Newsletter Articles

Why Naltrexone and Buprenorphine Will Disappoint In The Clinical Setting

Anti-Motivational Interventions are those interventions that, while perhaps well-intentioned, have the affect of reducing motivation or positive action toward recovery. Naltrexone and Buprenorphine, while perhaps having a role in a comprehensive system of treatment, will not attain their desired results for the following reasons...

The assumption regarding both medications, and other similar medications, is that relapse is a primary result of "craving" for the drug. While physical craving is indeed a key barrier to recovery, it is only one barrier. The anti-motivation quality of these medications is that they send the message, regardless of what the drug manufacturer claims, that the medication will reduce craving for the drug and make abstinence easier to attain. This ignores all we know about the post-acute withdrawal syndrome and other relapse dynamics that must be addressed for abstinence to be maintained. So, the risk persists that these medications will provide a "false sense of relief" that could reduce motivation to participate in the necessary emotional, social, and lifestyle adjustments required for continued sobriety. Also, craving is only one issue in relapse. A more powerful issue to relapse is the desire to be "high" that is not simply a response to craving. Most relapse is associated not with craving, but with a desire to attain the "remembered" feeling associated with the drug. This is where the real work of treatment and recovery occurs, "learning to live sober."

General practice physicians and psychiatrists are already gearing up to dispense these medications, and although there is a requirement or recommendation for "treatment" as a corresponding service we all know by history that the "medication" will be the primary focus. The introduction of new age anti-depressants has effectively diminished the amount of therapy for depression and these medications will probably follow the same trend.

will not increase the number of people receiving treatment, and could actually reduce the number of persons engaged in treatment. Once those outside the treatment field begin offering these medications they will become the "first choice" for many suffering from addiction. There is tremendous risk that the medications will be administered by those with little or no understanding of addiction. Clients will be given medications with no treatment. The client and their family will assume that they have received treatment, and when relapse occurs, will assume that "treatment failed," when in fact, no treatment took place.

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The Spirituality of Powerlessness

"I am powerless!" These are very difficult words for a person to say, especially when they are spoken in reference to alcoholism or other drug addiction. Yet, they are the very words that have led millions to freedom from the bondage of their addiction...

Powerlessness is not weakness! The first of reaction of most people, including many in the addiction treatment field, is to think that powerlessness equals weakness. This is far from the truth. To admit or recognize powerlessness is to begin a process of acceptance that there exist certain situations or conditions for which one?s personal willpower will ultimately be ineffective. Such is certainly the case when we are faced with an incurable disease, such as alcoholism or drug addiction. Powerlessness does not mean that we are hopeless or helpless, but it does expose a limitation for which help from outside our own resources will be required. This acceptance of powerlessness is a common thread for most diseases. Upon hearing the diagnosis of cancer a person is confronted with their own limitation regarding how effective their own willpower will be in experiencing cure or remission. The cancer patient will require help beyond their own abilities.

The acceptance of one's powerlessness leads to asking for help. Asking for help is a vital key in spirituality. Regardless of one's definition of spirituality, a common theme to most all the world's religions and spiritual movements is the recognition that some statement of powerlessness is necessary before a person can begin to fully open one's mind and heart to a Power that is greater than oneself. If my power is limitless, then what purpose does God or my Higher Power serve?

Those who have experienced addiction firsthand know the utility and rewards of powerlessness. They know the freedom and personal independence that emerges from the acceptance of powerlessness. They see this acceptance as a statement of strength, not weakness; a discovery and reason for celebration. For the declaration of powerlessness is the beginning of the end of isolation, embarrassment, hopeless, and despair. It is that famous "moment of clarity" from which the individual embarks on a path of positive direction and hope.

And what is this powerless state? With addiction the answer is two-fold. First is the recognition and acceptance that I have the "disease" of addiction, that when a mood-altering drug enters my body I experience the phenomena of craving and that this craving has grown progressively more powerful, and will continue to grow more powerful to the point of insanity or death. This process may take years to unfold and will be marked by periods of apparent improvement and control, only to be followed by less control and greater suffering. The alcoholic/addict will appeal to numerous methods to gain power over the effect that mood-altering substances have on his/her body and mind. These efforts will include substituting one drug for another, changing friends and living environments (better known as geographical cures), and countless contracts with relatives, friends, psychiatrists, ministers, legal authorities, and counselors for the purpose of quitting, cutting down, or controlling the drinking/drug use, or the various behaviors linked to drinking or drug use. Again, some of these promises or contracts may provide temporary improvements, only to be followed by a progression of the drug use and corresponding consequences.

This first level of admission and acceptance of powerlessness is usually recognized by statements from the individual such as "I've got a drinking/drug problem." "I need help," "I can't control my drinking/drug use." or "I want to quit, but I can't," The admission may be as subtle as "Maybe I have a problem," Or "I think I might have a little bit of a problem," Any admission is an important beginning and wonderful recoveries have begun with much less than full acceptance. In fact, an individual with an intent or desire to recover cannot adequately or accurately express their level of motivation. Even professionals cannot quantify the extent of an individual?s acceptance. The reality is that the vast majority of those who have recovered from addiction started with a minimal open-mindedness and extensive reservation about the consequences of their decision to try to recover. The amount of motivation verbally expressed at the beginning of the recovery process is thus little indication of the chances of recovery.

Is Hitting Bottom necessary to initiate recovery? Yes it is, in as much as hitting bottom represents the convergence of internal and external consequences along with an inspiration to experience a personal change. Every recovered person can point to a series of events, usually considered negative at the time, which combined to bring enough stress to initiate some action toward recovery. These stories of hitting bottom are varied, but generally involve a gathering host of negative consequences that are natural to the disease of addiction coupled with some new offer of help, or treatment, or some recollection of a past offer of help that may be re-visited. One consistent element of hitting bottom is that the person hitting bottom is never aware that they have hit bottom at the time of its occurrence. "Bottom" can only be recognized in hindsight, never in the moment, and especially not in foresight.

