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Who the heck do you think you are?...................12 Simplify your life............... 7 Your spiritual aura............ 8 Are you an "almost" alcoholic?.......................... 19

Lighting up while lit up Page 10

New York Edition

May/June 2012

Going All In: I Can’t Stop Gambling All bets are off for those whose brains turn a game into a gorilla By Jeffrey C. Friedman

British statesman Edmond Burke referred to gambling as “a principle inherent in nature.” Burke’s remark seems on the money since games of chance are a pass-time in every culture throughout the world. Gambling predates recorded history and can be traced to the earliest of human societies. Dice-like objects discovered in 40,000 year-old archeological sites suggest that even pre-historic man liked a little action now and then. In the last thirty years, legal gambling has proliferated throughout the world and now even into cyberspace. Today, legal gambling is a one trillion dollar global enterprise. But no one really knows how much money is actually wagered, since so much of the world’s gambling activity is extra-legal – unregulated and unrecorded. Regardless of whether a gambler bets in a government-licensed casino or with a street corner “bookie,” a vast majority of gamblers know the activity as just a

ecovering gambler Leo D. has a suggestion for everyone who suspects he might have a gambling problem. “If you eat one meal a day and it’s a buffet, you might be a compulsive gambler.” Leo should know. He lost thousands of dollars and as many nights of sleep before he finally recognized his gambling problem. “I always lost back everything I’d won, and then some – but, hey, what do you expect,” he says with bemused irony. “I’m a problem gambler.” Whether he was taking the Knicks and the points or calculating a roulette payoff, Leo’s gambling – and all gambling – was, is and will always be based on the same simple premise: someone stakes something of value on a contest of uncertain outcome. Then the race is run, the wheel is spun or the deal is done. And whether you lay the bet or cover it, someone wins and someone loses. In a 1780 House of Commons speech,

(Continued on page 14)

A Moment of Truce A happy ending with bad coffee and powdered creamer

By Benjamin Cheever

espite more purple eyeliner than even the most crass mortician would apply, I could see that this beautiful young woman was still very much alive. “Hello, Ben,” she said, and with a familiarity that would have been offensive, were it not so clearly authentic. I had no idea who this person was. She‘s forgotten her contacts, I thought. She’s mistaken me for somebody else. Somebody she knows and likes. How odd. How unusual. But then I hadn’t traveled 10 feet before an older gent in a gabardine suit stopped me to beam and crow. “Good morning,” he said, as if the two of us had shared a foxhole. A third stranger – this one in a tight dress with two gigantic bows – clicked into my field of vision and purred a greeting while I was still wondering privately why women dress themselves as presents when you aren’t supposed to open them up, not even at Christmas. The corporation at whose headquarters this all was happening had grown well beyond the limits of such easy companionability. I’d been at The Reader’s Digest for years, but most of my co-workers were strangers. We’d pass each other in the halls like salaried ships in the night. Good social Darwinists, we kept score. A few would win, many would stalemate, while others lost the game. “Fired,” we’d whisper, and wag our heads, our

faces frozen into masks of sorrow and concern. While inside we might be thinking, Yippee!! That poor sod’s gone, while Yours Truly dodged another bullet. On this golden morning, though, some sort of truce must have been signed. Apparently, I’d missed the memo. Headquarters had been designed with care, and at this time the building was still exquisitely maintained, but none of this could explain how fine the place began to look. The very quality of the light had changed. Strange happening, but also something I have always expected. Strolling the sidewalks of Manhattan, I’ll hear somebody say, “then,” out loud and (mistaking it for “Ben”) I’ll spin and give the royal wave. I once made a perfect fool of myself at a dinner party, where one of my elders-and-betters gave a speech about what a talented writer Ben was. Crimson with false modesty, I interrupted to reject the praise. Turned out it was another Ben he was talking about. “I didn’t know you wrote,” he said.

Tumbling into love

Such experiences rattled, but did not shatter my conviction that John Donne was right: “No man is an island entire of itself; every man is a piece of the continent, a part of the main.”

(Continued on page 19)

EDITOR'S•DESK

The Battle for My Brain I

f you want to learn amazing things about your body and mind, try this: stop smoking. I know because I quit six months ago – to the day, in fact, as I write this. As I read how nicotine captured my brain I began to understand why it’s so hard to stop. For me it was a physical, mental and spiritual battle. One friend even said I needed to think like a warrior. Only now is the smoke clearing from the battlefield, and now I know I can win. I enlisted a psychiatrist with something of a sub-specialty in smoking cessation. He gave me some prescriptions to parry the tactics of dopamine in my brain and to calm my nerves. Tobacco is a very efficient dopamine delivery system, another psychiatrist told me. It will also efficiently kill me. In about a week, all of the nicotine was out of my body, but I still wanted to smoke. It was an inherent part of my day. I smoked when I felt good, and I smoked when I felt bad. Tobacco obliges. I took short puffs for a quick fix when some bad thing happened, and drew out the inhaling and exhaling when I felt good. I began to discover the psychological triggers – the habits that had programmed me. Writing this column, for example, would have been a good enough reason to light up. Just walking into my study worked just as well. So I had to do something else – chew gum or exercise or breathe deeply or just walk around. The shrink and I agreed that I would practice aikido movements when temptation arose, and it did quite often at first. I got angry at those thoughts for intruding on my day.

The health issue (see page 10) never convinced me, obviously. But now I get it. In the blood work for my recent annual physical, my triglycerides plunged into normal territory, and my blood sugar was the lowest it has ever been. Nicotine, I learned, is a player in the metabolic syndrome – the cholesterol, triglyceride and blood sugar mechanisms. Nevertheless, health scares had been no match for my biochemistry and the primitive region of my brain, which considered nicotine not as pleasure but as survival. That wasn’t all. I had to resituate myself in another dimension of living – the spiritual plane into which I could retreat from the fog of war. I would not be free to be the real me if a chemical held me captive. And so I prayed, even asking God at one point to fiddle with the nicotine receptors in my brain. Body, mind, spirit. We devote a section of each issue of Together to these three dimensions of living. They are the three dimensions of recovery, as well. Work the first two and you can get nicotine or anything else out of your system. You have to work the third, however, if you want to replace a substance with serenity.

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GUEST•COLUMNIST

Recovery In This Economy You may be doing okay, but it’s likely that someone you know isn’t By Nicholas S. Perna

There are steps people can take on their own if they lose their jobs or feel that a bout of unemployment is imminent.

How does the economy affect people in recovery? Studies show that alcohol sales skyrocket during recessions and that people experiencing financial stress tend to drink more. There are indications that bad times lead more young people into selling drugs. Statistics show that drug and alcohol abusers are more likely to be unemployed. And it is not uncommon to hear people in recovery talking about financial setbacks – the loss of a home or a job. Given that this economy can exacerbate the problems of addiction and recovery, we asked a noted economist frequently quoted in the press for his personal take on the recession and how we should think about it.

nemployment statistics have always fascinated me. One of my early jobs was in Washington D.C. as labor economist for the President’s Council of Economic Advisers. The day before the unemployment rate was released to the press, I would go to the Labor Department to pick up the data to write a report that would be on the President’s desk before the news hit the wires. I was worried about losing the envelope on the way back to my office and causing a major national crisis, but it never happened. I still follow the numbers closely. In March, nearly 13 million people were “officially” counted as unemployed. However, this is only the tip of the iceberg. The total nearly doubles when we add those who are involuntarily working part-time but would prefer full time work if it was available and those who want a job but gave up looking. You have to look for work to get counted as unemployed. And these statistics don’t adequately measure the human toll of what has been called the “Great Recession,” which officially ended in mid- 2009, and the subsequent “Not So Great Recovery.” However, there is hope. Employment has been increasing, and most economists expect jobs to continue to grow in coming years. Furthermore, there are actions that unemployed individuals can take on their own to ease the pain and accelerate getting back to work.

The human costs A recent study by the Centers for Disease Control (CDC) concluded that the unemployed were much more likely to suffer from depression than those with jobs (21 percent vs. 6 percent). Other studies have found a link between unemployment and suicide. Not surprisingly, mass layoffs and prolonged unemployment have had a significant impact on suicide rates. The duration of unemployment has been especially long during the current sluggish recovery. Of course, nothing is ever simple: psychologists point out that depressed people might be more likely to become unemployed. In some European countries, economic conditions are much worse than in the United States. “Austerity measures” have turned life upside down for many workers and business owners. According to the New York Times, suicides among Italian men rose 52 percent from 2005 to 2010. Since then, unemployment and uncertainty have grown worse, not just in Italy but Ireland, Spain, Greece, Portugal and elsewhere. It doesn’t require expensive studies with stratified sampling to understand the connections between unemployment and emotional stress. In the United States, losing a job almost always means an immediate and sizeable drop in income and quite often the loss of medical insurance. For those who are eligible to collect, the benefit checks are considerably smaller than what they earned on the job. Also, unemployment compensation does not replace medical insurance. For many of the unemployed, this means having to go without insurance in order to feed and house their families.

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job, but putting a couple of kids through school when you are out of work can exhaust your finances very quickly. I had a number of suggestions based on my having been both a full-time and part-time college professor for many years, and they illustrate how you can analyze any financial challenge to find a solution. If a child’s first choice “name brand” school costs $55,000 per year, for example, maybe the family should discuss going to the local state college for the first two years and then transferring to the school of choice for the final two years. Living at home and paying “in-state” tuition can save a heap of money. Even if your job is going well, it is worth encouraging your young scholar to complete college in three years instead of the traditional four (or five?). This might involve taking extra advanced placement courses in high school as well as taking college courses during the summer. This not only saves on tuition and living costs but it gets your youngster into the workforce and off your “payroll” a year earlier. This slow recovery is causing all of us to be creative. For example, should you start your own business? Maybe your woodworking hobby can get you some part-time work making cabinet parts for a shop or doing small installations for your local lumber yard. White-collar workers usually turn to consulting. Perhaps your old company or a competitor can use an independent contractor. I hate to sound like an expert on everything. My mother used to warn me about becoming a “jack of all trades and master of none.” However, I did start my own business about a dozen years ago. Believe me, it was very scary leaving behind a nice salary, company-paid medical benefits, secretarial help, and computer support. I was quite fortunate in having a good reputation in my field and being in demand as a speaker and writer. Even so, I had to get used to being a one-man band. I resisted the temptation to spend money to get started. I worked out of my house and did most of my own secretarial tasks. I still do. I met potential clients at their place of business or at Starbucks for coffee. I came to realize how much time I had to devote to looking for projects. I’ll bet that the average “consultant” spends at least quarter of his or her time prospecting, writing proposals and networking – none of which pays anything. Maybe I should end with some advice from someone else, Yogi Berra: “When you come to a fork in the road, take it.” Yogi was supposedly giving directions to his good friend, Joe Garagiola. But to me, Yogi was saying, “If you just sit there, you’ll get rear-ended. So do something. If it’s the wrong choice, then try something else.”

It surprised even me to find out that only about half of the 13 million unemployed workers are receiving unemployment compensation. What about the rest? Some have exhausted the maximum benefits of 99 weeks, which has recently been reduced to 73 or 63 weeks depending on their state’s unemployment rate. Others are ineligible because they recently entered or re-entered the workforce. You have to have been laid off from a job in order to collect. Even those with jobs suffer severe emotional stress during times of recession and high unemployment. During the deep New England recession of the early 1990s, I was very fortunate to have kept my job with a large financial institution. However, it was still a time of very high anxiety for me and many of my colleagues. We took sizeable pay cuts and were in constant fear of getting laid off as we watched others getting pink slips. This went on for several years. Back to the future, there’s light at the end of the tunnel. The economy is recovering – albeit slowly. Jobs have been growing, and the unemployment rate has been dropping. Most economists predict that the progress will continue.

