I can't believe I p***ed away the whole morning on this, or

OMG! Someone's wrong on the Internet!

I had other things to do this morning. Lots of other things to do. But this is a subject that absolutely gets my blood boiling, because I believe it is harmful to steer people away from AA and its sister programs. This is my entire response to yet another gross misinterpretation of 12-Step philosophy. Basically, the poster conceptualizes mental health treatment and addiction recovery as opposing forces, compares AA to Scientology, and calls 12-Step programs blaming, punitive, and  "dangerous". I am not giving a link or naming the poster, a professional who is at least in part touting her book with her post, as I have no wish to give her argument any more exposure than it already has. Since, unfortunately, she is a guest-poster to a site I used to have in my blog roll and some of you may have read her already*, I am posting my response, verbatim, here:

[Poster] claims that AA is anti-treatment. This is totally not my experience, not as a recovering alcoholic 24 years sober, not as a psychotherapy patient, and certainly not as a psychotherapist with 29 years in clinical practice.

Alcoholics Anonymous (the Big Book) states quite clearly that medical professionals and medications have their place. Other officially-sanctioned AA literature includes brochures and pamphlets on mental illness, medications, and recovery. What is discouraged is medication that merely replaces (by mimicking the effects of) the alcohol/drug of choice (e.g., Valium, Xanax). In meetings it's called 'taking your alcohol from a prescription bottle' or 'taking your alcohol in pill form'. It is the abuse of prescription drugs and the naïveté of physicians who keep handing them out that AA sponsors worry about, not appropriate treatment.

Alcoholics and addicts are experts at obtaining prescriptions that they don't need and which may interfere with recovery to the point of precipitating a relapse to the drug of choice. Old-timers recognize this drug-seeking behavior when they see it because they spent many years doing it themselves, and warning against it is not "bad advice". It may save a life.

My professional and personal experience is that very few groups will tolerate the handing out of advice. It's one form of "cross-talk" when it happens within the meeting itself, and is actively discouraged if not forbidden outright. Sharing in meetings is supposed to include our "experience, strength, and hope". When we tell our stories we share "what it was like, what happened, and what it is like now". This basic instruction is read aloud at the beginning of every meeting. It means that when a topic is introduced, we share how we use the Program to deal with a given issue--not how you should do it. "Take what you want and leave the rest" is an oft-repeated slogan in 12-Step groups.

In the context of fellowship outside the meeting, telling another member what she should or should not do is considered to be working the other party's Program instead of your own, a sign that you at a stuck point in your own recovery process, and is similarly discouraged. While we will point it out if we think a person we are sponsoring is engaging in (pre-)relapse behavior, rarely, if ever, would a member with good quality sobriety tell another member not to take their medication or not to see a given professional.

Even so, of course some members will dispense bad advice. We're only human! The Program offers a built-in protection against that, as members periodically remind themselves and each other that for successful recovery one must place "Principles before personalities". In other words, keep the big picture in mind. Don't let one person's bad attitude or general wrong-headedness get you off track.

[Poster] is right about one thing, though: Of course nobody wants to hear about your diagnosis at meetings--because that's not what meetings are for. AA members recognize that they are not professionals and are not equipped to treat mental illness. AA can be independent, primary, or supplementary, to mental health treatment, but is not in competition with it. Meetings are for getting clean and sober. They are for talking about the solution rather than living in the problem.

The whole point of working the Steps is to learn to live life on life's terms, which is to say, clean and sober regardless of what happens to you inside or outside of your body. Got a funeral to go to? A divorce to get through? The Steps teach you to handle it sober. Talking about how you can't handle it will not. (That, by the way, is a basic principle of Cognitive-Behavioral Therapy--not anti-scientific at all!) Depressed? Working a good Program will get you through this episode sober. Sitting around talking about your depression will not, and anyway, you can (and should) do that in therapy.