The second level of acceptance of this powerless state pertains to the "solution" to the problem and less to do with the admission of the problem. Following the admission of powerlessness the individual is faced with the question "What do I do now?" Much debate still exists as to the answer to this question, but certainly we can agree that it is folly to think that someone should address their disease with wishful thinking or pledges to quit. Like most diseases, a strenuous course of action will be required to recover. This is where the second level of acceptance regarding powerlessness is necessary An individual must come to terms with his/her need for continued support and assistance in order to recover and reach an understanding that an effort to "just not drink/use" will result only in a short-lived solution. Interestingly, this is where most newly motivated/inspired people balk; they resist acceptance of a "plan" for complete and long-term recovery. How often have we seen someone survive an horrendous convergence of consequences, make a valiant effort to quit drinking/using, go through physical withdrawal, and begin the process of reclaiming their lives only to relapse after a few weeks or months? The relapse, ironically, is often preceded by statements of commitment to a life of sobriety. So what happened? Most commonly, the individual was not aware or ready to accept the next important level of powerlessness. Without a plan for recovery the desire to drink or use returns, and he has no effective defense against it. For many, the early period of abstinence may actually yield the false impression that they have conquered the disease when in fact they have actually only begun the process. It would be much like a cancer patient that takes a couple treatments, feels better and declares himself well, only to see his symptoms continue to worsen. With the alcoholic/addict, the desire to drink or use drugs will return and will be so powerful that unless proper preparations have been made, relapse is certain.

So the second level of acceptance is the recognition that without an action plan of recovery the alcoholic/addict will drink/use again regardless of the consequences or initial commitment to stopping. The real turning point of acceptance of powerlessness is the commitment to an "action plan" of recovery that is not one's own. The alcoholic/addict is no more able to develop their own plan of recovery than is a cancer patient. Yet, the strong tendency is for the alcoholic/addict is to attempt to do just that, develop their "own" plan rather than adopt a proven plan such as one offered by a treatment professional or a Twelve Step recovery group member.

A newly recovering person is operating with a mind contaminated by drug use and drug experiences. A discovery made by many recovering people is "My best thinking got me in this mess," And in early recovery, one's best thinking will not be sufficient to lead one to stable recovery. The alcoholic/addict must be willing to accept his/her powerlessness over the potential for taking the first drink or drug, and that he/she will require the assistance of others to develop a plan to permanently avoid, on a daily basis, that drink or drug.

Is reliance upon a Higher Power necessary for recovery? Yes. But let's look at these words, "higher power." As represented in the literature of Alcoholics Anonymous and Narcotics Anonymous these words refer to "God, as you understand God." "As you understand God" is an important distinction which separate spirituality from religion. Twelve Step Programs do not offer a description of God, nor do they require any "belief" for membership. And these words "Higher Power" have a broader meaning as well. The newly recovering person is being introduced to the need to identify sources of help and assistance, a higher power for direction, sanity, advice, suggested actions, and even companionship. This source of power is available from helpful people, groups of other recovering persons, the ideas and suggestions of experienced recovery people who have "walked the walk" and recovery-oriented literature. There will be a need for a source of power greater than, and outside of, oneself. The disease of addiction cannot be overcome without it. Such is the nature and importance of powerlessness.

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What Is Hypoglycemia?

Hypoglycemia is not a "disease". It is a condition that can be treated and reversed. Hypoglycemia is the body's inability to properly regulate blood sugar levels, causing the level of sugar in the blood to be too low or to fall too rapidly...

Professor Joel H. Levitt, writing for Alternative Mental Health, writes that "Blood sugar, in the form of glucose, is the basic fuel for all brain operations and physical activity. If the available fuel is too inadequate, any marginal physical or mental system may start to shut down. In addiction, the glandular imbalances that result, as the glands struggle to regulate the sugar level, cause their own symptoms, especially high adrenaline, which is usually perceived as anxiety or panic," Dr. Levitt also points out that Hypoglycemia will often cause the following emotional symptoms:

Anxiety
Phobias
Nervousness
Restlessness
Irritability
Depression
Violent outbursts
Obsessive-compulsive behavior
Forgetfulness
Inability to concentrate
Unsocial, Asocial, and Anti-social behavior
Nightmares and night terrors

These additional physical symptoms are often present:

Headaches
Tachycardia -- racing pulse due to high adrenaline
Fatigue, weakness
Tremor
Twitching, jerking, or leg muscle cramps
Sleep problems
Tinnitus (ringing in the ear)
Abnormal weight, too high, too low
Compulsive craving for sweets, colas, coffee, alcohol
Fainting
Blurred vision
Lack of sexual drive
Joint pains

James Milam, in "Under the Influence" and Katherine Ketchum in "Eating Right To Live Sober" point out that the majority of alcoholics/addicts suffer from Hypoglycemia as either a corresponding condition to the physiologic predisposition to addiction, or due to the pancreatic dysfunction caused by heavy alcohol and drug use.

The treatment of Hypoglycemia focuses upon the adoption of a diet that avoids refined carbohydrates, nicotine, caffeine, and of course, alcohol and drugs.

People with Hypoglycemia attempt to regulate their unstable blood sugar much the same way an alcoholic attempts to treat a hangover, by consuming more of that which caused the problem to start with. Those with Hypoglycemia will "crave" sugar and refined carbohydrates and will often struggle with addictions to nicotine and caffeine.

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Food Addiction

Millions of Americans suffer from the symptoms and consequences of food addiction, making it the commonest untreated addiction in the country. Responses to the problem have come in the form of innumerable diets, weight loss programs, pills, and other so-called "cures," Approaches to food addiction mirror the sordid history of drug addiction treatment with their conflicting theories, questionable treatments, and money-making scams, all perpetrated upon vulnerable, suffering people...

The next time you are in the checkout lane at the grocery store, notice the topics on the magazine covers. Each will feature a diet promise such as, "Lose Ten Pounds in Ten Days," "Get Ready for the Beach with the Grapefruit Diet," or "Lose that Tummy with our Movie Star Diet." And pictured on the same cover will be the biggest double chocolate cake imaginable. The real message? Lose weight and eat that cake, too!

Many overweight people will respond to one or more of the hundreds of diets that are promoted through magazines, books, physicians, talk-show hosts, and media. A few will adopt a plan and be successful. But what of the people who have tried many of the diets yet continue to struggle with their weight, high blood pressure, diabetes, or other nutrition-related disorder? Are these people weaker, sicker, lacking will power, or mentally ill? No; they likely suffer from food addiction. Food addiction is the abnormal metabolism of certain foods, which creates a craving for those foods and leads to a compulsive pursuit of their mood-altering effects.

The problem with most of these diets is that they include these addictive substances. The presence of these foods, even in small quantities, assures the continuance of craving and ultimate failure. Unfortunately, people usually blame this failure on a lack of commitment, deficient will power, or emotional instability. Rarely do they understand that their effort was doomed from the beginning, as were the drug addict's plan for quitting cocaine through the use of marijuana and the alcoholic?s plan to avoid whiskey by drinking only beer.