What to do There are steps people can take on their own if they lose their jobs or feel that a bout of unemployment is imminent. I Googled “unemployment support groups Connecticut,” where I live, and found pages of helpful listings, such as a document prepared by the United Way citing the numerous programs and agencies that can be of help with psychological counseling and financial assistance. In a recent Harvard Business Review article, Justin Menkes outlined four steps to help individuals deal with the “trauma” of unemployment. (1) Acknowledge the trauma by discussing it with family and friends so each can understand how it is affecting them. (2) Push yourself physically to not only provide some relief from the stress but also build yourself up emotionally. (3) Make 10 networking calls every day to create a sense of accomplishment and to find opportunities. (4) Finally, remind yourself that this will pass. Involving family is especially important. I remember reading about a Japanese “salary man” who lost his job when Japan’s economy imploded during the early 1990s. Every morning he dressed in his business suit and left the house carrying his briefcase as if he was going to work. The poor fellow couldn’t bear the shame of telling his family that he no longer had a job. A few weeks ago I did a guest spot on a local radio show in which we got around to talking about the huge costs of a college education. It’s hard enough if you have a good paying

Nicholas S. Perna, PhD, advises several large financial institutions about the economy. He is a participant in the Wall Street Journal’s monthly survey of forecasters and teaches a course on the U.S. financial system at Yale University.

Q uotable:

"I like living. I have sometimes been wildly, despairingly, acutely miserable, racked with sorrow, but through it all I still know quite certainly that just to be alive is a grand thing." – Agatha Christie

IN•THE•NEWS

Headliners • • • • • •

Epidemic of overdoses A recent study that found soaring hospitalization rates for combined drug and alcohol overdoses among young adults suggests doctors could play a pivotal role in educating the public about the dangers of combining these substances, The Partnership at Drug Free.org reports. The study found hospitalization rates for combined alcohol and drug overdoses increased 76 percent among adults ages 18 to 24 from 1999 to 2008. During that same period, hospitalizations for alcohol overdoses alone increased 25 percent, and for drug overdoses, 55 percent. There was a 122 percent increase in hospitalizations for narcotic pain medication poisonings, and alcohol overdoses played a role in one in five such hospitalizations. “While the increase could be due to better reporting, we think, given corroborating evidence, that this represents an actual increase in the rate of overdoses for drugs, alcohol and the combination of the two,” says study author Aaron White, PhD, Health Scientist Administrator at the National Institute on Alcohol Abuse and Alcoholism (NIAAA). He is concerned that too few young people

are aware of the dangers of combining drugs, particularly prescription medications, and alcohol. “Drugs such as narcotic pain medications, some anti-anxiety medications and benzodiazepine-like sleep medications are very risky to combine with alcohol due to their depressant effects on brain function,” he points out. Adding them to alcohol can increase the risk of injuries, amnesia and death. White explains that alcohol can cause death by suppressing neurons in the brainstem that control vital reflexes like breathing and gagging. Some prescription drugs, such as narcotic pain medications, suppress these same brain stem areas, making them especially dangerous to combine with alcohol.

A vicious eating cycle New research provides evidence of the vicious cycle created when an obese individual overeats to compensate for reduced pleasure from food, the American Psychotherapy Association reports. Obese individuals have fewer pleasure receptors and overeat to compensate, according to a study by University of Texas at Austin senior research fellow and Oregon Research Institute senior scientist Eric Stice and his colleagues. It was published in The Journal of Neuroscience. Stice shows evidence that this overeating may further weaken the responsiveness of the pleasure receptors (“hypofunctioning reward circuitry”), further diminishing the rewards gained from overeating. Food intake is associated with dopamine release. The degree of pleasure derived from

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eating correlates with the amount of dopamine released. Evidence shows obese individuals have fewer dopamine receptors in the brain relative to lean individuals and suggests that obese individuals overeat to compensate for this reward deficit. People with fewer of the dopamine receptors need to take in more of a rewarding substance – such as food or drugs – to get an effect other people get with less. “Although recent findings suggested that obese individuals may experience less pleasure when eating, and therefore eat more to compensate, this is the first prospective evidence to show that the overeating itself further blunts the award circuitry,” says Stice, a senior scientist at Oregon Research Institute, a nonprofit, independent behavioral research center. “The weakened responsivity of the reward circuitry increases the risk for future weight gain in a feed-forward manner. This may explain why obesity typically shows a chronic course and is resistant to treatment.”

Medicating the troops In a small but growing number of cases across the nation, lawyers are blaming the U.S. military’s heavy use of psychotropic drugs for their clients’ aberrant behavior and related health problems, The Los Angeles Times has reported. Such defenses have rarely gained traction in military or civilian courtrooms, but military psychiatrists and court-martial judges are not blind to what can happen when troops go to work medicated. After two long-running wars with escalating levels of combat stress, more than 110,000

active-duty Army troops last year were taking prescribed antidepressants, narcotics, sedatives, antipsychotics and anti-anxiety drugs, according to figures recently disclosed to The Times by the U.S. Army surgeon general. Nearly 8% of the active-duty Army is now on sedatives and more than 6% is on antidepressants — an eightfold increase since 2005. “We have never medicated our troops to the extent we are doing now.... And I don’t believe the current increase in suicides and homicides in the military is a coincidence,” said Bart Billings, a former military psychologist who hosts an annual conference on combat stress.

Off the reservation Legislation in Nebraska that would curtail alcohol purchases to residents of a dry Indian reservation has stalled in a key committee whose members have received thousands of dollars in campaign contributions from the alcohol industry, according to state records, The New York Times reported. At least seven of the eight senators on the General Affairs Committee have received contributions from Anheuser-Busch, which brews Hurricane High Gravity Lager, a high-alcohol malt liquor favored by the dozens of men and women who sleep outside beer shops in rural Whiteclay, Neb. The town sells four million cans of beer and malt liquor annually to residents of the Pine Ridge Indian Reservation in South Dakota, just north of the state line. The Oglala Sioux tribe on the reservation says alcohol has been at the root of almost all of its health and crime problems.

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BODY•MIND•SPIRIT

Fit For Recovery A conversation with fitness guru Jolene Matthews By Suzanne Riss

Together: What role can exercise play in recovery? Jolene Matthews: Exercising can build self-esteem and produce a natural high by releasing endorphins. It puts the focus on a positive goal and deflects from obsessing over a substance. For me, dancing helps, doing Zumba (a dance fitness program), or spinning to get my heart rate up. For men in the throes of addiction or in recovery, lifting heavy weights and seeing their bodies be transformed can help a lot, especially if their muscles have atrophied.

Did physical activity play a role in your recovery? When I was drinking, I was sick and tired and never wanted to get to the gym. Now I feel so healthy and strong mentally and physically. Exercising changes the way I feel about myself. It’s also social. Addicts can isolate, obsess about triggers. Exercise keeps you in a healthy environment. As group fitness director and personal training manager at Sky Club Fitness in Hoboken, N.J., I teach classes three times a day during the week and do my own workouts on the weekend. I love to feel good.

I had alcohol in my life from an early age. My father walked out the door when I was 12. He left my mother after 25 years for a woman 20 years younger. There was so much change in so little time. I remember watching my dad drink. So at 12, I started to drink to feel closer to him. I’ve learned that if you start drinking before the age of 14, you change the neurons in your brain, and you have a higher chance of becoming addicted. In high school, I was first to say, “Let’s go to a party. Let’s get a drink.” I was a party girl. I was always involved in after-school activities and I also did well in school. I worked hard and played hard. I was also a dancer and took 15 dance classes a week. My addictive brain told me it was all or nothing. I had to be the best in school. On the weekend, I binge drank because I deserved it.

Was there drinking in your family besides your father? I grew up with grandparents, aunts and uncles who were all alcoholics. They would drink in the morning. I’d visit my uncle and see him drink a six-pack before work. I’d visit my grandmother and we’d go to the pub. I never met my grandfather because it was more important to him to drink.

What was your first encounter with alcohol?

(Continued on page 6)

Jolene Matthews is a nationally known certified group fitness instructor/dancer, model and personal trainer. She has made a variety of appearances in films and on such TV shows as the FOX Morning Show and Saturday Night Live. An avid athlete, Jolene enjoys teaching all forms of fitness. Jolene uses her national platform to promote three charitable organizations: Big Brothers, Big Sisters, and Animal Rights. She founded The Page Family Foundation, which provides meals to alcoholics living a life of recovery and sobriety. Learn more at www.jolenematthews.com and her blog, jolenematthewsaddictionfitness.blogspot.com/.

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Fit for Recovery (Continued from page 6)

Did any of them get help? I grew up in England and there wasn’t a lot of help readily available. What is great about society today is that there is help. Now people understand that alcoholism is a real disease. It’s not just a problem for homeless people or a random uncle. It’s one in 12 people who have an addiction issue.

What role did alcohol play in your life as an adult? Champagne and Chardonnay were my best friends. They always helped me relax. They were always there. I started getting a lot of anxiety as an adult. Drinking took that anxiety away.

When did you start to realize you had a problem? I got married seven years ago at the age of 28. By then I had 15 years of drinking under my belt. My husband would comment that there were a lot of bottles of wine coming into the house. You cross the line pretty quickly. I remember waking up and wanting a drink to relax, to get straight because I was hung over from the night before. My husband thought I had a problem. So I started hiding drinks. I’d sneak extra drinks in the kitchen. I needed three drinks to everyone else’s one. I became

embarrassed about my drinking. I noticed that my drinking started to slow down my goals at work as a personal trainer with my clients. I wouldn’t be feeling well. I also wanted to have children, and my husband said I needed longterm sobriety first.

How did you go to your first AA meeting? My husband pushed me. He asked a few times. He said: Try not to drink for a month. I went to prove to him that I didn’t need to go to those stupid meetings. I went to my first meeting about three years ago. I didn’t get it right away. It’s progress not perfection. I did have hope. I’ve been in recovery for about a year.

What did you discover in the rooms? I kept hearing the same story from older people, younger people, men, women. They all had the same story about how alcohol started to destroy their lives. Some people have lower bottoms than others. I never got a DUI, but if I continued on that path, I knew I would get there.

What else helped with your recovery? I spent 28 days at Hazelden where I experienced profound changes. They call it the house of miracles. I went in there so ashamed and broken. I worked on spiritual issues and addiction issues. I learned that unprocessed grief can lead to addiction, and once you heal the places that hold the grief, you can move on.

Why did you decide to share your story? For me, it helps to be open. I’m able to tell my story to anyone. We all have some kind of a vice. To share my experience, strength and hope on TV or at gym or in a newspaper helps me. It’s important to just be me. I don’t think my sobriety needs to be kept a secret. I’m proud of myself for all I’ve overcome. I also want to help remove the stigma about AA. I think that’s changing slowly. People tell me I don’t look like a typical alcoholic. I come from a well-off family. The shame kept me sick. I learned that you’re a winner when you accept yourself for who you are. My biggest misconception is that I thought AA would be a bunch of old men. I made a lot of great friends there and we do sober, fun activities together. It’s hard for a lot of people who never had an addiction issue to understand. But ask them what they do everyday, whether it’s check email or go on Facebook or work on their computer. And tell them not to do it for a month. It’s a great way for people to start to understand how hard it is. No texting for a month! And of course it’s even harder for someone who’s struggling with an addiction issue.

What changes have you noticed in recovery? The obsession starts to lift. But I learned at Hazelden that your brain is permanently damaged from alcoholism. An addiction becomes the top priority above food, water, and reproduction. I know I can go right back to that lifestyle and downward spiral. That scares me. It’s a healthy fear to have. I keep my brain on track with AA meetings. Now my life is better than when I was drinking. It’s proof that the program works.

You’ve said you meditate daily. We live in such a rushed society. People work 10-hour days. They sleep and go right back to work again. They don’t have time to go to the gym. We’re not talking time to

center ourselves, relax and breathe. It was hard for me to get into meditation. But spirituality is like a muscle. You need to work it. So many people don’t feel comfortable sitting with themselves. I meditate every morning to stay connected to my Higher Power and to myself. It can ease anxiety and stress. I started meditating for 20 minutes. I closed my eyes, focused on a color or a place I wanted to be, like a beach, to get relaxed. I focus on my breathing. Then the thoughts start to creep in: I need to go to the dry cleaner; what am I going to eat for lunch? When you get a thought, you let the thought arrive and let it go. Meditating can be hard at first, but if you do it with discipline for eight weeks straight, you will see some great changes. They say that praying is talking to God and meditating is God talking to you.