This may sound cold, but it is not. It is practical. Raise your issue in the meeting then take the cotton out of your ears, put it in your mouth, and listen to how people who are happily sober many years longer than you handle similar situations in their lives. You may learn something. Again, far from being anti-scientific (or even lacking in common sense), modeling is a basic principle of learning theory, intuited and put into practice by recovering alcoholics decades ago. AA is like dust-bowl empiricism: We use what works.

Old-timers hold newcomers accountable because they ARE accountable for their behaviors, as is everyone else trying to live life as a mature adult responsible member of family/society. Relapse is a behavior, a decision, a choice. Alcoholism is not. It is a disease. But now that you know you have this disease, you are responsible for your recovery. AA does not hold people responsible for their mental illnesses any more than they hold them responsible for being alcoholics.

"Think before your drink" and "the time to call your sponsor is before not after" are no different than our expectation as therapists that a cutter or suicidal patient be responsible for her recovery by picking up the phone to call us before she picks up a razor blade or a gun.

Nor does AA apply consequences for relapse. When your patient returns to his home group to pick up another white chip (think behavior therapy tokens) after a period of 'going back out to improve on his story', he will be greeted with a chorus of "Welcome back!" and hugs, not punishment. Relapse has its own natural consequences--another basic learning theory principle intuited by Bill W. and the other originators of the Program.

Most, if not all, AA members have struggled with symptoms of anxiety and depression at some time, if not chronically, and many may qualify for formal diagnoses. Child sexual abuse survivors, for example, are heavily represented in women's meetings. I believe you would be hard put to find a home group that has not lost at least one member to suicide. So the old-timers know exactly what it's like to suffer from emotional pain. The Big Book from the First Edition addressed the dual-diagnosis issue directly in the Promises, where it reads that even the severely mentally ill can achieve sobriety if they are capable of being honest. But old-timers also know that drinking when you are feeling blue or antsy not only will not help, it will inevitably make symptoms worse: Statistics show that alcohol is directly involved in a significant proportion of suicides, and AA members are more aware than most of this connection. The quip heard in meetings is that "I never had a problem that was made better by pouring liquor on it".

Because of AA's acute awareness of the consequences of untreated mental illness/addiction, "hitting bottom" does not mean abandoning a person to his own self-destruction. AA members fully appreciate the dangers therein. However, just as in therapy, the person needs a certain amount of motivation to succeed in recovery. All "hitting bottom" means is becoming sufficiently "sick and tired of being sick and tired". Members compare it to being on an elevator going down: You can get off on any floor. But sobriety is not something you can impose from the outside in: It's an inside job. AA members reach out to the suffering alcoholic as part of their 12th Step work, but at the same time recognize that the newcomer has to "want what we have and [be] willing to go to any lengths to get it" in order to resist the siren call of alcohol.

In short, AA as a whole--completely unlike Scientology--is hardly anti-treatment, never mind anti-science or lacking in common sense. C.J. Jung had a lot of input into the early development of the Program. As noted above, a lot of common-sense psychological principles are incorporated into it.

Many members come to the Program through treatment, because it's the rare addiction program that does not incorporate required attendance at AA meetings as part of the treatment plan. AA, NA, CA, and other groups meet on treatment-facility campuses. Off-campus groups send representatives to host meetings in hospital facilities, serve as temporary sponsors, or meet one-on-one with patients. Many, if not most, of the staffers in these facilities are recovering alcoholics/addicts.

I have personally seen a pair of old-timers bundle a newcomer into their own car and drive her directly from her first meeting to a treatment facility, recognizing as they did that she was in withdrawal and needed professional attention, STAT. Members routinely refer each other to their own psychotherapists and psychiatrists, many of whom are in recovery themselves.

Real world, then, the overlap between mental health and addiction "cultures" is nearly 100%. Setting up a false dichotomy like treatment-vs-recovery tears a great hole in the safety-net fabric for alcoholics/addicts to slip through, potentially falling to their deaths. It does this by providing them with an excuse not to participate in real recovery, to wit, "My therapist says it's a cult". Just going to psychotherapy alone is a softer, easier way, and if we enable people to do that, the choice is a no-brainer for the active alcoholic/addict. And it won't work. We can practice our empathic listening skills, pretending we are doing something to get them clean and sober and feeling good about ourselves, until we coddle our poor victims of mental illness right into the grave.