Food addicts typically overeat refined carbohydrates, which include sugars, flour, wheat, and other foods that have been highly processed. Examples include potato and corn chips, white rice, french fries, and pretzels. Foods containing refined carbohydrates are abundant and must be avoided. Many refined sugars appear disguised as white sugar, brown sugar, caramel color, corn syrup, fructose, dextrose, honey, maltose, high fructose corn syrup, malt syrup, molasses, maple sugar, maltodextrin, and rice syrup.

By producing a feeling of physical well-being, food is a mood-altering chemical for nearly everyone. But for some people this uplifting experience is much more powerful and, in fact, addicting. Studies have linked high carbohydrate foods to significant increases in insulin production and a corresponding elevation in serotonin levels. Judith J. Wurtman, Ph.D., from the Massachusetts Institute of Technology, has linked these biochemical influences to both bulimia and obesity. For many people, then, food serves as a numbing anesthetic. And when this mood-altering experience is linked to craving, a state of powerlessness is likely to follow. This powerlessness is progressive and accompanied by denial and efforts to control. And this, of course, is addiction in action: As problems related to the emotional, physical, and spiritual consequences of food addiction accumulate, additional food intake becomes the "solution."

Normally, when food is consumed, blood sugar is affected: it rises relatively rapidly and then gradually returns to normal. With food addicts, however, ingesting refined carbohydrates causes an abnormally sudden spike in blood sugar levels, which then drop below normal. This leaves the individual sluggish and irritable, and usually craving a substance that will produce another blood sugar elevation -- and quickly. This substance, of course, is any refined carbohydrate. This cycle then repeats itself again and again. Interestingly, caffeine and nicotine have the same effect on blood sugar as a refined carbohydrate. They cause the blood sugar to spike and then drop below normal. So caffeine and nicotine are both guilty of causing and sustaining unwanted food cravings.

In any chemical addiction, when mood is artificially altered to create a "high," there will always be a corresponding "low." The net effect for food addicts is that addictive foods cause depression. For this reason, in the evaluation of symptoms relating to mood, the treatment professional should always consider the client's diet and the use of caffeine and nicotine before reaching a conclusion regarding a true mood disorder.

Answering "yes" to three or more of these basic questions suggests the presence of food addiction:

Have you failed at numerous diets and other weight loss efforts?
Do you think food is a problem for you?
Do you eat large amounts of high calorie food?
Do you eat when you are tense, angry, anxious, or disappointed?
Has your eating interfered with any part of your life?
Do you often eat more than you planned?
Can you identify specific food cravings?
Does your eating seem out of control?
Do you hide your eating?
Do you enjoy eating alone?
Are you frequently hungry shortly after eating?
Do you prefer foods that are high in refined carbohydrates, sugar, or flour?
Do you continue to overeat, or eat harmful foods, even though a health care professional has warned you about health consequences?
Can you not picture life without your favorite foods?

There Is a Solution! A growing movement is addressing food addiction as a significant health problem for which there is a reasonable solution. As with addictions in general, it is important to identify the abused substances which produce the craving and set in motion the biochemical and emotional manifestations of addiction. In food addiction, the substances are refined carbohydrates. The solution, then, is abstinence from these substances.

Most food addicts cannot imagine life without donuts, pizza, cakes, or pies. They generally must "hit bottom" and experience the negative consequences created by these foods. Only then are they able to make the necessary lifestyle changes. Following a period of what amounts to detoxification from these foods, the craving leaves and sanity returns. For those who finally make these changes, a true miracle has occurred.

It is difficult, if not impossible, for anyone to deal with addiction alone. Primarily for this reason I highly recommend involvement in a Twelve Step program that addresses overeating and food addiction. Food Addicts Anonymous and Overeaters Anonymous are groups that meet in many communities. Food Addicts Anonymous has a helpful web site. I also recommend an important book, Food Addiction: The Body Knows, by Kay Sheppard.

Understanding Is Fundamental: Struggling with food addiction leaves an individual ashamed, afraid, defeated, and unhealthy. An important first step is to recognize that an addiction, not a weakness, is at the root of the problem.

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The Disease of Addiction

In 1939 Alcoholics Anonymous World Services, Inc. published Alcoholics Anonymous. Commonly referred to as the Big Book, this volume served to spread a new message of recovery across the nation and throughout the world. In addition to outlining a program of recovery, the book contained a "To Whom It May Concern" letter dated July 27, 1938, from a doctor specializing in the treatment of alcoholism and other drug addictions...

The physician, Dr. William D. Silkworth, was Medical Director at Charles B. Towns Hospital in New York City. Of particular interest was the doctor?s depiction of alcoholism/addiction as an "allergy," Also, in the chapter "More About Alcoholism," the condition was termed an "illness."

This may sound like old news today, but in 1939 portraying addiction as a physical illness was new and innovative. Silkworth indicated that the basis of this portrayal was the "phenomenon of craving." Rather than invoking psychological or environmental origins, he instead regarded the root causes to be within the physiology of the person -- the body itself. Although primarily anecdotal, Silkworth's observations and the insights of recovering AA members would eventually be verified by more scientific researchers. James Milam, Kathleen Fitzgerald, R.S. Caldoret, Marc Schuckit, and many others would demonstrate the biogenic nature of alcoholism and drug addiction.

The disease model of addiction presumes that different people have different reactions to the presence of mood-altering chemicals within their body-systems. In fact, recent research clearly indicates that people have varying experiences with any introduced substance -- whether it is alcohol, nicotine, antibiotics, milk, or a Poptart -- and that these experiences are not based upon one's personality, psychological make-up, or environment. Of course, not everyone experiences the phenomenon of craving for another drink or another drug or another doughnut. The problem has been that those who do experience this craving have been deemed weak-willed, flawed in personality, or mentally ill.

The chief indicators of the disease of addiction do not appear in the DSM (Diagnostic Service Manual) IV. The DSM IV only denotes symptoms that occur in the later progressive phases, or symptoms that represent consequences of the disease, such as withdrawal, efforts to stop or control use, or drinking despite a serious health problem. The disease model of addiction, however, recognizes that the condition existed long before these more advanced symptoms appeared.

The primary signs of the presence of the disease include:

1. Abnormal metabolism of mood-altering chemicals. This abnormality is most easily recognized with alcohol, or ethanol, which is technically a sedative drug and toxic to the body. Before the sedative effects of alcohol are experienced, the drug is first enjoyed as a stimulant by most everyone. For the individual with normal metabolism, the stimulant effect is short-lived and, following additional consumption, is replaced by the sedative effect. This explains why the normal drinker has little problem saying "no" to another drink. When the stimulant effect has subsided and the sedative/toxic effects are being experienced, it takes no great amount of will-power, character, common sense, or mental health to say "no more." However, alcoholics metabolize alcohol in another way, causing them to experience a prolonged stimulant effect and thereby postponing the sedative effect. The ability to consume larger amounts of alcohol then sets the stage for the next significant factor in the disease.