Are you working to become a licensed alcohol counselor? Yes, I’m in the middle of getting my license. I think it will be a great addition to the work I do in the health club. A health club is a more relaxed atmosphere to get help for an addiction than a doctor’s office. My work at the health club is about overall wellness. I’ve even designed a fun bling, bling workout clothing line for women in recovery that’s fun and sexy and will inspire them.

What has been your biggest revelation during your recovery process? Addiction is like the color of your hair. It’s not the result of something you did. It’s in your genes. It wasn’t my fault that I have the disease of alcoholism but my recovery is my responsibility. Suzanne Riss is a writer and editor who specializes in health and women’s issues. Most recently she was Editor-in-Chief of Working Mother magazine. Her first book, The Working Mom Survival Guide, was published by Weldon Owen in October.

In F act:

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A history of binge eating may make an individual more likely to show other addictionlike behaviors, including substance abuse, according to Penn State College of Medicine researchers. “Substance-abuse and binge eating are both characterized by a loss of control over consumption,” says said Patricia Sue Grigson, Ph.D. “Given the common characteristics of these two types of disorders, it is not surprising that the co-occurrence of eating disorders and substance abuse disorders is high."

T gether

New Yorkers suffer with addictions. Addiction affects family and friends all over the city. How do you reach them? Advertise in Together Tap into the country’s number one market! Join the conversation about addiction, recovery and healthy lifestyles

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BODY•MIND•SPIRIT

Put Your Life on Autopilot Slow down and notice how little self-control you have. By Tony Schwartz “Civilization advances by extending the number of important operations which we can perform without thinking about them.” – Alfred North Whitehead

hy is it that three prominent books published during the past several months focus on the subject of willpower? The first answer is that neuroscience has finally begun to open a window into the complex way our brains respond to temptation and what it takes to successfully exercise choice. Second, a raft of recent studies have shown that the capacity for selfcontrol – even more than genetic endowment or material advantage – fuels a range of positive outcomes in life, including more stable relationships, higher paying and more satisfying work, more resilience in the face of setbacks, better health, and greater happiness. Finally, these books – Willpower, The Willpower Instinct, and The Power of Habit – are a response to an increasingly evident need. Demand in our lives is truly outpacing our capacity. The sheer number of choices we must make each day – what foods to eat, what products to buy, what information merits our attention, what tasks to prioritize – can be overwhelming. As Roy Baumeister puts it in Willpower, “Selfregulation failure is the major social pathology of our time.” Each of these books provides compelling studies and fascinating stories that illustrate the challenges we face in exercising more self-control. All of them also come to the same paradoxical conclusion that I did two years ago in a book of my own, Be Excellent at Anything.

Our primitive brains

Put simply, the more conscious willpower we have to exert each day, the less energy we have left over to resist our brain’s primitive and powerful pull to instant gratification. According to one study, we spend at least one-quarter of each waking day just trying to resist our desires – often unsuccessfully. Conversely, the more of our key behaviors we can put under the automatic and more efficient control of habit – by building something I call “energy rituals” – the more likely we are to accomplish the things that truly matter to us. These rituals are highly precise behaviors, done at specific times until they become automatic so they no longer drain your reservoir and undermine your capacity for self-control. How different would your life be, after all, if you could get yourself to sleep eight hours at night, exercise every day, eat healthy foods in the right portions, take time for reflection and renewal, remain calm and positive under stress, focus without interruption for sustained periods of time, and prioritize the work that matters most?

Right now, the vast majority of what we do each day occurs automatically. We’re often triggered, as these authors make vividly clear, by subtle cues we’re not even aware of – a smell, a visual image, a familiar sight. These cues prompt us to move away from any potential pain and discomfort, no matter how minimal, and toward immediate reward and gratification, no matter how fleeting. The primary role of our prefrontal cortex is to bias the brain towards doing the “harder” thing. Unfortunately, our rational capacity is often overwhelmed by the power of our own most visceral and primitive desires. We’re often captive to our biochemistry. When the neurotransmitter dopamine is triggered, for example, what we feel is craving, not pleasure. This explains not just why we fall into a range of selfdestructive addictions, but also why we don’t take better care of ourselves and make wiser choices day in and day out. The solution is to learn how to co-opt the more primitive habit-forming regions of our brains, so that rather than reinforcing our negative impulses, they become the soil in which we build positive rituals that serve our long-term interests. So how do you get started? The first step is simply to understand better what you are up against. That requires slowing down. Speed is the enemy of reflection, understanding and intentionality. When we slow down, we can begin to notice both what’s driving us and how to take back the wheel.

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Self-observation Eat slower, for example, and you not only begin to notice how rarely you savor the food you eat, but also how often you eat for reasons other than hunger and how rarely you notice when you’ve had enough. To begin strengthening your capacity for selfobservation, take two or three minutes at several designated times a day to breathe in to a count of three and out a count of six with your eyes closed. Notice the thoughts, feelings or sensations that arise, name them, and then let them pass. Return to the breath. You’re training mindfulness. We each have an infinite capacity for selfdeception – endless ways that the awesome power of our desires causes our prefrontal cortex to defend the indefensible and rationalize behaviors that aren’t serving us well. The first step to building willpower and self-control is recognizing how little we currently have. You can’t change what you don’t notice. Tony Schwartz is the president and CEO of The Energy Project, which works with people and companies to create a fully engaged workforce using the multidisciplinary science of high performance. Become a fan of The Energy Project on Facebook and connect with Tony at Twitter.com/TonySchwartz and Twitter.com/Energy_Project.

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BODY•MIND•SPIRIT

A Field Theory View of Recovery We are continuously projecting and aligning with an unseen force By Pat S.

extreme, touching another person almost always produces a direct, hyper-connection. This connection may be positive (affection) or negative (assault). Some doctors will deliberately touch a patient to establish a calming bond. You want evidence of spiritual fields? I use what I call my TSA Test to measure my field. When I approach the security counter at an airport, I first ask, ”How are you today?” with a smile. A smile (of sorts) is always returned. Frowns come before and after, but a smile is always returned. Negative fields are equally powerful, but I choose not to test those.

hy do some of us recover, and others continue down the nasty spiral to destruction or death? There are many theories, from divine intervention to dumb luck. Whatever the motivation, there are certainly factors that support, or hinder, one’s recovery. Environmental factors play a significant role. Hang out with people who are drinking, and you are more likely to drink. Hang out with sober folks, and you are more likely to stay sober. However, there may be less obvious forces at play. Here’s my hypothesis: like gravity and magnetism, there is another force, a spiritual force, which is just as measureable and predictable. The spiritual force emanating from us is perhaps many times stronger, given our relatively low mass and voltages. What is really cool is that we can control this spiritual force almost instantly. On the other hand, gravitational pull increases and decreases with mass. I have yet to master my ever-increasing gravitational pull. And I am sure that the magnetic fields emanating from the

A pure field

circuits of my nervous system are imperceptible, though I have never tried to measure them. We see evidence of this spiritual force (or field) as we walk through life. We feel elated

or depressed based on the interacting forces of those around us. We even feel the effect of other people’s spiritual forces long after we experience it, thanks to our ability store the spiritual patterns of others. Our ability to recollect factual data, such as time, temperature, sequence and distance, is far less acute that our ability to recall how we feel about someone (or even something, though our feelings about things are often based upon the spiritual fields of those nearby.)

Part of a whole

I refer to field theory here not as the psychological theory espoused in the ‘50’s. In fact it is closer to Quantum Field Theory, which holds that despite appearing as individual particles under consideration (humans in our case), we are actually part of a whole. For our purposes, let’s consider a field as an overriding environment or current that colors our experience or perception. For example, if we are in a room that is bathed in blue light, everything appears blue. If we are at a wedding, everything appears happy. If we are on the moon, everything appears to have less mass. We are overwhelmingly affected by the surrounding environment and must behave within that context. When the power of that field exceeds certain limits, the results can be catastrophic: imagine trying to survive in an oven. At some point we succumb. Some people believe the converse: that if we are resonating with a higher-power field, we become immortal. I have yet to see evidence of such. What we are talking about here are microfields, those much smaller fields that emanate from us human beings. However, they have a powerful impact on those around us when there exists sufficient proximity. Taken to the

A pure field is one that is motivated only by spreading joy; it does not seek reward. It is usually successful unless there are countervailing forces. Positive fields generated for material gain (such as a free upgrade to business class) are less predictable and less enjoyable (though may provide immediate gratification). How can we control this force? Move a muscle and change the world. Smile as you approach your next stranger. Ask how she is doing. Stop and help change a tire. Some postulate that if everyone were to take a step in the same direction, we could stop the Earth’s rotation. Not that we would want to. If everyone were to smile at once, would the resulting force be so strong as to banish ill will forever? I would love to see it, but we should beware the rule of unintended consequences: What if everyone smiled all the time; would smiles lose their meaning? Let’s make the world a better place, one field at a time (our own). Alcohol and other substances of abuse have a profound impact on our ability to generate fields or control the fields that we are able to generate. Alcohol also inhibits our ability to accurately or effectively align to others’ fields. Indeed, our receptors are either numbed to appropriate alignment and interpretation, or are unable to read others’ fields at all. As a result, alcoholics in the throes of their disease may misinterpret the well-meaning efforts of others as criticism. Spiritual Field Theory also explains the alcoholic’s inappropriate behavior: inability to align with individuals’ or the broader, prevailing higher-power fields. When we talk of God in 12-step programs, we talk of the Gift Of Desperation, Group Of Drunks, Good Orderly Direction, or some such thing. The fact is, God is a field, and we can align to this field and relax as the events of our lives flow past in spiritual harmony. Or we can turn counter to this field and struggle through every seemingly innocuous moment of the day. If we drink, we lose all sense of direction and risk being swept away. When we walk into the rooms of Alcoholics Anonymous, we enter a collection of micro-fields, all eagerly aligned to the Higher field and away from the chaotic, destructive force that was our past. It is this micro/macro alignment with patience, kindness, tolerance and love that is the power of recovery.

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PRACTICUM

Life

Yo u When Life Doesn’t Play Fair In life, as in golf, we need a ritual. By Thomas Crum

s the golf ball sliced toward the woods, his face grimaced in disgust. He slammed his club on the ground, muttered something under his breath, and shook his head. His walk down the fairway was a physical display of failure – head and shoulders slouched and feet dragging as if his clubs and the world had let him down again. I have seen this many times watching talented junior golfers and high school golfers. It is not their swings or athleticism that is letting them down; it is their inability to deal with their mental and emotional game. Golf is a complex mind/body art and when the mind gets disturbed, the body often follows suit. The good news is that golf is just slow enough that it becomes the ideal sport to learn about the mind/ body/emotion connection. So when I was asked to work with our local high school golf team, a wellcoached state-championship contender, I knew where I could contribute. I asked the kids about their pre-shot ritual, a precise, individualized, step-by-step procedure that prepares them for the proper set-up of stance and alignment to maximize swing potential and minimize thought distraction (like a baseball player’s pre-swing ritual in the batter’s box). The pre-shot ritual is repeatable time after time, and these kids, like all good players, each had one. Then I let them in on a secret that most golfers do not know – that they needed a post-shot ritual as well. Whether they knew it or not, they already had one and for some of them, their post bad shot rituals were deteriorating their games. I asked them to act out their post bad shot rituals. Some threw or dropped their club, others swung it viciously in disgust, one let fly a four-letter word. Weak physiology ruled,

and emotions of anger and humiliation dictated their next actions. They could easily see how this ritual could negatively affect the next shot. They knew they needed to create and practice a new post bad shot ritual, one that supported their goals and their values. In the game of golf, as in life, we are going to have some bad shots. This is our opportunity. We can create a post-event ritual ourselves. We can get centered, by aligning the body so it is balanced and powerful rather than weak and slouched. We can focus on our breathing to bring us back to the present moment. From center, we can feel and observe the emotion, like witnessing a passing rainstorm, rather than “act out of it.” Next, we can learn from the situation; what did I actually do and how could I do it differently? See and rehearse the possibility of an excellent “swing” and result for the next time. And finally look to the mystery – it’s now a new opportunity to discover and to play fully, with aliveness and awareness. When our world doesn’t show up as we expect, and anger, resentment, jealousy, or sadness flood our bodies, we need our own conscious practice. Create yours, practice it daily, and watch your “game” improve!