"Poor me, poor me, pour me a drink" is not just a slogan, it's a real and deadly phenomenon.

My professional experience over three decades is that I cannot get patients clean and sober without their active 12-Step involvement. In all that time I have never once found either the Program or its members to interfere with someone's mental health recovery. I have, of course, often had clients engage in splitting between the therapy and the Program, and I am reasonably certain they employ the same defense in reverse when they are at their meetings. Seasoned therapists in possession of a deep familiarity with personality structure, the dynamics of addiction, the process of good psychotherapy, and with how 12-Step programs work, however, will recognize that for what it is and work through it with the patient to the latter's ultimate benefit.

AA has succeeded in helping many people who were formerly considered hopeless causes, and they've done it in a completely transparent manner, from the publication of the Big Book (probably the original manualized treatment!) forward. Furthermore, they do it entirely through the efforts of volunteers who wish only to give of their time and energy to share what they have found with the still-suffering alcoholic. It is a gross insult (not to mention, a false analogy) to compare AA to a secretive cult that charges its members each hundreds of thousands of dollars over a lifetime for a completely bogus process. All AA asks of you is that you put a buck in the basket if you have it, and that you stick around to "pass it on". You do your patients a grave disservice when you compare individual A.A. members to a manic, over-paid actor who publicly insults people who seek treatment for emotional problems. You do them a disservice when you dismiss all the people over the past six decades who have found sobriety and a new life through the Program as lacking common sense.

*Also, because it is so ridiculously long (longer than the original post!) that it may not make it through moderation.

I guess I'm just a sentimental old fool

Image by George Eastman House via Flickr

"I'm a dog person," I told my client. "I'm going to cry right along with you." And I did.

I have cried with clients before. I have cried with women whose fathers were dying, couples whose children died, and once even at a wake for a client who died. But mainly, I cry when people's dogs die.

I can only hope that it's therapeutic. Because I really have little choice except to proceed. I mean, what am I gonna do, say, "Sorry, I don't 'do' dogs"? Because really, I do dogs. I am, after all, a dog person.

I feel your pain. 

I have always had dogs. There was a dog in the house before I was born. I got a puppy of my own for my seventh birthday. Starting with her, I count six who have blessed my life with their love, companionship--and in some cases, sense of humor--over the years. They have, variously, served as playmates, bed-warmers, bodyguards, co-therapists, physical fitness trainers, and travel companions. I loved every one, each in her or his own way. I have grieved the loss of five, and I can tell you that it never gets any easier.

We're supposed to be objective professionals. But lose your dog? I will lose all objectivity.

Huzzah, anyway

Apparently, some time last weekend, while I was distracted by all the kooks likening Mr. Obama to Hitler, the former snuck through a law to make pharmaceutical companies reveal in detail their payments to physicians, including which drugs they are flogging, where, and when. Doug Carlat writes:

It is this kind of granularity of information that will truly make doctors think twice before pursuing careers as hired guns.

Probably not, actually. Some docs, by virtue of the nature of their caseloads (geriatrics, families on welfare, psychotics, etc.) can pretty safely bet that their patients will not even know about the law, never mind have the computer access, cognitive capacity, or general literacy to do the research. Others will do the math and figure out that they are still better off as hired guns.

For example, if one makes $23,000 a year selling, say, one of the newer antipsychotics, one would have to risk losing 230 appointments per year just to drop to the break-even point. How many psychiatrists have 57 patients (each seen quarterly =  228 appointments) who are (a) going to look up this information, and (b) quit over it and go looking for a new doc? Out of those, how many will have the option of finding a doc who's geographically accessible and takes their insurance and is taking new patients and treats their particular problem? And who cares? Psychiatrists are generally booked months out: There are always more patients where that 57 came from.

