, to seek security, to seek justice, but as an abstraction, an aphorism, love provides no solace. Love is not what moves history. Love can soothe and hold us as we make or bring forth history, but it does not, in my understanding, change systems.

For individuals today experiencing the sting of loss, love is necessary for healing. But to effect change in our world, love is not enough.

Responding to Tragedy

I have tried to limit my consumption of news generated to exploit the tragedy in Orlando. Of the handful of media responses I have seen, the most powerful has been Samantha Bee’s monologue on Full Frontal. The crux of her speech is the insufficiency of the “standard operating procedure [that] love wins, love conquers hate.” Her position obviously aligns with my own.

I think what struck me the most was Samantha Bee's use of anger, her righteous indignation. In fact, after watching her monologue I decided to reread Malcolm X’s 1964 speech, “The Ballot or the Bullet.” 

Both highlight the systemic hypocrisy that undergirds so much of our nation’s history, then and now. There is a recognition that the deliberate speed of our democratic republic, while rational and perhaps even largely beneficial, also at times is a hindrance to necessary change.

Malcolm X pronounces at one point, “I'm not anti-Democrat, I'm not anti-Republican, I'm not anti-anything. I'm just questioning their sincerity, and some of the strategy that they've been using on our people by promising them promises that they don't intend to keep.”

The same, I think, could be said about politicians urging their constituents to pray or even to love in response to naked hatred such as took place in Orlando.

If change is what we want, we need more than love. It is time for action.

What Now?

We need, for example, to hamstring the power of groups such as the NRA, which successfully has stymied even the funding of national research on the societal impact of gun violence, an honest to goodness epidemiological area of inquiry if I’ve ever seen one.

We need to close loopholes that allow individuals to purchase weapons at gunshows without background checks. We need to reexamine the importance of high capacity magazines for civilian use. We need all gun owners to be licensed and registered. These are just the examples that come to mind at this moment in time.

Love may inspire action, but love is not the action necessary to engage in the arcana of updating and refining federal and state law to reflect current and shifting realities.

I recognize that this topic is not inherently therapeutic or healing. I recognize that I could lose clients over my belief that our country needs to amend its positions on firearm availability and safety. I also recognize that there are limitations to my field, and rightly so.

I help individuals heal. A part of healing is the resumption of living a full life. In my estimation, this includes being an informed and engaged citizen.

When our friends and family are being killed on a regular basis by individuals who have legal access to so-called “modern sporting rifles” inspired by military weaponry and which, by the way, also deliver hefty revenues to gun manufacturers, it is time to acknowledge love’s limitations.

Love can heal, but love cannot reanimate. At this moment in history, love simply is not enough.

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