2. Variance of effect. A person who consumes large amounts of alcohol necessarily produces, in the liver, increased amounts of acetaldehyde, the primary chemical by-product. In people with an abnormal metabolism -- those with the disease -- two things occur. First, because of the ability to consume larger amounts of alcohol, acetaldehyde is created in larger amounts. And second, because the breakdown of acetaldehyde to acetate is less efficient in the alcoholic, a further build-up of acetaldehyde occurs. This large amount of acetaldehyde then invades the brain and is treated as a toxic substance. The brain, in turn, creates a new, opiate-like substance -- tetrahydraisoquinolone, or TIQ -- when it metabolizes the excess acetaldehyde. Thus the alcoholic gets "high" from the combined actions of the stimulant effect of ethanol and the narcotic effect of TIQ. The physical experience of alcohol consumption is therefore quite different for the person with this special metabolism.

3. Tolerance Increase: Once again related to the difference in alcohol metabolism, the alcoholic will experience an increased ability to sustain the stimulant effect and corresponding avoidance of the sedative/toxic effect. Since the disease dynamic requires more and more alcohol to attain the ethanol/opiate "high" as described earlier, larger amounts are consumed with greater frequency, and cellular adaptation -- addiction -- is greatly promoted and hastened.

4. Relationship Development: It is a human characteristic to try to form a relationship with anything that makes us feel good -- be it material possessions, sex, food, or sports. Because of the physiological make-up of the alcoholic, the association with alcohol begins with a courtship that does not initially appear dangerous or threatening. As the amount and frequency of use increase, so does the denial process that protects alcohol from blame for consequences that are being experienced.

An important psychological dynamic of this relationship is the diminished significance and enjoyment once derived from activities that brought fulfillment, such as school, job, family, hobbies, and self-development. The attractiveness and intensity of the "high" make these pursuits both boring and difficult and are now viewed by the alcoholic as drudgery.

As the disease progresses, the alcoholic struggles more and more with these psychological issues. Some alcoholics apply great amounts of willpower to control their drinking in order to fulfill their obligations to school, job, and family, while others disconnect from most of their responsibilities to be free to pursue their relationship with alcohol. Still others may have so little control over the addictive process or their behavior while drinking that they are forced into the criminal justice system.

So this is the "disease" of alcoholism. While the process is very similar to that found in other drugs, many substances are more addictive than alcohol and may not require the same degree of physiological predetermination.

It is important to understand that different people experience the effects of drugs differently and that this difference is primarily physiological -- not psychological or environmental, nor an issue of character, willpower, or mental health.

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Debunking Dual Diagnosis "The Race To Medicate"

In my twenty-four years of working in the counseling field, I have never before been so concerned about the current trend of using dual diagnoses and medication in the treatment of addiction. This has reversed much of the previous progress made in our recognition and understanding of the disease model of addiction. My goal in this article is to (1) explore the origins of this present trend; (2) identify the misconceptions about mental illness and addiction; and (3) offer a reasonable "best practice" in the treatment of addiction and its symptoms...

(1) The Origins of Co-Occurring Disorders and Medication in the Treatment of Addiction

The current fashion of identifying and labeling alcoholics and addicts with a "co-occurring" mental illness, or a secondary diagnosis, is not new. Instead, we are witnessing a revival of past misunderstandings by those who view addicts as individuals suffering from a mental illness rather than a physiologically-based disease dynamic. This is evidenced by the resurgence of such erroneous adages as "an alcoholic drinks because he is depressed," or "he is self-medicating his symptoms of anxiety."

What is new to this popular trend, however, is the widespread use of psychotropic medications in the disease of addiction and the willingness of addiction counselors to participate in this usage. Many practitioners in the treatment field are ignoring information and experience which confirm the danger and ineffectiveness of this practice.

Mental health professionals have never truly accepted the disease model of addiction and have readily advocated the use of psychotropic medication in the treatment of alcoholics and drug addicts. Addiction professionals have, in the past, shouldered the responsibility for guarding against this practice by promoting an abstinence-based treatment model that views most psychiatric diagnoses as symptoms of addiction rather than co-occurring, or dual disorders.

Recently, however, more addiction professionals are following the mental health concept of addiction. While some, new to the field, were originally trained in mental health programs, even many of our experienced addiction professionals, lacking the administrative or clinical support to resist, feel coerced into conforming to this new trend.

And where did this trend begin? In the research laboratory or from research-based, best-practice studies? No, the real impetus originated in insurance company boardrooms and pharmaceutical company marketing plans.

In the mid-1980s, insurance companies began looking for ways to decrease their costs for addiction treatment, which had been growing steadily. Their primary method was to reduce drastically the number of allowable inpatient treatment days. Most companies reduced those days to five, covering only the detoxification period. This, of course, created a tremendous upheaval among hospital-based treatment providers. In a counter-effort to lengthen the allowable inpatient treatment period, providers began assigning additional diagnoses to their patients. And because alcoholics and drug addicts present with symptoms of depression, anxiety, schizophrenia, and other psychiatric disorders, the practice was easily justified.

The disease model of addiction had previously been embraced by the majority of inpatient facilities, which had correctly viewed these add-on conditions as symptoms of an underlying disease and not a dual diagnosis. But the financial incentive to extend treatment days quickly overcame any moral concerns over abandoning the disease model and abstinence-based treatment. Since the dual-diagnosis concept was now being applied to alcoholics and addicts, it followed logically that some form of treatment was indicated. This resulted in the introduction of various psychotropic medications, primarily the Selective Serotonin Reuptake Inhibitors (SSRIs), such as Prozac and Zoloft.

A parallel marketing program was also taking place in the pharmaceutical industry. To increase the likelihood that more people would consider using anti-anxiety and antidepressant medications, drug companies broadened the definition of these disorders to include most any mood other than "happy," And, in an effort to explain the conditions of sadness, nervousness, dread and other mood variations, the phrase "chemical imbalance" was invented. So instead of viewing anxiety or depression as a normal consequence of alcoholism, drug abuse, grief, domestic violence, sexual abuse, marital conflict, job dissatisfaction -- any of life's difficulties -- the new cause became "chemical imbalance."