When our world doesn’t show up as we expect, we need a routine to stay centered.

Thomas Crum is an author and presenter in the fields of conflict resolution, peak performance, and stress management. For more than 30 years, he has been a teacher of Aikido, a graceful martial art that uses energy rather than force to resolve conflicts, and he includes principles and movements from Aikido, Tai Chi Chuan, Qi Gong, and other mind-body arts in his presentations to government and corporate groups. He is the author of Three Deep Breaths and other books. This article originally appeared on his blog, Centering Hint, at www.thomascrum.com.

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SPECIAL

Lighting Up When Lit Up Smoking and drinking commonly go together, and commonly kill together. A group of smokers outside a 12-step meeting is as predictable as the coffee pot inside. The accepted wisdom among those in recovery and at rehab centers is that it’s best to deal with the alcohol or drug addiction first and that addressing smoking at the same time may hinder that. Current research is indicating otherwise. From The National Institute on Alcohol Abuse and Alcoholism

lcohol and tobacco are among the top causes of preventable deaths in the United States. Moreover, these substances often are used together: Studies have found that people who smoke are much more likely to drink, and people who drink are much more likely to smoke. Dependence on alcohol and tobacco also is correlated: People who are dependent on alcohol are three times more likely then those in the general population to be smokers, and people who are dependent on tobacco are four times more likely than the general population to be Together Q pg CH 10/27/11 4:20 PM dependent on alcohol.

The link between alcohol and tobacco has important implications for those in the alcohol treatment field. Many alcoholics smoke, putting them at high risk for tobacco-related complications including multiple cancers, lung disease, and heart disease. In fact, statistics suggest that more alcoholics die of tobacco-related illness than die of alcoholrelated problems. Also, questions remain as to the best way to treat these co-occurring addictions; some programs target alcoholism first and then address tobacco addiction, whereas others emphasize abstinence from drinking and smoking simultaneously. Effective treatment hinges on a better understanding of how these substances – and their addictions – interact. The National Institute on Alcohol Abuse and Alcoholism’s 2001–2002 national survey, one of the largest comorbidity studies ever, confirmed the widespread use of alcohol with tobacco. Approximately 46 million adults used both alcohol and tobacco in the past year, and approximately 6.2 million adults reported both an alcohol use disorder and dependence on nicotine. Page 1 Alcohol and tobacco use varied according

Sometimes

We Have to Get Away Before We Can Be Fully Present

to gender, age, and ethnicity, with men having higher rates of co-use than women. Younger people tended to have a higher prevalence of alcohol use disorders, nicotine dependence, and co-use. Comorbid mood or anxiety disorders are another risk factor for both alcoholism and nicotine dependence. Data show that alcohol abuse is strongly correlated with a co-occurring mood or anxiety disorder. The presence of comorbid mental illness also raises the risk for tobacco addiction. Another study found that 50 to 90 percent of people with mental illness or addiction were dependent on nicotine.

A double whammy Alcohol and tobacco use may lead to major health risks when used alone and together. In addition to contributing to traumatic death and injury (e.g., through car crashes), alcohol is associated with chronic liver disease, cancers, cardiovascular disease, acute alcohol poisoning (i.e., alcohol toxicity), and fetal alcohol syndrome. Smoking is associated with lung disease, cancers, and cardiovascular disease. Additionally, a growing body of evidence suggests that these substances might be especially dangerous when they are used together; when combined, alcohol and tobacco dramatically increase the risk of certain cancers. Cancers of the mouth and throat. People who drink and smoke are at higher risk for certain types of cancer, particularly those of the mouth and throat. Alcohol and tobacco cause approximately 80 percent of cases of cancer of the mouth and throat in men and about 65 percent in women. For people who both smoke and drink, the danger of mouth and throat cancer increases dramatically – in

fact, the combined risk is greater than or equal to the risk associated with alcohol multiplied by the risk associated with tobacco. Alcohol and tobacco co-use appears to substantially increase the risk of at least one type of cancer of the esophagus. Liver cancer. During the past decade, the incidence of liver cancer has increased dramatically in the United States. Although some studies have reported that alcohol and tobacco may work synergistically to increase the risk of liver cancers, more research is needed. Cardiovascular disease. The American Heart Association estimates that more than 34 percent of the U.S. population has some form of cardiovascular disease. Tobacco use and alcohol consumption both are major risk factors for various forms of cardiovascular disease. However, little evidence exists to suggest that drinking and smoking together raise the risk more than the sum of their independent effects. Determining the risk factors for car-

Stopping Both At

T CUMBERLAND HEIGHTS Alcohol & Drug Treatment Center 201-600-2665 • 800-646-9998 A Non-Profit Foundation • Nashville, TN • Founded 19 66 cumberlandheights.org

here are many reasons to provide concurrent tobacco and alcohol dependence treatment: the serious health effects of smoking, the synergistic adverse health effects of comorbid tobacco and alcohol use, the adverse effects of smoking on neurobiological and cognitive recovery from alcoholism, the fact that the majority of these smokers are concerned about their smoking and do not believe that quitting would threaten their sobriety, and that the majority of studies indicate that concurrent treatment does not compromise and even seems to enhance alcohol and other drug outcomes. In addition, alcohol consumption appears to potentiate the rewarding value of smoking. This suggests that if the positive effects of smoking are diminished during alcohol abstinence smokers may be more receptive to motivational and cessation interventions at this time. Alcohol treatment programs now recognize the importance of treating polysubstance disorders. The notable exception in many of these programs, however, continues to be the treatment of tobacco dependence. Researchers have provided detailed discussions of the steps needed for the suc-

cessful implementation of tob addiction treatment settings. since of this work, tobacco dep integrated into the majority o Smoking is often overlooke variety of barriers, including a residents should avoid major l cessation during their first ye smoking may jeopardize drug/a

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L•FOCUS diovascular disease is difficult because the issues involved are extremely complex. First, cardiovascular disease encompasses a variety of conditions (such as heart attack, stroke, and hardening or narrowing of the arteries), which result from numerous factors. Second, although tobacco has been shown to raise the risk for cardiovascular disease in a dose-dependent manner – the more a person smokes, the more his or her risk of developing cardiovascular disease increases – alcohol’s effect on cardiovascular disease depends on many factors, including gender, age, and drinking patterns. Overall, moderate drinking appears to reduce the risk for many forms of cardiovascular disease, whereas drinking large amounts of alcohol generally increases the risk.

Mutual craving Why do tobacco and alcohol use co-occur so frequently? Clearly environmental factors contribute to the problem. Both drugs are legally available and easily obtained. Over the past two decades, however, it also has become clear that biological factors are at least partly responsible. Although tobacco and nicotine have very different effects and mechanisms of action, it has been speculated that they might act on common mechanisms in the brain, creating complex interactions. These possible mechanisms are difficult to study, because alcohol and nicotine can affect people differently depending on the amount of the drugs consumed and because numerous factors, including gender and age, influence the interaction between nicotine and alcohol. Still, a common mechanism might explain many of the interactions between tobacco and alcohol, as well as a possible genetic link between alcoholism and tobacco dependence. Studies show that consuming tobacco and alcohol together can augment the pleasure users experience from either drug alone. For example, in one study subjects were given either nicotine-con-

taining or nicotine-free cigarettes and asked to perform progressively more difficult tasks to earn alcoholic beverages. The subjects who smoked nicotine-containing cigarettes worked harder and drank more alcohol than those smoking nicotine-free cigarettes. Conversely, another study showed that drinking alcohol enhances the pleasure reported from smoking cigarettes. This research is supported by animal studies, which show that nicotinetreated animals consumed more alcohol than did control animals. Evidence increasingly suggests that both alcohol and tobacco may act on the mesolimbic dopamine system, a part of the brain that is involved in reward, emotion, memory, and cognition. Brain cells (i.e., neurons) that release dopamine – a key brain chemical involved in addiction – have small docking molecules (i.e., receptors) to which nicotine binds. Evidence suggests that the interaction between alcohol and tobacco may take place at these nicotinic receptors. When nicotinic receptors are blocked, people not only tend to consume less nicotine but also less alcohol. This common mechanism of action may explain some of the interactions between alcohol and tobacco, including why alcohol and tobacco can cause users to crave the other drug and the phenomenon of cross-tolerance. A decrease in a person’s sensitivity to a drug’s effects often is referred to as tolerance. This phenomenon occurs when a person must consume more of a substance in order to achieve the same rewarding effect. In the case of alcohol and tobacco, this puts him or her at greater risk for developing dependence. Cross-tolerance – that is, when tolerance to one drug confers tolerance to another – also has been documented in people who smoke and drink.

A Quitter’s Medicine Cabinet Bupropion Bupropion is the only antidepressant that has been approved by the Food and Drug Administration for the treatment of nicotine dependence. Slow-release bupropion has been shown to be effective in the treatment of depression and nicotine dependence; however, it has not been shown to be effective for the treatment of alcohol dependence.

Nicotine Replacement Therapy (NRT) Although NRT has not been shown to reduce drinking, it might be an important treatment component in patients who use tobacco and alcohol to self-medicate for a mood disorder. Research suggests that NRT may improve the mood of depressed abstinent smokers, in addition to helping them quit smoking.

Varenicline Varenicline works at the nicotine receptor level to diminish nicotine’s effects. Recent studies have shown that it is significantly more effective than placebo in helping patients to quit smoking.

Topiramate Topiramate is an anticonvulsant drug. Researchers have demonstrated that subjects who received 300 mg/day of topiramate were much more likely to abstain from both alcohol and tobacco than patients receiving only brief therapy. In this study, topiramate had no effect on mood. – NIAAA

A family affair Recent studies suggest that common genetic factors may make people vulnerable to both alcohol and tobacco addiction. Clearly, both alcohol and nicotine dependence run in families. Identical twins (who share 100 percent of their DNA) are twice as likely as fraternal twins (who, like all siblings, share 50 percent of their DNA) to be nicotine and al-

(Continued on page 16)

At The Same Time

bacco dependence treatment in . However, even after 15 years pendence treatment is still not of these treatment programs. ed in these programs due to a attitudes of treatment staff (e.g., life changes including smoking ear of recovery, that stopping alcohol recovery), lack of knowl-

edge about the treatment of nicotine dependence, and a treatment culture amenable to smoking (e.g. “smoke-breaks” structured into the treatment day). Nicotine dependence may also be viewed as a low priority, when compared to more immediate harms of alcohol and illegal drug use, and drug treatment staff may believe their patients are not interested in quitting smoking. However, most alcoholics in treatment are concerned about their smoking and the preponderance of evidence indicates that trying to quit during substance treatment does not interfere with sobriety and, in fact, appears to be associated with better alcohol and other drug abuse outcomes. In addition, the clinical trial that produced the highest smoking abstinence rate to date was also fully integrated into the substance treatment program. – David Kalman, Department of Psychiatry, University Of Massachusetts School of Medicine, and colleagues

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I nsight

Who The Heck Do You Think You Are? How to replace self-loathing with self-love By Jean Campbell

hen my grandmother turned 90 years old, I remember asking her, “What’s the best part about being 90?” She thought about it for a moment and said; “I really don’t care what anyone thinks of me anymore.” I smiled at the thought, and then replied, “You mean I have to wait until I’m 90 for that?” It’s the human condition: we care what other people think about us. Brene Brown, the noted therapist and shame researcher, says that one of the loudest inner voices that can emerge with shame is the one that says, “Who the heck do you think you are?” It’s that voice that tells us to not even bother taking the risk, whether it’s to write this article, share a confidence with a friend, or to take any action that goes against how you were raised. You still live by those pesky family rules even though you haven’t lived with your family in years. The journey to overcome those voices, however, allows you to step into alignment with your true self, if you’re willing to walk through all the feelings that go along with it. Low self-esteem and grandiosity are inversely related: the less you feel good about yourself, the more you have to convince everyone else that you’re okay. But if you feel good about you, you don’t obsess over what anyone thinks of you. If at your core you feel worthless and ashamed, you’re going to be overly focused on what people think of you, and make every effort to get them to like you, often at your own expense. Our society is filled with example upon example of this, including attempts to “keep up with the Jones.” I’ve heard it said that people buy things that they don’t need so that they can impress people that they don’t even like. But why do we do this? Before we answer that question, we need to make an important distinction.