Still. Some patients will, and even one life saved will be well worth it.

And colleagues like me can (and hopefully will) look up each and every doc to whom we refer, and alter our referring habits accordingly.

Huh?

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I mean, what is it with Jason Aronson lately? Once the premier publisher of psychodynamic literature, they've gotten embarrassingly sloppy lately. Seems like everything of theirs that I pick up these last few years desperately needs editing: Their books are riddled with errors ranging from the merely distracting ("eliotogical" for "etiological") to the completely obfuscating.

As an example of the latter, I hereby challenge you to tell me just what the heck the the following sentence is supposed to mean:

Vaillant demonstrated that there is a very high correlation between the severity of a person's alcoholism and social deviancy/consequences, and the assessment and identification of these related factors has a much higher reliability than the measurement 'of ephemeral concepts of loss of control or alcoholism p. 17' and subjective reports on consumption levels.

Other than the obvious "p. 17" thingy floating there where it does not belong, I'm not even sure where the error is. Is Vaillant saying alcoholism is an ephemeral concept that can't be reliably measured in the very same sentence in which he is telling us it can be reliably measured? Surely that is not it, because the author is too critical a thinker to let that one pass. Perhaps the very occurrence of the word "alcoholism" in the second clause is itself in error. Or could part of the sentence be missing? I just don't know.

I give up. I've been studying on it for some time now, but I just can't sort it out.

This was at least the fourth error in 19 pages. There is "integratetively" on p. xi, a misattributed--or unattributed, it's difficult to say--quote (p. xii), and "lightening rod" (p. xiii). So far, we're running right at one error per page--and we're not even out of the Foreword yet, which was written by a Harvard professor, for heaven's sake. I think it's a safe bet these are not his errors any more than the Vaillant mish-mash is the author's.

The whole thing reads like it hasn't even been edited: One wonders if the new owner (Rowman & Littlefield Publishers, Inc.) laid off all the Aronson editors in one fell swoop during the takeover. Regardless of the cause, an error on every page is inexcusable.

(Although I will say, I kind of like "integratetively". That probably ought to be a word, except that it reads a bit like a visual hiccup, and is somewhat difficult to pronounce. So, well, maybe not.)

But to get back to Aronson, the shame of it is that this is a meticulously researched book by one of the greatest thinkers in the field. Aronson ought to hang their heads over how poorly they've served this author.

The last book published by Aronson that I tried to read, a collected work on technique, was so badly edited that I could not understand the first article at all. I am not exaggerating: It really was that badly mangled. It might as well have been written in Cuneiform. I didn't even try to finish that book.

Those of you who know me might, understandably, at this moment be thinking to yourselves, "Aw, that's just her being her usual hypercritical self." Alternatively, some of you may be thinking I'm just not smart enough to understand, say, a book on technique. So let me just mention here that I am also currently reading van der Kolk's latest on trauma therapy, and having no such difficulties with it. That book is no walk in the park, intellectually speaking, but if it is not 100% error free, I haven't found the goof-up yet. And that it is well-edited allows it to be not only understandable, but enjoyable.

By contrast, this current tome will be the last Aronson publication that I will ever spend money on. I had really looked forward to reading it, but it's being very frustrating. I'm not naming it, although technically I suppose I should in order to appropriately credit the source, but I deeply admire the author and am reluctant to slam anything that he's had anything to do with, especially in a manner that would pop up in a Google search on his name. And as I say, it's not just this book, this author; it's everything Aronson has touched lately.

It is my fervent hope that the author will find a new publisher for his next work.

Therapeutic Texting

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My young client arrived in tears. Seems she'd not only had problems with a date this week, but also with the friend to whom she'd turned for support. A good deal of these problematic interactions had taken the form of text messages back and forth between the three of them. My client scrolled back to some earlier texts to quote both the date and the friend.