It sounds so enticing on a television commercial: "Are you often sad?" "Do you not feel like yourself?" "Have you been irritable or having trouble sleeping?" "Have you been nervous or bored lately?" "Your problem may simply be a chemical imbalance in your brain." Admittedly, there is evidence that various brain chemicals affect a person's mood, energy level, enthusiasm, and many other physical and emotional attributes. But to suggest that a person just "wakes up one morning" to find that his brain chemicals have become misaligned, discombobulated, or out of balance, is an egregious distortion of the relationship between brain chemistry and mood. The obvious marketing goal here is to sell medicine, with SSRIs being promoted as panaceas for the tribulations of life.

While the solicitation messages often include the phrase "these medications are effective when combined with therapy," the reality is that they are being marketed to general practice physicians who lack both the counseling skills and network systems for the provision of therapy. The reality is that the use of therapy decreases as the reliance upon medications increases.

It was natural, then, that people with alcohol and drug problems would be targeted as consumers of these medications and, since insurance companies have long preferred to pay for medication instead of more expense therapy, psychotropic drugs proliferated within the addiction treatment field.

(2) Misconceptions About Mental Illness and Addiction

In the vast majority of cases, depression is a symptom or consequence of another physiologic or environmental condition, which affects the way the brain and other organs function. The major causes of depression and other mood disorders include:

1. Alcoholism and Drug Addiction: The impact of toxic substances on the brain and other organ systems is dramatic and damaging. Alcohol and drug abuse create a cascading effect of various brain chemical dysfunctions, which contributes significantly to the occurrence of depressive symptoms in alcoholics and drug addicts. Since these individuals usually present with a plethora of symptoms, on any given day they might also be diagnosed with most any psychiatric disorder listed in the DSM-IV. Does this mean that a dual, or co-occurring, disorder is present? No, it means simply that a set of symptoms exists that is directly attributable to the toxic effects of alcohol and other drugs.

2. Chronic Stress: Long-term stress results in increased adrenaline levels, which initiate a series of chemical reactions which, in turn, yield higher amounts of serotonin and dopamine. These latter substances lead to a depressed mood. Persistent stress also elevates cortisol levels. This steroid is toxic and interferes with brain function. By these pathways the chronic stress of alcoholism, drug addiction, marital conflict, financial crisis, domestic violence, and other life problems can lead to depression.

3. Nutritional deficiencies: Anger, anxiety, fatigue, insomnia, headache, irritability, sadness, poor concentration, forgetfulness, restlessness, isolation, worry, diminished sexual desire, feelings of dread, and suicidal thoughts are all symptoms of a classic case of depression. However, they are also symptoms of certain conditions associated with nutritional deficiencies. Hypoglycemia, for example, is a blood-sugar imbalance that is extremely common in addicted individuals.

4. Minor Stimulant abuse: Caffeine and nicotine are often primary contributors to depression because of their impact on brain chemistry, as well as their negative contribution to blood sugar levels.

Reasons for Not Using Antidepressants in the Treatment of Alcoholics and Drug Addicts

1. They don't work. A headline from the July 7, 2002, issue of USA Today: "Study: Antidepressant Barely Better Than Placebo," University of Connecticut psychologist Irving Kirsch compared antidepressants to placebos and demonstrated that these medications are "not meaningful for people in clinical settings," This is old news to many of us working in the addiction field, and clients have been reporting the ineffectiveness of these drugs for years.

2. Side effects. Untoward reactions to antidepressants remain another major concern. For Prozac alone, Eli Lilly lists the following as frequent side effects: rash, pruritus (itching), headache, tremor, dizziness, insomnia, anxiety, nervousness, agitation, abnormal dreams, drowsiness, excessive sweating, nausea, disturbances of appetite, diarrhea, weight loss, weight gain, muscle pain, painful menstruation, sexual dysfunction, urinary tract infection, and chills.

3. Illusion of treatment. The use of antidepressants often creates the erroneous impression that treatment is succeeding. This, of course, prevents the patient from addressing the root causes of his depression. For example, a client may present to a therapist/counselor/physician with symptoms related to a troubled marriage. Antidepressants are prescribed, but no therapy is provided concerning the marital problem. Is this treatment, or just an illusion of treatment? Also, the client will frequently play a significant role in this illusory game by opting for the pill instead of the difficult emotional work required to address a serious life problem. Finally, the use of antidepressant medications reduces client motivation to remain abstinent and face the significant life changes needed to maintain that abstinence.

4. Drug Interactions. Manufacturers of antidepressants warn of the dangers of mixing their medications with alcohol and other drugs. Yet these substances are regularly prescribed for people who are new to the recovery process. Considering the high relapse rates among people in early recovery, and especially in those being discharged from detox units, prescribing such drugs is medically risky.

5.Easier, Softer Way. There are three basic stages of readiness regarding recovery from addiction: not ready, getting ready, and ready. As clinicians we provide services to people in all three stages; part of our job is to help people move from one stage to the next. When faced with the prospect of needing to make significant lifestyle changes that require much work and dedication -- abstinence, intense counseling, personal inventory, amends-making, AA/NA meetings -- the "not ready" or "getting ready" people often balk and seek alternative solutions. These substitutes almost always fail and frequently make matters worse. A commonly preferred option is to view the problem not as addiction but as mental illness. Expectations of abstinence and personal change are thereby minimized and the use of a mood-altering drug is acceptable. As a result, many alcoholics and addicts readily gravitate toward treatment professionals who offer this "easier, softer way."

(3) An Abstinence-Based, "Best Practice" Approach to Addiction Treatment

1. Maintain abstinence: For an appropriate evaluation, the client must remain abstinent from all mood-altering substances. Before attempting to diagnose a co-occurring psychiatric disorder, a minimum of six months of sobriety is recommended. The central nervous system needs this amount time to recover, and the introduction of mood-altering drugs only slows or arrests the healing process.

2. Determine the appropriate level of care: Individuals with exaggerated symptoms of depression, anxiety, or mood disorder often benefit from residential treatment. Here the client is safe and accessible to counseling and support. Treatment providers must be familiar with the symptoms of withdrawal so they can adequately assist the alcoholic or addict to understand the relationship between his symptoms and the addiction.

3. Provide primary health care services: If we are concerned about "co-occurring disorders" then we should identify the most common of such disorders, health problems. Diabetes, heart disease, liver problems, and malnutrition are very common in alcoholics and addicts and can greatly interfere with the recovery process if not addressed.

4. Develop "waiting" skills: The meaning of the word "wait" is often poorly understood by alcoholics and drug addicts. Addiction demands immediate gratification; symptoms such as insomnia, depression, fear, worry, and sexual dysfunction become unbearable. Too many professionals attempt to short-circuit the development of this waiting process by introducing medication. This practice, however, ensures that the individual will never attain the necessary skills of patience, tolerance, and acceptance. The "waiting" allows him to discover his own strength and the strength of others. This approach requires that the addiction counselor be both comfortable with his client's discomfort and confident in the recovery process.