Guilt vs. Shame Guilt is “I’ve done something wrong,” while shame is “At my core, I am wrong.” As Brown said, with guilt, the focus is on behavior; with

Since shame is part of addiction, addicts are skilled at covering up and convincing the world that they’re fine, even when their inner world is crumbling.

shame, the focus is on self. When you’ve done something wrong, you can fix it or change it, or at least apologize for it. But how do you fix or change or apologize for yourself, for just being you, for just being alive? Shame comes from a variety of places: parents, religious groups, schools, peers, advertising. In the language of psychodrama, shame occurs due to inadequate doubling and too much negative mirroring. If you’re not given a healthy sense of yourself from the inside (doubling), nor a healthy sense of yourself from the outside (mirroring), then your ability to move out of the world of yourself into the world of others is distorted, and often stops altogether. In a healthy upbringing, what typically happens is that your primary caretakers attend to your needs: you cry and you get fed, burped, changed, and this doubling helps you develop a sense that you matter. Then you

receive a proper balance of positive (“You’re a great artist”) and negative (“You lied to me, and I am upset with you”) so that you can learn who you are in the world and make the transition from it being “all about you” to living in the world. It’s your parent’s job to hold up a mirror to you to help you get a sense of yourself. We all need some negative mirroring: it’s how you learn right from wrong, and it teaches you that we have an effect on other people. When a parent mirrors you in a loving way, you can hear it better. For example, “You know that I love you, but you did a bad thing by hitting your younger brother.” By having it delivered it in this way, you can hold on to the love, support and safety from your parent, and you’re more likely to integrate the lesson without feeling shame. If, however, you grow up in a dysfunctional and/or addictive environment, your process of development is virtually the opposite, and shame develops.

One of the hallmark symptoms of shame is perfectionism, and it paralyzes people. Shame-based people often believe that they’re supposed to know how to do everything by themselves, without asking for help, or having someone teach them how to do it. For example, when I went skiing for the first time, I was terrible at it: I spent most of the day on my butt instead of my skis. When we got into the car to go home, my friend asked me how I liked it. I told her, “I hate it, and I’m never skiing again.” The truth was that I felt ashamed that I had struggled with it all day. I was supposed to be good at it, even though I’d never had a lesson and had never done it before, right? Wrong! The following winter I swallowed my false pride, which lives at the core of shame, and took a lesson. Turns out that not only do I like skiing, but I’m actually pretty good at it.

Shame and addiction In an addicted (to alcohol, food, people, gambling, or anything else) family, shame is pervasive. Sharon Wegscheider-Cruse, a pioneer in the treatment of addicted families, talks about three “rules” in this type of family: Don’t Talk, Don’t Trust, Don’t Feel. How can you exist with those rules? The short answer is, you can’t. As interventionist Vince Casolaro says, the core rule is, “Don’t Exist.” So the only choice you have is to shut down, internalize all your feelings, needs and wants, and give up any sense of who you are as a person. Children have an innate desire to attach to their primary caretakers. If you’re allowed to attach, you develop a healthy sense of self, and feel safe and secure in yourself and in the world. If you’re not allowed to, because your caretakers are too caught up in themselves due to addiction, denial or mental illness, you become clingy and anxious, don’t develop trust in the universe, and you end up feeling a great void inside. Most addicts are familiar with that void: they spend years filling it with substances or unhealthy behaviors. Moreover, part of the disease of addiction is the need for the addict and his enablers to withhold the truth from themselves and oth-

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I nsight ers, i.e., denial. So when your Mom shows up drunk at your school play and you’re feeling ashamed and angry, your Dad, the chief enabler, will most likely discount your feelings by telling you it’s not that big a deal, or completely deny your reality by trying to convince you that Mom really isn’t that drunk. Add to that the fact that addictive family systems are punitive, judgmental and critical environments, and one of the unspoken rules is that when something goes wrong, you blame someone else. Because there is such a negative environment, you don’t have a good sense of yourself from the inside (not doubled), and then you’re constantly being told what you’re doing wrong on the outside (negatively mirrored). As a result, not only do you feel ashamed, but you’re constantly looking outside of yourself for someone to define you. So your deep fear of abandonment results in your abandoning yourself. Codependents routinely abandon themselves – their needs, thoughts and wants – so that they can focus on everyone around them, and “earn” the love and attention of others, and then feel “okay” inside. So if your development process was smooth, when Mom comes home in a bad mood, you don’t take it personally. If however, you were raised in a shame-based environment, her bad mood must be your fault.

Healing the shame When people come into recovery, they are consumed with shame. Their addiction has been a defense that has served them by allowing them to hide from themselves. Since shame is part of the disease of addiction, addicts have gotten highly skilled at covering up and convincing the world that they’re fine inside, even when their inner world is crumbling. If you’re a shame-based person, you probably walk around believing one of two things: either everything is your fault or nothing is. The trick is learning how to take on what is yours, and not take on what isn’t. “I didn’t know how I was feeling until I heard someone else say it.” One reason 12-step programs are so effective is that they allow you to listen to other people’s stories and be doubled (inside feelings) and mirrored (reflecting back you to you). And because it’s done in a non-confrontational way, you can hear it. It also busts through your shame because, unlike so many other places in your life, you can identify and you feel part of rather than different. So it becomes easier to say to yourself: “Maybe my life isn’t working so well. Maybe I do need to change.” One of the deepest fears most shame-based people walk around with is the idea that if people really know you, they won’t like you and will abandon you. That abandonment drives all sorts of addictive and obsessive behaviors.

Q uotable:

"Self-importance is our greatest enemy. Think about it - what weakens us is feeling offended by the deeds and misdeeds of our fellowmen. Our self-importance requires that we spend most of our lives offended by someone." – Carlos Castaneda

On the other hand, if the speaker at a 12step meeting shares about some of the demoralizing things he did in the throes of his addiction, and you have done those things, too, then suddenly you don’t feel so ashamed. Someone else gets it from the inside and can identify with you, so you’re not alone. Moreover, the fact that he can share it in a room full of people, and possibly even laugh about it, allows him to become a power of example of what can happen to you in your own recovery process, if you’re willing to take the

12-step rooms, and to proper feedback in therapy. Suppose you grew up in a home where someone always had a criticism or a sarcastic comment about something you said. When you finally take the risk in a 12-step meeting or in therapy to share how you’re feeling or what you’re thinking, it’s important that no one shares an opinion or judges what you’ve said. That freedom to share without comment builds a sense of trust and further allows you to share more. If, however, you don’t feel safe when you

Recovery means letting go of the “Itty Bitty Sh*tty Committee” in your head. risk to share who you are. Over the years, I’ve heard from many recovering people say that they were terrified to share a particular piece of their story with their sponsor when they turned over their 5th step (sharing your inventory). What a relief to know that the sponsor has done the same thing – or something worse. “Yes,” he might say, “I have that, too, and no, it doesn’t make you a horrible person. It makes you a recovering addict.” There’s a caveat here: not all things are meant to be shared with all people. An important lesson in recovery is learning whom to trust with what. The fact is that not everyone has good boundaries and can actually keep confidential what you’ve shared. So choose wisely.

share about yourself, then by all means, don’t throw the baby out with the bath water: find somewhere else where it is safe and keep moving forward. Another important thing to know is that if you’ve grown up in a shame-based environment, then initially you might to be drawn to people who are abusive or judgmental, which might not be obvious at first, and you might get hurt again. But as you work the steps and “stick with the winners,” your intuition will lead you towards kinder, safer people. It’s okay to “outgrow” people in recovery and to gravitate towards a new crowd, a new sponsor or a new therapist. When you say something shameful about yourself, the question to ask is, “Whose voice is that?” Often the answer is, “It’s mine.” The

negative voice has been in your head so long that you can’t separate it out from your own voice. I’ve been known to then ask, “Well, I’m sure you didn’t come out of the womb believing that about yourself, so who taught you to think that way?” Recovery means letting go of the “Itty Bitty Sh*tty Committee” in your head. By sharing yourself with others who are on the same path, and feeling that people understand and identify, the negative voices get smaller and quieter. As they shrink, there’s more room inside for the positive voices to come in, the ones that are an accurate reflection of who you are. For maybe the first time ever in your life, your insides will begin to match your outsides. It’s a struggle at first to let in that positivity. The initial instinct is to push away those loving and supportive comments, or undervalue them, but a key transition point in recovery is when you start to allow even a teeny, tiny little bit of light in, and begin to digest that compassion and love. When you can, you’re on the road to replacing selfloathing with self-love. Jean Campbell, a licensed clinical social worker, is also a Certified Trainer, Educator and Practitioner of Psychodrama, Sociometry and Group Psychotherapy and a Practitioner and Trainer of Psychodramatic Bodywork®. As Director of the Action Institute of California (www.theactioninstitute.com), she offers training on the use of action methods, with a focus on addiction, codependency and trauma. She is committed to using action to effect change on a mind, body and spiritual level.

Whom do you trust? A wonderful technique taught at the Caron Foundation is called the share, check, share process. When you are starting to share about yourself with someone, start by sharing a little. Then stop and check it out and see what the reaction is. Did the person judge you? Did the person give you advice that felt shaming? Or did the person smile at you, nod his head and share his own identification with what you’ve shared with him? Once you’ve assessed the reaction, if it feels safe enough, then you can share a little bit more of yourself, and once again stop and check it out. If, on the other hand, you don’t feel safe, or you feel judged or shamed, then by all means, don’t share any more with that person. The link between shame and addiction speaks to the need for no cross talk in the

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COVER•STORY

Gambling

(Continued from page 11) harmless, though occasionally expensive, diversion. Gambling is inherently neither immoral nor pathological. Most gamblers wager only what they can afford to lose and will never experience a problem related to their gambling. In about three percent of gamblers, however, the activity triggers a resonating, bells and whistles reward response in their limbic brains. For these few, being in action wakes an impulse to keep gambling so strong that it can endure catastrophic consequences and defy even a firm resolve to quit. For these unfortunate ones, these disordered gamblers, their gaming ultimately progresses to the point where it fills their lives with severe financial and social problems.

There are marked similarities between problem gambling and chemical addictions.

Your brain on escape gambling

Does this mean you? Identifying the root cause of disordered gambling is complicated. There are a number of variables in the diagnostic process as well as several fundamental misconceptions about the behavior. For years, the terms commonly used by the mental health community to refer to disordered gambling were compulsive gambling or gambling addiction. Though some problem gamblers may show signs of compulsivity, disordered gambling is neither a compulsion nor an addiction, but rather an impulse control disorder. People who suffer from behavioral compulsions usually loathe their compulsive actions, while those who struggle with impulse control disorders almost always get a short-term reward from their impulsive behavior – even if, ultimately, that behavior turns out to be ruinous. And, even when a person’s gambling is clearly disordered, his or her out of control gaming behavior may be explained as sign of another, related psychiatric problem. Impulsive gambling can be an expression of a manic or hypomanic state typical of bipolar disorder, dis-inhibited behavior caused by the use of intoxicants, or even the unhappy side effects dopamine agonists – a class of drugs used to treat movement disorders. While most behavioral health practitioners do not consider disordered gambling to be a true addiction, there are marked similarities between problem gambling and chemical addictions. These disorders share the common dynamics of progression, tolerance, and a rather high incidence of co-occurring mood problems. Even though disordered gamblers are drawn to a process rather than to a substance, gamblers too can develop a neurobiologically based tolerance to that process. And just as drug or alcohol addicts often need more and more of their accustomed substance to achieve a “high,” problem gamblers can reach a point where their brain needs them to bet with ever-increasing sums of money to feel fully in action. This behavioral tolerance combined with problem gamblers’ well-known tendency to chase their losses drives many disordered gamblers to go to desperate lengths to get the funds necessary to stay in action. Gamblers attempting recovery often show up to their first Gamblers Anonymous meeting with a history of criminal offenses like theft, embezzlement and check fraud. The sad fact is that, statistically, more disordered gamblers end up in prison than do those who suffer from chemical addictions.