And then, and this is where it gets interesting, while we were talking about all this, she received a text and dashed off a response. I considered asking her not to do that during the session, but what the heck? Here was the very interpersonal issue we were discussing unfolding in the here and now! So I sat back and waited.

Pretty soon, the little phone buzzed with a response, I asked her about it, and so it began: We would talk a bit, she'd send a text or receive a response, and we'd process them. The whole thing was most interesting, and different from work I've done in the past. People have printed out e-mails before and brought them to therapy, and have even brought their laptops in to show me MySpace pages, but this is the first "live" internet interaction I've processed in session as it unfolded. I think it was productive.

Having the actual texts as they unfolded gave us accurate data from her interpersonal world as a basis for discussion of gender roles and expectations--this gave the work a here-and-now immediacy, vs. the there-and-then that is all too often the stuff of psychotherapy. In the course of the hour we were able to establish that she doesn't like confrontation. Smart, perceptive, and funny as hell, she responds with sarcasm when wounded. She is a feminist. She is highly empathic and tries to be supportive to the important people in her world, yet finds herself again and again in non-reciprocal, sexist relationships.

If I have a problem with how the session unfolded, it is that if one has needs that aren't getting met in one's relationships, then the phone is a tremendous distraction from the face-to-face opportunity to get those needs met, available right here, live and in real time, in the therapeutic relationship. So I guess I wouldn't want to do this every week. But today? Cool.

#7: Patience is a virtue

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Patients occasionally (okay, frequently) express impatience with their progress in therapy. Impatient with themselves, they become impatient with me for not fixing them faster. And they worry that perhaps I am impatient with them for not doing more, better, faster than they actually are. 

Wood's Rule #7: Patience is a virtue

Because cultivating this virtue helps you "cease contributing to your own suffering and confusion and perhaps to that of others", Jon Kabat-Zinn¹ describes patience as a "fundamental ethical attitude" (1994, p. 48).

"From the perspective of patience," Kabat-Zinn writes, "things happen because[emphasis added] other things happen" (p. 48). You get sober, whether sooner or later, because you got drunk. The teenager you've brought to me for therapy will develop maturity and judgment (eventually) precisely because he has been immature and impetuous. For that matter, we can only learn patience who began our journey with impatience.

And if that is true, then it is also true that

what will come next will be determined in large measure by how we are now. This is helpful to keep in mind when we get. . . frustrated, impatient, and angry in our lives (p. 50). 

What will being impatient and irritable right now this two seconds create in our next few minutes, days, weeks, or months? Years down the road, what quality of life will all this rushing around and crankiness have produced for us?

So I would remind my patients to, in Kabat-Zinn's words,

. . . [remember] that things unfold in their own time. The seasons cannot be hurried. Spring comes, the grass grows by itself. Being in a hurry usually doesn't help, and it can create a great deal of suffering--sometimes in us, sometimes in those who have to be around us (p. 48).

It's how I think of you when you are struggling, when you have hit a wall. I know that I cannot make a flower bloom, or control its form and color when it does. All I can do is make sure to plant it where it receives enough sunshine (but not too much); then I must water and fertilize it (but not too much). It grows on its own, in its own time and in its own way. And so will you, dear, so will you.

Kabat-Zinn closes this chapter, poetically titled "The Bloom of the Present Moment", with a quote from Lao-Tzu:

Do you have the patience to wait
till your mud settles and the water is clear?
Can you remain unmoving
till the right action arises by itself
                            -from the Tao-te-Ching 

If I allow myself to become impatient in session, then I act before my mud has settled. It is not likely that anything that I do will come out of right mindfulness or right understanding. To the contrary, it is highly likely that I will do something to make your journey harder, or longer. And that would be unethical.

 

1. Kabat-Zinn, Jon (1994). Wherever you go there you are: Mindfulness meditation in everyday life, pp. 47-51. Hyperion: New York.

The Carlat Psychiatry Blog: WebMD's Big Lie

The Carlat Psychiatry Blog: WebMD's Big Lie

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