5. Lifestyle Change: In an old recovery joke, the Old Timer tells the Newcomer, "There's only one thing you have to change to be happy and sober for the rest of your life," Eager to hear what that might be, the Newcomer quickly asks, "What is that one thing?" The Old Timer smiles and says, "everything!" Certainly, if lifestyle changes do not occur, life will be stressful, unsuccessful and, finally, unhappy. And for the unhappy alcoholic or addict in recovery, relapse will soon follow. So, our challenge is to provide counseling and therapy. No easy fixes, just good, old-fashioned, down-in-the-trenches counseling. This will include confrontation, encouragement, inspiration, motivation, coaching, teaching, and guidance. Add experience, strength and hope and you have treatment.

6. Improve nutrition: Introducing a sound nutritional program often significantly diminishes the symptoms of depression, anxiety, and mood swings, and will greatly enhance the recovery experience. The eventual elimination of caffeine, nicotine, and refined carbohydrates, with the addition of regular meals, vitamin supplements, and exercise, is basic to this regimen. Attempting to treat someone for depression while he is drinking a pot of coffee, smoking two packs of cigarettes, and eating little but refined carbohydrates is discouraging if not futile.

7. Maintain Twelve-Step Recovery: Emerging from all the studies of the treatment of addiction is one constant: Those who do recover have a higher rate of attendance at Twelve-Step Recovery programs. Do some people recover without such a program? Sure they do. But as a treatment professional, I am obligated to recommend the most consistently successful approach. If a loved one were diagnosed with cancer, you would expect the doctor to suggest a treatment regimen with the best chance of succeeding. We, as addiction treatment providers, have that same responsibility. No other program delivers positive outcomes that can compare with Alcoholics and Narcotics Anonymous.

8. Continue to Evaluate: Each client should receive continuous monitoring of symptoms and progress. The professional should be able to offer support and strategies for dealing with lingering symptoms of addiction. As with the general population there will be a small percentage of clients who will have a psychiatric disorder. The presence of such a disorder can be assessed once the client has been stabilized and benefited from a program of recovery activities. There will be times when an individual may require a mental health intervention. Suicidal ideation and psychosis that presents a threat to the client or others are examples.

Is There Ever A Use For Psychotropic Medications James Milam's research indicates that mental illness occurs in the addicted population at the same rate it does in the general population. By this standard we would anticipate that about 3 to 5% of the addicted population will have a dual-diagnosis. But, again, this diagnosis cannot be made until the person is sober for a reasonable period of time. There can be occasion where the treatment of addiction must be secondary to the treatment of a mental disorder such as a person experiencing psychosis or suicidal ideation. But even in these instances we should be slow to attach the "dual-diagnosis" label since these can be acute states of addiction.

There are those with a co-occurring disorder that will not respond to abstinence, nutritional therapy and 12 Step recovery. Research and common experience verifies that many who suffer from Schizophrenia are also alcoholic or drug addicted. Their treatment will have to account for the presence of both diseases. this disturbing trend of diluting the definition of mental illness to include the majority of people, while good for pharmaceutical companies, is very bad for those with a true dual diagnosis. There are only so many resources available to treat mental illness. Creating a pseudo-definition of mental illness that broadens the population of those to be served only serves to lesson the opportunities and resources available for those who truly need them.

Resources Used For This Article:

Milam, Ph.D., Under the Influence, Katherine Ketchum, Ph.D., Eating Right to Live Sober, Irving Kirsch, Ph.D. and Guy Sapirstein, Ph.D. Listening to Prozac but Hearing Placebo: A Meta-Analysis of Anti-Depressant Medication, Article Prevention and Treatment, Vol. 1, June 26, 1998, American Psychological Association, Charles Gant, M.D., Ph.D. Using Antidepressants versus Finding the Underlying Medical Causes of Depression, Article for Alternative Mental Health, Safe Harbor, On-Line, Charles Gant, M.D., Ph.D., End Your Addiction Now, Peter R. Breggin, M.D. The Anti-Depressant Handbook, Peter R. Breggin, M.D. Your Drug May Be Your Problem

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The Art and Science of Addiction Counseling

What is addiction counseling? First let's look at what it is not. It is not classical or contemporary mental health counseling. Because an ever-growing number of professionals have moved from the mental health field to addiction treatment over the past twenty years, much confusion surrounds this issue...

What was the basis for this movement? Addiction treatment, as drafted and provided by a fledgling group of recovering alcoholics, addicts and enlightened mental health professionals, WORKED! It was successful. Or, in the current vernacular, it produced positive outcomes. And what fueled these early professionals and para-professionals? It was the disease model of addiction; abstinence-based treatment; collaboration with and referral to Alcoholics Anonymous, Al-Anon, Narcotics Anonymous; and courage. Upon the shoulders of these historic workers, the current treatment system was built and expanded. They had the courage to develop a treatment approach that was not based upon mental health strategies or theories. They possessed the strength to stand up to psychiatrists, psychologists, and other highly-degreed mental health professionals that attempted to abort or divert the recovery movement. They said "no" to aversion therapies. They said "no" to controlled drinking approaches. And they said "no" to the Valium and Librium treatment models. Thus they resisted efforts that attempted to integrate addiction treatment into mental health treatment models.

Regarding the nature of addiction, there is a basic disparity between the fields of mental health and addiction treatment. James Milam, Ph.D., author of "Under the Influence," outlines this disagreement in his position paper entitled "The Alcoholism Revolution," In this paper Milam states that the psychogenic model, as followed by most in the field of mental health, sees addiction as "a symptom or consequence of an underlying character problem, a destructive response to psychological and social problems, a learned behavior," In contrast, the biogenic model "recognizes that alcoholism is a primary addictive response to alcohol in a biologically susceptible drinker, regardless of character and personality."

My own professional career is an example of the difference between the treatment of addiction and the treatment of mental illness. My master's degree is in Public Service Counseling, which is similar to most of the master's programs in counseling or social work; it offers training in the provision of counseling services. I studied counseling theories and techniques and followed that with internships and work experiences that yielded additional training in working with clients. My first employment was in a family life counseling center, which focused primarily on services for the development of parenting skills. I next worked for a community mental health center with a primary focus on services to the severely mentally disabled. Later I worked more as a generalist, treating outpatients who presented with a variety of problems, such as marital difficulties, depression, and anxiety disorders.