This kind of gambling is known to activate the brain’s signaling molecules, dopamine and norepinephrine. These are the neurotransmitters of reward and arousal and, interestingly, the same neurotransmitters energized by cocaine and meth. Because dopamine and norepinephrine are energized, when the gambler is in action he or she can experience intense focus and feelings of pleasure and excitement. And some researchers believe that action gamblers might even be biologically predisposed to seek augmented norepinephrine activity. Research conducted by the Illinois Institute for Addiction Recovery indicates that disordered gamblers have lower norepinephrine levels than normal gamblers or non-gambling controls. Action gamblers often suffer from pre-existing, biologically based mood difficulties like depression and attention disorders – problems that are associated with dysregulation of dopamine and norepinephrine.

Gambling and the brain In the last decade, many behavioral health clinicians have come to believe that, just like drug and alcohol addiction, disordered gambling is a biological illness. Many who treat the disorder are used to seeing two subtypes of gambling, each providing the gambler with its own kind of neurobiological reward. One subtype of gambling, called action gambling, seems to provide the gambler with an augmented arousal state, while the other, known as escape gambling, appears to offer the gambler a markedly reduced state of awareness/arousal. Players who prefer to augment their mood, called action gamblers, seek the stimulation gambling can provide, and are often flat, restless and easily bored when not in action. Action gamblers prefer gambling activities that involve suspense, information processing and decision-making, and where they can exercise perceived skill – typically, activities like poker, blackjack, sports betting and horse handicapping. Action gamblers who also abuse substances tend to prefer stimulant drugs like cocaine and meth, and the initial stimulating effect of alcohol. Those gamblers who seek to reduce their arousal states are known as escape gamblers. Their preferred activities narrow their scope of attention and can produce states similar to sedation or dissociation. Escape gamblers are more likely to prefer passive activities – games of pure chance that demand little skill or decision making on the part of the gambler. Slot machines, bingo and scratch-offs tend to be their games of choice. Escape gamblers who also abuse substances often prefer sedatives like opiates and benzodiazepines.

Your brain on action gambling Action gambling is thought to produce, in the brains of disordered gamblers, mood-augmenting effects chemically similar to stimulant drugs like cocaine and methamphetamine.

Contrasted with action gamblers, players who are drawn to escape gambling activities appear to experience a kind of dissociative, or trance, state when in play. Some researchers have hypothesized that escape gambling may mobilize endorphins within the gambler’s brain. Endorphins are naturally occurring opioid-like neurotransmitters, activated in response to stress, and which block the transmission of pain and anxiety signals within the brain. Interestingly, escape gamblers report a higher incidence of chronic pain issues than either action gamblers or non-gambling controls. Escape gamblers often report grief and anxiety issues as well. Some researchers think that at least some escape gamblers may suffer from pre-existing insufficiency or dysregulation of endogenous opioid neurotransmitters.

Receptor roulette In a small minority of the population there appears to be a connection between the therapeutic use of a class of drugs called dopamine agonists and a sudden and unexpected onset of disordered gambling. A small but significant number of patients who have no history of problem gambling, and who are prescribed dopamine agonists (medications like Mirapex®, Requip® and levodopa) for movement disorders like Parkinson’s disease and restless legs syndrome, will suddenly begin to gamble impulsively. Dr. Valerie Voon, a researcher at the National Institute of Neurological Disorders and Stroke (NINDS), has investigated the idea that dopamine agonists might figure in the sudden onset of problematic gambling. In a study of 297 Parkinson’s patients receiving dopamine agonists she found that 7.2 percent reported the development of disordered gambling or some similar impulse-control problem related to their use of dopamine agonists. For the affected patients, problematic gambling began only after each was started on or had a dose increase of a dopamine agonist. In these same patients, problematic gambling that began coincident with the start of dopamine agonist therapy stopped abruptly after the medication was discontinued. A majority of patients experienced a complete resolution of their gambling problem within a month of stopping dopamine agonist therapy. These data provided Voon with even stronger evidence of

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for two years. One of the assignments that patients at that time presented in primary group was a timeline in which the patient depicted

person’s as I spo ing in re person was shi As I s corner p up. It w him. He had rec looked in his tw — the p said, “D dead!” H you to k going to I wok my face his grav his tom about m feeling been lif Over my pur entered therapi at the a bedside day dea recover from ne Florida there to last mo My m as an al was abl when I every st be there This wa lost my

As my body and mind healed, an interesting phenomena occurred when I had about three

COVER•STORY a relationship between disordered gambling and dysregulated dopamine. Patients who reported other dopamine agonist-generated impulse control problems, like hypersexuality, shoplifting or impulsive spending, also reported a complete cessation of these behaviors within a month of discontinuing dopamine agonist therapy. Dr. Voon also found that those study subjects in whom dopamine agonists triggered problem gambling, tended to score higher for novelty seeking and impulsivity in personality testing than did non-affected controls. Affected patients also reported a higher incidence of personal or family history of alcohol abuse. As more and more research has shown a connection between dysregulated norepinephrine and dopamine and impulse control disorders, clinicians who treat these illnesses are counseling their gambling clients to include skillful nutrition as an important part of a successful gambling recovery. Many behavioral nutritionists believe that foods rich in the amino acids tryptophan and tyrosine can provide the brain with chemical precursors that can optimize the production of new dopamine, and norepinephrine and help to re-regulate the levels and action of these neurotransmitters. The disordered gambler might be wise to give consideration to eating fresh and nutritious food (foods that contain high levels of the amino acids tryptophan and tyrosine) as a way of improving their brain’s biological ability to regulate mood and impulse control. Recovering gamblers might also be encouraged to exercise as well, since moderate aerobic activity appears to help the synthesis of tryptophan and tyrosine into new dopamine and norepinephrine.

Betting the family farm The families of pathological gamblers, when compared to loved ones affected by chemical dependence, can display even more stubborn denial about their family member’s addiction. Families of gamblers often have difficulty appreciating the severity of their loved one’s problem, possibly due to the fact that there is much more limited general awareness of disordered gambling than there is of alcoholism and drug addiction. Denial can be institutional too. Not all insurance companies offer reimbursement for disordered gambling-specific treatment. Some HMOs don’t even recognize the disorder. Cultural factors and familial norms can also influence how family members view and react to a loved one’s problematic gambling. In some Asian communities, a high acceptance of gambling as a family-centered activity can undermine recovery efforts. In other cases, members of the gambler’s family might even have enjoyed benefits related to the gambler’s lifestyle and become attached to the comps and glitz that are routinely offered to the “high-roller.”

Recovery strategies for action gamblers Action gamblers, whose favored coping strategies typically cluster around power and control, may have particular difficulty accepting the concept of powerlessness over gambling. Education on the dynamics and progression of disordered gambling and attending Gamblers Anonymous meetings (www.gamblersanonymous.org) can be valuable in helping the problem gambler cultivate a “surrender to win” attitude. The action gambler will also benefit from the development of more adaptive “affect man-

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agement” skills, which means learning to handle feelings of boredom and restlessness. Otherwise, these mood states can remain as powerful triggers to the impulse to gamble. Mind/body practices like yoga and meditation can also help the disordered gambler cultivate healthy mindfulness and a greater awareness of how and where in their body they experience distressful feelings.

Recovery strategies for escape gamblers Improving their management of feelings can also be a key part of recovery for escape gamblers. When applicable, grief counseling and therapy aimed at improving distress tolerance can help escape gamblers to develop better self-soothing and mood intervention skills. And escape gamblers who suffer from chronic pain can benefit greatly from pain-management strategies like massage and acupuncture. Gamblers Anonymous meetings can also be a mainstay in the recovery of escape gamblers. But escape gamblers, often anxious and disempowered, may have difficulty with the idea of taking the social risks involved in accessing and using twelve-step support.

Jeffrey C. Friedman, MHS, LISAC, is a primary therapist at Cottonwood Tucson, an inpatient behavioral health treatment center in Tucson, Arizona. He is a summa cum laude graduate of The School of Human Services of Lincoln University (PA). His work includes treating disordered gambling patients, lecturing on the neurobiology of addictive and mood disorders, and presenting workshops on a range of behavioral health issues at counseling conferences throughout the Unites States, Europe and Asia. His articles have appeared in Together, Counselor Magazine and Addiction Professional.

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An inside straight When attempting recovery from disordered gambling the gambler is well advised to start with a thorough – and, if possible, multi-disciplinary – medical, psychological and social assessment – an assessment aimed at identifying the root cause of their gambling problem and calculated to rule out possible differential diagnoses. Assessing clinicians will want to determine the type of gambling and neurobiological payoff that most appeals to the gambler. A good clinician will also assess family members’ economic, safety and emotional needs, and make appropriate referrals for the loved ones of the gambling patient. Establishing strong, safe and trusting alliances with other recovering gamblers can form the bedrock of sustained gambling abstinence. Trusted others can also help the gambler take a clear and critical look at their gambling behavior, appreciate the level of impulsivity of their gaming and accept the need for an active recovery effort. But, like drawing to an inside straight, recovery from disordered gambling is hard. It is typically a long and difficult process, with many challenges and a few setbacks along the way. Patience and persistence is invaluable. And, as Leo D. might advise, “For heaven’s sake, stay away from the buffet.”

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Smoking

Teenagers and Treatment

on happiness, relationships, fun, pursuit of their daughters. If a mom places a huge quite peaceful after doing so. Of course, passions and helping others. It was obvistress on physical appearance in her what she doesnâ&#x20AC;&#x2122;t realize is such serenity ous that their positive energy is infectious. from page 11)is the result of endorphins flooding her own life, this can(Continued easily be passed on to (Continued from page 12) Recovery is a powerful thing to witness. her daughter. Sometimes, a daughterâ&#x20AC;&#x2122;s bloodstream â&#x20AC;&#x201D; the bodyâ&#x20AC;&#x2122;s attempt to cohol dependent if the other twin Strains mice These miracles are happening every day obsession with calorie counting and is dependent. soothe itselfofafter vomiting. The next time one time had very little hope of a successhave been beection moreof orher lessmotherâ&#x20AC;&#x2122;s tolerant to alcoholâ&#x20AC;&#x2122;s effects. And she copes by eating for young people, and so much of it starts clothing sizebred is a to refl she feels high anxiety, ful adult life were truly happy, exchanging ven though substance fact that his addictions to alrecently, the Collaborative Study on the Genetics of Alcoholism â&#x20AC;&#x201C; with something so simple and often given attitudes and behavior. 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It cannot and be stressed all, people it works. throughout their lives. alcohol use disorders nicotineenough dependence.the behavior. Because after that at someone they knowHow diedwonderful it is that having dealt estimates of howResearchers critical it issuggest for fathers focusoverlap on a may existWhat people rarely realize the outset Josh Azevedo, LISAC,that CACabout II, is75% the Owner thattosome between genes because In- alcohol and drug use early on esophageal cancers that code for sensitivity toinstead alcohol of and those thatofinfluence sensitivdaughterâ&#x20AC;&#x2122;s good qualities, her any eating disorder is how muchofit an willaddiction. and Program Director at are Thecaused Pathway with their steadInpeople say things like â&#x20AC;&#x153;He ity to nicotine. PeopleWhat may abeprofound more or less sensitive to alcohol andtheir lives. physical appearance. eventually control the case Program. by chronic heavy drinking. For they were able to focus their young lives in a car accidentâ&#x20AC;? (leaving people who are also addicted tobaccoâ&#x20AC;&#x2122;s effects because natural genetic variations in the num-deal ofwas difference it would make ifofgirls could of bulimia, a great effort inevitably out that he was driving drunk to tobacco (as Hitchens was) ber and type of nicotinic receptors that they possess. just grow up confident in the knowledge goes into acquiring the food, planning again) or â&#x20AC;&#x153;Shethe died of a strokeâ&#x20AC;? risk of this form of cancer is More than half of patients in treatment for alcohol and other that what really mattered in life was binge, ensuring the immediate environment (omitting that it was brought even higher than that grim drug dependence die from tobacco-related illnesses. Yet, tobacco who you are, not is what looked like. safe to notOne onlyofeat all this food, but on by methamphetamine use). statistic suggests. addiction often notyou addressed in recoveringisalcoholics. perform the ritualistic vomiting. It isSullivan all Andrew was friends Many alcoholics would like the major barriers to treating tobacco dependence in patients with withdonâ&#x20AC;&#x2122;t the author Christopher Hitchens and has written to believe that their problem in life is something â&#x20AC;&#x201C; consuming. Youdifsee, bulimics engage BULIMIA NERVOSAalcohol use disorder is the notion a co-occurring that it is too about him. He had the forthrightness to anything â&#x20AC;&#x201C; other than alcohol. To wit, there is a joke in this unhealthy behaviormovingly just occasionally; All eating disorders hold one thing in and that ficult to quit both alcohol and tobacco attempts to quit describe Hitchens as the addict that he clearly was, yet among Alcoholics Anonymous members about the guy it is not unusual for the person to binge common: food. adversely But whereas anorexia tobacco might affect the patientâ&#x20AC;&#x2122;s recovery from alcoholalso maintains and purge a dozen or more times a day. that, â&#x20AC;&#x153;What killed him was not the who gets drunk for the thousandth time and wrecks isism. defined by restriction, bulimia is alcohol as such or the many years of smoking, but the his car, leading him to solemnly swear off driving. Treatment facilities often concentrate addiction Thatâ&#x20AC;&#x2122;s a lot of food and even more planning. characterized by bingeing and purging. on the â&#x20AC;&#x153;primaryâ&#x20AC;? force of will that simply didnâ&#x20AC;&#x2122;t rest, and seemed to When we put into cultural discourse the myth that an to alcohol treatconsume tobacco use as a more benign addiction. When laxativeFewabuse is involved, a whole Those with and bulimia enormous punish his body with ludicrously brutal days and nights alcoholicâ&#x20AC;&#x2122;s problem really isnâ&#x20AC;&#x2122;t alcohol, whether we er than 1 in 10 treatment facilities ban tobacco use on their grounds, new dimension amounts of food, often of sleeplessenters drive.â&#x20AC;? want to or notin we the are feeding the denial of people who and many treatment facilities do not screen for or treat tobacco Hamptons the equation. is not thousands of calories, in a PeopleItsaid similarly romantic things when the great need to face some unpleasant facts, including that Most experts believe dependence. Moreover, several researchers note that many treatSubstance Abuse Treatment for a persondied, e.g., â&#x20AC;&#x153;Her heart wasAlcohol short of time. Amy Winehouse just too & among a thousand other risks they are greatly increasmentperiod facilities enableThey patient smoking by adjourning meetings for uncommon the American media sensitive for this aching world.â&#x20AC;? But a sensitive heart ing their risk of dying from to steal both food and eat much more than would â&#x20AC;&#x153;smoke breaksâ&#x20AC;? and allowing staff to smoke openly with patients. Where the healing begins..... cancer. â&#x20AC;¨Â no more The world has lost a unique and remarkable human due tokilled the that poor woman than force of will be considered reasonable Studies show that quitting smoking cause plays adoes keynotrole inabstinent this laxatives, caused cells in Hitchensâ&#x20AC;&#x2122; esophagus

to become cancer- being to addiction. Letâ&#x20AC;&#x2122;s not avoid that sad reality and Another and far beyond the point alcoholics to relapse andofmay actually decrease the likelihood of cost involved. lose even- more process. Adults - Adolescents Familypeople - Men in &the Women relapse. However, is less clearproblem whether co-occurring tobacco and aspectous. that a bulimic comfort. When theyit simply by consistently Hitchensâ&#x20AC;&#x2122; prided himself on his honesty and his â&#x20AC;&#x201C; Keith Humphreys, professor of psychiatry at Stanalcoholconsume addictions cannot anyought to be addressed one at a time or concur- rarely recognizes so letâ&#x20AC;&#x2122;s honor his memory by facing up to the 1-800-448-4808 ford University rently.they Study results are mixed. Although some studies show that at thecourage, reďŹ&#x201A;ecting our societyâ&#x20AC;&#x2122;s outset of the more, purge the food, usually by vomiting. In obsession (Continued on page 18)with thinness. disorder is the profound shame, guilt and addition, they often abuse laxatives, ingesting up to The message is if a girl embarrassment she will ultimately experience. 200 laxatives a day. These can just lose enough The absolute truth behaviors are extremely is that no one â&#x20AC;&#x201D; not hard on the body. The weight, she can, and even an individual medical consequences of will, have it all. completely engaged in bulimia include injury to bulimia â&#x20AC;&#x201D; can defend, the esophagus, stomach Addiction Specialists or even really explain, and intestines as well her behavior. They as damage to the heart, often isolate, becoming more and more lungs, kidneys and teeth. Although the alone, and dependent on, the disorder. mortality rate is not as high as anorexia, Unlike anorexics, who often like the way those with bulimia can die from medical they look and are proud of their discipline, complications related to their disorder. self-loathing is quite common for bulimics. Why would anyone willingly Anorexia and bulimia are extremely subject themselves to such a high complex disorders. People who have never consumption of food in tandem with had an eating disorder are usually baffled the subsequent purging behavior? by the very idea of them. Yet, those who Hereâ&#x20AC;&#x2122;s why: bulimia, like many eating are engaged in these behaviors absolutely disorders, is not about food, itâ&#x20AC;&#x2122;s about know why they do them. Whatâ&#x20AC;&#x2122;s more, feelings. Those who engage in bulimia do even if these individuals look terrible and so as a form of emotional regulation, in feel even worse, they may find it nearly effect, as a way to cope with unpleasant impossible to give the disorder up. This emotions. Consider this example: a young is why professional help is frequently woman goes away to college, leaving home required, especially if the disorder has for the first time. Nothing is familiar, been going on for a long period of time. â&#x153;ş everything is foreign â&#x20AC;&#x201D; a whole new environment, friends, academics, etc. She wants so desperately to do well, to make Dena Cabrera, Psy.D., is a licensed a success of her life. Her anxiety level is psychologist and has been on staff at very high. She is homesick and scared. She Remuda Ranch Treatment Centers for notices that her stress level diminishes 10 years. Dr. Cabrera is an expert in the while eating; the food provides comfort, psychodiagnostic assessment and treatment like an old friend. She consumes more than of eating disorders. She presents to national normal and worries about weight gain. She audiences on state-of-the-art treatments of has heard talk around the dormitory that eating disorders and difďŹ cult mental health many students vomit after they eat to stay problems. Dr. Cabrera has written numerous thin. She tries it and it works. Although articles in journals and magazines and she feels a certain amount of repugnance has appeared in several national media by the act of throwing up, she actually feels interviews.

Christopher Hitchens, R.I.P.

SEAFIELD

May/June 2011 | www.together.us.com

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cover • story

Truce

(Continued from page 1) The feelings engendered by that morning’s transformation of many strangers into many friends were not new. I felt as I do when tumbling into love. But it wasn’t my precious wife, Janet, I yearned to get entangled with, it was the great spinning globe herself. Most of what passes for socializing is really just a dagger fight with words. Who’s son went to Harvard? Who’s got the bigger house? Sticks and stones may break your bones, but words can ruin a chance encounter. Although there have always been the truces. There are moments when – just as in The Declaration of Independence – we’re happy to be equals. Sneaking out of a boring dinner party to share a cigarette, a perfect stranger can become a perfect friend. Or out on one of the 20-mile runs you need before a marathon. “What’s said on the trail, stays on the trail.” Then there’s AA. You’re probably quicker than I am, dear reader, and have puzzled out what took me a couple of hours on that golden morning at The Reader’s Digest long ago. I’d been to a meeting the night before with my father. Because I was sitting with a celebrity, these strangers all remembered me. Because it was AA, they all knew my first name. I didn’t know much about my new-found friends, and what I did know wasn’t good. They presented the opposite of status. They’d been sick, or somebody they loved had been sick. Some had been fired, divorced, extracted from the wreck of a burning car.

A hidden drug?

So why did we all like each other so much? Was there a powerful, but hidden drug in the Styrofoam cups of coffee? Meetings are at night. People are tired. Brotherhood and fatigue are often linked. At the end of a marathon, hurting all over, I am feverish with the love of all mankind. I’m buoyed by the camaraderie of the ordeal, an impression given concrete substance in New York where the crowd that’s finished, but hasn’t yet exited Central Park, is so tightly packed that even a dead runner couldn’t find the space to fall down in. The Athens Marathon empties in a marble stadium. The year I ran it many of the athletes weren’t English speakers. It was as if we’d completed the Tower of Babel and entered heaven, but lost the ability to understand one another. I heard greetings and congratulations called

out in a dozen languages, all echoed and amplified by stone. I wonder what we’ll speak in heaven. Spanish? Chinese? Esperanza? When atheists ask why I believe in God I’m nonplused. “I don’t know. An intuition.” But when they ask me about heaven, I’m comfortable. I’ve been. Heaven is the house in Robert Frost’s “Death of a Hired Man.” “Home,” the farmer says, “is the place where when you have to go there, they have to take you in.” His wife calls it “Something you somehow haven’t to deserve.” I love my father and admire his prose, but I’m sorry that the word “celebrity” has to soil my opening example. In America today celebrities are divine. And I don’t mean divine as in “these chocolates are divine.” I mean divine as in closer to God than the rest of us. Kings used to be divine, you know, thought to be descended from the Sun. Didn’t last, and there were leaders who regretted this. “I have come into the world too late,” Napoleon said. “There is nothing great left for me to do. I do not deny that I have a defined career, but what a difference between me and the heroes of antiquity. Look at Alexander for instance. After he has conquered Asia, he declares himself to be the son of Jupiter, and the whole East believes him, save only his mother and Aristotle and a handful of Athenian pedants. But if I nowadays were to declare myself the son of the Father Eternal, every fishwife would laugh in my face. There is nothing great left for me to do.” Celebrities have a piece of what Napoleon wanted. Many take on the responsibility manfully, reading endless screenplays, giving away great fortunes, ignoring a shower of poison darts, living exemplary lives. Others are more like the Gods of Greek Mythology, drunken teenagers with super powers. After my father died, I went to AA once a week for almost a year. I wanted to see if I could go that long without a drink. I also wanted to visit the source of so much light. The candor at a meeting is both shocking and refreshing. If they ever come up with a machine that can detect grace in the atmosphere, the needle will go into the red zone at most every meeting. Lives are saved. My father’s life was saved. Because of AA he and I had a chance to reconcile.

Find

for a worthy cause, will use a telling phrase: “Let go. Let God. Next right thing.” Generic advice, but also markers for the friends of Bill. AA is not the place, but it’s a glimpse of paradise. That’s how life on earth could be. I know, I know, we might perish tomorrow. I’ve seen pictures of the mushroom cloud. But also there’s the other ending, the happy ending. I hate happy endings in most books and movies, because they are so conspicuously contrived. But this is a happy ending with bad coffee and powdered creamer. It’s a happy ending I’ve seen played out in the basements of churches and in parish halls. I saw it racing like a brush fire through the halls of a corporation on that morning long ago. Couldn’t the feeling spread? Poison ivy spreads. Kudzu spreads. Negativity spreads. What about the brotherhood of man? If only we can stop thinking strangers are so strange. What if we stopped hating one another? What if we took an even more difficult step? What if we stopped hating ourselves? What if we did that – just for a moment? Would it change the light? We could open the doors then, couldn’t we? We could step outside and turn our faces to the sun. Benjamin H. Cheever has published four novels (The Plagiarist, The Partisan, Famous After Death, The Good Nanny). He’s also written two works of nonfiction (Selling Ben Cheever and Strides). He edited The Letters of John Cheever. He’s taught at The New School for Social Research, and the Bennington M.F.A. program. He hosts a TV show called “About Writing,” which can be seen at PCTV76.

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Out in the world now, but no longer in AA, I’m astonished how often it’ll turn out that the person who stops to help with that flat tire has gone to meetings. The man lining up to give blood, or the woman who volunteers full time

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RESOURCES

Do You Need Help? Resources & Links

Together’s mission is to serve the extended community of individuals and families seeking information about relief from addiction-related issues to lead healthier and happier lives. Here is a partial list of referrals with a more comprehensive list on together.us.com. Together is not affiliated with any 12-step program or organization, although we do support them all. One essential of recovery is knowing you don’t have to walk alone.