In each of these work settings there were alcoholics, drug addicts, and family members impacted by addiction. However, they were rarely treated for their addictions. We instead tended to either ignore the addiction problem or tried to treat the addiction by approaching the symptoms of the addiction. Then, in 1981, I was introduced to the work of Milam and others, who were focusing on the disease model of addiction. I was attracted to both the research and the utility of this model and eventually devoted myself to providing treatment solely to alcoholics, addicts and their family members. I soon discovered that many, or perhaps most, of the skills I had developed in the field of mental health were not only ineffective in treating addiction but were, in fact, harmful.

Although the addicted person often presents with symptoms of mental illness, attempts to treat these symptoms as part of the initial treatment of addiction are distracting, ineffective, and potentially harmful. Any treatment that does not focus on the acute health and social issues associated with drinking and drug use is detrimental since the consequences of continued drinking and drug use are serious and potentially fatal.

I often use the example of the emergency room. If you had a loved one admitted to the emergency room with a severed artery following an accident, and you found the treatment provider asking questions about the patient's marital life, problems with depression, conflicts with parents, etc., you would probably become very upset. Although these problems may be real and even serious, shouldn't someone be doing something about the bleeding?

Alcoholic and drug-addicted clients need help first to stop drinking and using drugs. The process of stopping, however, does not mean not drinking or using for a few days. Instead, it means an extended period of time to allow the body and mind to heal from the long-term trauma experienced from addiction. Treatment strategies need to focus on the problems and challenges of sobriety. In my case, I had to learn new skills and abandon the approaches I used as a mental health professional. Because the treatment of addiction is not similar to the treatment of mental illness, the approaches, skills, techniques, and strategies must be different. So while mental health treatment should be applied to those who have a primary mental health problem, addiction is primarily a health problem. Now let?s explore some of these more significant differences.

Exploring versus Accepting Emotional States Emotional states exist. A person is happy, sad, glad, angry, etc. Mental health counseling seeks to explore these states as a way of uncovering issues that could be beneficial in helping the client. However, the newly sober client's emotional state is too volatile to explore and is most often related to withdrawal or organic brain dysfunction associated with chemical use. Attempting to investigate these emotions and yield understanding or insight from them is futile and harmful. It is harmful in that to explore them while in early counseling suggests that the exploration will somehow maintain sobriety. Addiction treatment strives to help the client accept the presence of these emotional states, begin to recognize their volatility, and thereby stay sober in spite of them.

Medication-Reliant versus Abstinence-Based Depression, anxiety, and mood swings are all expected symptoms of the chemically-impacted brain. Effective addiction treatment strives to attain a period of abstinence from alcohol or drugs before even attempting to determine the presence or extent of these problems. Addiction professionals who understand the biogenic nature of the disease generally believe that a period of several months is required before attempting to determine the need for treatment of other disorders. These professionals have historically been at cross-currents with other professionals regarding the issue of medication. Addiction specialists have been courageous in past efforts to educate the public and other health care professionals about the dangers of benzodiazepines, sedatives, and other mood-altering medications that may hinder or exacerbate the recovery process. Addiction professionals believe that counseling and the life-changing power of Twelve Step recovery principles are the only appropriate options for interventions into life problems.

Problem-Focused versus Abstinence-Focused There is considerable personal and social "wreckage" when someone begins a recovery process. The number of difficulties, problems, issues, and stressors can be overwhelming to both client and counselor. There is a temptation to attempt to solve, or least address, all of these problems. And the client adds to the counselor's dilemma with his normal obsession with his litany of stressful problems. However, addiction treatment should focus on helping the client stay sober through the stress of the problems that have accumulated. Trying to address these complicated issues in early recovery, with a chemically-impaired brain which is producing varying and unpredictable emotional states, is non-productive and will generally cause an apparent worsening of the problems. Effective addiction treatment addresses the need to stay sober. It tackles only those problems that may pose an imminent threat; the counselor must decide which problems must be addressed first.

Client-Centered versus Counselor-Centered A health care professional treating a brain-injured client in the emergency room would not rely on the client to design his own treatment plan or establish the hierarchy of services to be provided. Addiction treatment, especially for those clients in the first months of recovery, is counselor-centered, meaning simply that the counselor knows how the recovery process works and the client does not. Because of the impairment caused to mental and emotional functioning, the client needs direction and assistance to stay sober. The power of addiction, with its components of craving, lifestyle and withdrawal, is the central governing influence for the newly recovering person. The power of the addictive thought process will almost always lead to the wrong decision if the client is left to his own devices. Addiction counseling is directive, inspirational, and based upon the successful experiences of others. It is focused like a laser beam on the actions that lead to continued sobriety. As the mind and emotions heal, so does the process of decision-making improve and develop, allowing the recovering person finally to rely on and trust in his own thinking and judgment.

Promoting Dependence versus Promoting Independence The ultimate goal of any counseling or treatment is that the client will eventually not require the service. Addiction counseling is directed toward this goal. It is abstinence-based, non-medication dependent, and realizes that the recovery process leads to healing and personal transformation, which creates a person of greater strength, confidence, ability, knowledge, and wisdom than existed prior to the onset of the crisis. It is no accident that so many recovering people are working in the field of addiction: their lives have been restored to wholeness.

Uncomfortable with Pain versus Understanding the Utility of Pain It is very difficult to be with someone who is experiencing pain, be it physical or emotional. The symptoms of addiction are painful to experience and painful to watch. The tendency for the professional -- in fact the very reason why many people enter the field of counseling -- is to try to remove the pain. This tendency leads many professionals to go to great lengths to solve long-developing personal problems, build up the client's ego and self-esteem, or remove the symptoms with psychotropic medications. All of these efforts fail in the treatment of addiction because pain has a great utility in its treatment. Every recovering person can attest that it was the pain of addiction that motivated him to ask for help, to take direction, and to go to an AA meeting. When the counselor attempts to remove this natural consequence of addiction -- pain -- he may be inadvertently removing the motivation to stay sober. To be comfortable in the presence of the pain of addiction, the counselor must have the utmost confidence in the recovery process and his ability to promote that process. And this is where recovering counselors are so effective: they are not intimidated by the painful consequences of addiction. They are not overwhelmed by the apparent hopelessness of the situation. They know the client can recover through the pain and the problems that permeate his life.

Finally, if a miracle is an outcome that cannot be explained by the sum of all the treatment efforts, addiction treatment not only believes in miracles, it relies on them. Not surprisingly, miracles often exceed the counselor's imagination. The counselor can participate in the celebration of these miracles if he is willing to learn the skills and undergo the personal and professional development required for this dynamic and challenging pursuit.