12-step organizations

Adult Children of Alcoholics Al-Anon & Alateen Family Groups Alcoholics Anonymous Chapter 9 | Couples in Recovery Cocaine Anonymous Codependents Anonymous Crystal Meth Anonymous Debtors Anonymous Food Addicts in Recovery Anonymous Gam-Anon Gamblers Anonymous Marijuana Anonymous Narcotics Anonymous Overeaters Anonymous Sex & Love Addicts Anonymous Nicotine Anonymous

Telephone

562-595-7831 212-941-0094 212-647-1680 888-799-6463 212-262-2463 646-289-9954 212-642-5029 212-969-8111 781-932-6300 718-352-1671 888-424-3577 212-459-4423 212-929-6262 212-946-4599 212-946-5298 212-824-2526

National and institutional organizations Center for Alcohol and Substance Abuse Center for Substance Abuse Treatment National Association of Addiction Treatment Providers National Clearinghouse of Alcohol and Drug Information National Council on Alcoholism and Drug Dependence, Inc. National Eating Disorders Association National Institute on Drug Abuse National Institute on Alcohol Abuse and Alcoholism Partnership at DrugFree.org

Contact Together

Website

adultchildren.org nycalanon.org nyintergroup.org chapter9couplesinrecovery.org canewyork.org codependentsnyc.org nycma.org danyc.org foodaddicts.org gam-anon.org gamblersanonymous.org ma-newyork.org newyorkna.org oanyc.org slaany.org nicotine-anonymous.org

casacolumbia.org csat.samhsa.gov naatp.org health.org ncadd.org nationaleatingdisorders.org drugabuse.gov niaaa.nih.gov drugfree.org

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Smoking

(Continued from page 16) simultaneous treatment of tobacco and alcohol addiction improves outcomes, others suggest that concurrent treatment can worsen outcomes. Some of these contradictory results may be attributed to differences in what is considered to be “concurrent” treatment from study to study – some researchers began smoking cessation treatment early in substance abuse treatment, whereas others began smoking cessation after sobriety was achieved or between two treatments. New Jersey is the first state to require that residential addiction treatment facilities address tobacco dependence as well as dependence on a primary substance. The new policy requires residential facilities to assess and treat patients for nicotine dependence and to maintain smoke-free grounds. Despite initial concerns that the new regulations would negatively affect treatment (e.g., that patients might leave treatment early, before the full course was completed), preliminary results are encouraging. But this study had obvious limits. New Jersey’s Division of Addiction Services implemented the program but did not enforce penalties for facilities that failed to comply (i.e., failure to comply did not result in citation or loss of license). This might have compromised the effectiveness of the program.

Smoking and mental disorders Patients with co-occurring disorders, such as major depression, alcohol use disorders, and nicotine dependence, are increasingly common in clinical settings. Treating these patients presents challenges because the relationship between alcohol and tobacco de-

pendence and major depression is complex and self-sustaining. Patients may drink or smoke in an attempt to “self-medicate” to alleviate their feelings of depression. Additionally, depression and anxiety are associated with cravings for alcohol and nicotine. And long-term use of alcohol and nicotine can produce low levels of the brain chemical serotonin, which might trigger or worsen depression. Given the apparent link between drinking, smoking, and depression, some researchers suggest that clinicians must address both addictions and major depression in order to treat these patients effectively. Medications and psychotherapy can be useful in treating these patients. The researchers conclude that combining pharmacotherapy with psychotherapy might be the best mode of treatment. Because of the mortality and morbidity associated with both tobacco and alcohol abuse, it is important to address both addictions. Research is beginning to explain some of the reasons behind the frequent co-occurrence of these disorders. Treating co-occurring disorders remains a challenge; however, evidence suggests that combining treatments might be the most effective way to address concurrent addictions. Special populations, such as depressed patients and adolescents, present additional challenges, but research is exploring new strategies targeting these groups. Although more work needs to be done, it is clear that research already is helping to improve the lives of people with cooccurring addictions to alcohol and nicotine.

Not Thinking Too Clearly

R Tony Murphy

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T gether Online.

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Find us on together.us.com 18

ecent studies demonstrate that chronic cigarette smoking compounds both structural and functional alcohol-induced brain impairment. Compared to their nonsmoking counterparts, alcoholic smokers have smaller temporal, cortical and total gray matter volumes, larger frontal white matter volumes and poorer cerebral perfusion. Research has also found lower concentrations of the metabolite Nacetylaspartate in frontal white matter and midbrain and lower concentrations of choline in the midbrain. Lower levels of N-acetylaspartate are believed to contribute to neuronal atrophy and loss, and lower concentrations of choline compromise the integrity of cell membranes (e.g., synthesis and turnover). Consistent with these findings, alcoholic smokers have poorer cognitive functioning relative to their nonsmoking counterparts across a broad range of measures, including processing speed, auditory-verbal learning and auditory-verbal memory. Smoking severity (but not severity of alcohol use) was inversely correlated with measures of cognitive functioning among current heavy drinkers and alcoholics following one month of alcohol abstinence. – David Kalman

www.together.us.com | May / June 2012

Together Welcome FINAL•WORD

The Forbidden Addiction

Are You An “Almost” Alcoholic?

BY KAY BUTLEr-LUEKing

some people dispute whether this type of extreme sexuality can actually be considered an addiction. Since no chemical or substance is involved physical symptoms such as tolerance and withdrawal are not measurable. However, research indicates that sex addiction follows similar patterns and affects the brain similarly to other addictions. Although it is not currently included in the Diagnostic and Statistical Manual for Mental Health Disorders (DSMIV), efforts are underway to include it under the title of Hypersexuality in the 2012 edition. Currently, a diagnosis of Sexual Disorder, Not Otherwise Specified does exist.

he taboo topic of sex addiction is plastered all over the media these days. So, what is sex addiction and why is there so much controversy surrounding it? Noted expert, Dr. Patrick Carnes defines sex addiction as a recurrent behavioral pattern which The includesDrinking the inability toWorld resist engaging in extreme sexual behaviors. Sex addiction can also be seen as the use or dependence on sexual expression to deal with life’s stressors. Like other addictions, sex addiction usually NORMAL ALMOST ALCOHOL follows several distinct and predictable SOCIAL patterns. When a pattern is continually ARE SOME SPECIFIC EXAMPLES ALCOHOLISM ALCOHOLISM ABUSE WHAT repeated despite negative consequences, it WHICH MIGHT INDICATE SEX ADDICTION? DRINKING can be considered an addiction. The cycle Compulsive use of pornography and or of addiction also predicts the addicted self-gratification, numerous affairs or sexual person will experience the onset of cravings partners, compulsive ©2012 use of Harvard phone or computer University to continue the behavior, intense pleasure sex, use of prostitutes, and violent sex would most almost alcoholics (asacting well as health care come ing in terms of a spectrum (see illustration). and alcoholics for sex the addiction. same reason. relief in planning and out all bealmost examples of possible This illustration more accurately reflects professionals) often fail to see the link between There are many pathways into the almost alrituals, followed by a period of withdrawal According to experts, Drs. Ralph and the real “drinking world.” What it suggests is drinking and any problems these people may coholic zone, and for that reason there must and onset of cravings once again. Marcus of Psychological Counseling solutions. that an individual’s drinking can range any- complain of. Being able to “connect the dots” be many Earle Engaging risky behaviors anddrinking distortedand Services, Ltd. (PCS), individuals who are see the in relationship between where from normal social drinking at one end and patternsallows also often go hand-in-hand concerned the possibility of sex or such problems the almost alcoholic to Dr. Josephabout Nowinski is an internationally of the spectrum, to almost alcoholic in the thinking make decision: to remain in the almost al- recognized clinical He is co-aumid-range, to alcohol abuse or dependence. with sexa addiction. Examples of distorted love addiction can psychologist. look for the following coholic patterns zone (and risk venturing further to- thor with signs: RobertConstantly Doyle, MD, of Almost AlcoMoreover, these different areas are not sepa- thinking include: obsessions, warning seeking a sexual ward alcoholism), or toand “shift left” back toward holic: Is My My Loved One’s)cant Drinking rated by sharp lines; rather, they blend into rationalizing, justifying denial. partner, new(or romance or signifi other; a one another. Of the three “problem” zones, the normal social drinking. Problem? He lives in Tolland, Connecticut. The controversy surrounding the subject inability or difficulty being alone; using sex, No one sets out intending to become an This article originally appeared in The Huffalmost alcoholic zone is by far the largest. of sex addiction may stem from the fact that seduction Normal social drinking is the person who almost alcoholic. Similarly, people do not be- ington Post.and intrigue to hold onto a partner; has a beer or two, or a glass of wine or two, not more than a few times a month, and almost always in a social context. This is the man or woman who meets friends for happy hour after work on Friday, who joins friends to watch a game on television, or who is invited to a party. Millions of people are normal social drinkers, and many of them never go on to be more than normal social drinkers.

You may not be “official,” but you can be close. By Joseph Nowinski • A father who falls asleep on the couch after having several drinks three or four days a week, thereby missing out on time with his kids and wife. • A sales executive who likes to “sip” scotch on the rocks from the time he finishes his dinner to the time he goes to bed. • A college student who repeatedly has trouble making it to class because he was drunk the night before. • A mother who looks forward to her daily double glass of wine to help her get through the day. • An assisted living resident who finds that two or three brandies every day helps to relieve her boredom. What do all of the above people have in common? They are almost alcoholics. And there are many more “almost alcoholics” like them than there are true alcoholics in the world. For many years, health care professionals have been accustomed to thinking about drinking in terms of just two diagnostic categories: alcohol abuse, and alcohol dependence. To qualify for one of these diagnoses, an individual has to suffer some fairly severe and obvious consequences directly related to drinking: a major health crisis, an arrest, loss of a job. To be diagnosed as alcohol dependent, a person also has to experience physical symptoms of withdrawal if he or she stops drinking. Meanwhile, men and women whose drinking is not severe enough to qualify for one of these two diagnoses have essentially been considered “normal.” A major limitation of this approach to diagnosis is that it fails to address the very real problems caused by drinking that don’t rise to the level needed for a diagnosis.

It may apply to you As it works on the first major revision of its Diagnostic and Statistical Manual (DSM) in 15 years, the American Psychiatric Association is contemplating moving from categorical thinking like the above with respect to a number of diagnoses. In its place, they are considering viewing a number of diagnoses in terms of a spectrum. This is where the concept of almost alcoholic fits in – and it may apply to you or someone you love. Rather than thinking in terms of just three categories (normal, alcohol abuse, alcoholism), it is probably more productive to look at drink-

Inter-care is dedicated to providing high quality individualized outpatient treatment to individuals and families impacted by substance use disorders

Almost alcoholics suffer As the illustration suggests, there is a large “gray area” that lies beyond normal social drinking but falls short of alcohol abuse and dependence. Many people slip into this gray zone. Some go only a short distance; others venture much deeper over time, but still are not alcoholics. That said, men and women whose drinking patterns lie in the almost alcoholic zone are likely to be suffering, as are their loved ones. For example, they may be experiencing one or more of the following:

Services

Substance Use Evaluations Motivational and Early Intervention Services Intensive Outpatient Program (IOP) Early and Advanced Recovery Programs Executive and Professionals Programs Dialectical Behavioral Therapy (DBT) Groups Dual Diagnosis Program DWI/DUI Programs Drug and Alcohol Testing Individual Counseling and Psychotherapy Gender Specific Counseling Gay Men’s Groups Other Addictions Group Relapse Prevention Drug and Alcohol Education Family Program and Codependency Treatment IMAGO Therapy for Couples 12-Step Recovery Groups Alumni Association 24-Hour Hotline Support

• • • •

Trouble sleeping soundly Mild depression Marital or family conflict Health problems that aren’t recognized as related to drinking • Declining performance at work One thing that has become very clear is that

P onder:

"We lift ourselves by our thought, we climb upon our vision of ourselves. If you want to enlarge your life, you must first enlarge your thought of it and of yourself. Hold the ideal of yourself as you long to be, always, everywhere - your ideal of what you long to attain - the ideal of health, – Orison Swett Marden efficiency, success.”

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