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Ten Ways Family Members Can Help A Loved One With A Drug or Alcohol Problem

The pain and suffering of addiction is not limited to the alcoholic or drug addict. Family members share a tremendous burden as well. Shame, guilt, fear, worry, anger, and frustration are common, everyday feelings for family members concerned about a loved one's drinking or drug use. In most cases, the family has endured the brunt of the consequences for the loved one's addiction, including the stress of worry, financial costs, and life adjustments made to accommodate the addicted person's lifestyle. Addiction perverts the positive influences of the family. The disease twists love, concern, and a willingness to be helpful into a host of enabling behaviors that only help to perpetuate the illness...

Family and friends are usually very busy attempting to help the alcoholic or addict, but the help is of the wrong kind. If directed toward effective strategies and interventions, however, these people become a powerful influence in helping the loved one "hit bottom" and seek professional help. At the very least, families can detach themselves from the painful consequences of their loved one?s disease and cease their enabling behavior.

Here are ten ways family members can help their loved one and themselves:

1.Do learn the facts about alcoholism and addiction. Obtain information through counseling, open AA/NA meetings, and Al-Anon. Addiction thrives in an environment of ignorance and denial. Only when we understand the characteristics and dynamics of addiction can we begin to respond to its symptoms more effectively. Realizing that addiction is a progressive disease will assist family members to accept their loved one as a "sick person" rather than a "bad person," This comprehension goes a long way toward helping overcome the associated shame and guilt. No one is to blame. The problem is not caused by bad parenting or any other family shortcoming. And attendance at open AA/NA meetings is important: families need to see not only that they are not alone in their experience, but also that there are many other families just like theirs involved in this struggle. Families will find a reason to be hopeful when they hear the riveting stories of recovery shared at these meetings.

2.Don?t rescue the alcoholic or addict. Let him experience the full consequence of his disease. Unfortunately, it is extremely rare for anyone to be "loved" into recovery. Recovering people experience a "hitting bottom," This implies an accumulation of negative consequences related to drinking or drug use which provides the necessary motivation and inspiration to initiate a recovery effort. It has been said that "truth" and "consequences" are the foundations of insight and this holds true for addiction. Rescuing the addicted person from his consequences only ensures that more consequences must occur before the need for recovery is realized.

3.Don't support the addiction by financially supporting the alcoholic or drug addict. Money is the lifeblood of addiction. Financial support can be provided in many ways and they all serve to prolong the arrival of consequences. Buying groceries, paying for a car repair bill, loaning money, paying rent, and paying a court fine are all examples of contributing to the continuation of alcohol or drug use. Money is almost always given by family members with the best of intentions, but it always serves to enable the alcoholic or addict to avoid the natural and necessary consequences of addiction. Many addicts recover simply because they could not get money to buy their drug. Consequently, they experience withdrawal symptoms and often seek help.

4.Don't analyze the loved one's drinking or drug use. Don't try to figure it out or look for underlying causes. There are no underlying causes. Addiction is a disease. Looking for underlying causes is a waste of time and energy and usually ends up with some type of blame focused on the family or others. This "paralysis by analysis" is a common manipulation by the disease of addiction which distracts everyone from the important issue of the illness itself.

5.Don't make idle threats. Say what you mean and mean what you say. Words only marginally impact the alcoholic or addict. Rather, "actions speak louder than words" applies to addiction. Threats are as meaningless as the promises made by the addicted person.

6.Don't extract promises. A person with an addiction cannot keep promises. This is not because they don't intend to, but rather because they are powerless to consistently act upon their commitments. Extracting a promise is a waste of time and only serves to increase the anger toward the loved one.

7.Don't preach or lecture. Preaching and lecturing are easily discounted by the addicted person. A sick person is not motivated to take positive action through guilt or intimidation. If an alcoholic or addict could be "talked into" getting sober, many more people would get sober.

8.Do avoid the reactions of pity and anger. These emotions create a painful roller coaster for the loved one. For a given amount of anger that is felt by a family member in any given situation, that amount -- or more -- of pity will be felt for the alcoholic or addict once the anger subsides. This teeter-totter is a common experience for family members: they get angry over a situation, make threats or initiate consequences, and then backtrack from those decisions once the anger has left and has been replaced by pity. If anger can be avoided, then so can pity. The family can then follow through on their decision to not enable.

9.Don't accommodate the disease. Addiction is a subtle foe. It will infiltrate a family's home, lifestyle, and attitudes in a way that can go unnoticed by the family. As the disease progresses within the family system, the family will unknowingly accommodate its presence. Examples of accommodation include locking up money and other valuables; not inviting guests for fear that the addict or alcoholic might embarrass them; adjusting one's work schedule to be home with the addict or alcoholic; and planning one's day around events involving the alcoholic. (A spouse recently confided that she would set her alarm to get up and pick her husband up from the bar.)

10.Do focus upon your own life and responsibilities. Family members must identify areas of their lives that have been neglected due to their focus on, or even obsession with, the alcoholic or addict. Other family members, hobbies, job, and health, for example, often take a back seat to the needs of the alcoholic or addict and the inevitable crisis of addiction. Turning attention away from the addict and focusing on other personal areas of one's life is empowering and helpful to all concerned.

Each of these suggestions should be approached separately as individual goals. No one can make an abrupt change or adjustment from the behaviors that formed while the disease of addiction progressed. I cannot over-emphasis the need for support of family members as they attempt to make changes. Counseling agencies must provide family education and programs to share this information. They must offer opportunities for families to change their attitudes and behaviors. The most powerful influence in helping families make these changes is Al-Anon. By facing their fears and weathering the emotional storms that will follow, they can then commit to ending their enabling entanglements.

The disease of addiction will fervently resist a family's effort to say "no" and stop enabling. Every possible emotional manipulation will be exhibited in an effort to get the family to resume "business as usual," There will always be certain family members or friends who will resist the notion of not enabling, join forces with the sick person, and accuse the family of lacking love. This resistance is a difficult but necessary hurdle for the family to overcome. Yet it is necessary if they are to be truly helpful to the alcoholic or addict. And being truly helpful is what these suggestions are really about. Only when the full weight of the natural consequences of addiction is experienced by the addict -- rather than by the family -- can there be reason for hope of recovery.

I also find it very helpful to tell family members that these suggestions offer the best opportunity for the alcoholic/addict, perhaps motivating them to seek help for their problem. In the beginning, family members are extremely focused on helping their sick family member and have very little interest in helping themselves. So, a strategy of ending enabling behaviors and withdrawing inappropriate support that is designed to help their love one become more willing to seek help will be more readily accepted by the family and will provide them with incentive to take these difficult actions. The family will eventually recognize the positive effect their changed behavior is having on them as well.

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