Wednesday, November 15, 2017

Some Thoughts on Our Addiction Epidemics

Newspapers are full of stories about the U.S.'s opioid epidemic. It's only one of several addiction epidemics that are ravaging the country, although it's the one that is getting the most attention from politicians and the media. The root cause of all these epidemics is profits.

Approximately 10 percent of the population is thought to be predisposed to addiction, from a combination of genetic and early environmental factors. Such persons can become addicted to anything--drugs, food, sex, shopping. Persons without this predisposition can abuse substances, and will develop a physical dependence to a substance with certain chemical properties if they use it regularly enough--but it's a matter of opinion whether these persons can truly be called "addicts." But even if only 10 percent of the population are truly addictive personalities, that's enough, more than enough, to create an epidemic. Since that percentage doesn't change, why do addiction epidemics appear and disappear in societies?

When evaluating any phenomenon, it's important to ask the question "Who benefits?" The current  identified culprit for the opioid epidemic is the pharmaceutical industry. Some states are suing pharmaceutical companies for engaging in allegedly deceptive marketing practices. This may be a valid allegation, and it makes for good politics, but the main culprit is doctors. Medical training includes extensive study of anatomy and physiology. There is no way a licensed M.D. doesn't know that an opioid is addictive. I don't believe for one second that any M.D. was bamboozled by a pharmaceutical company into believing that a new opioid wasn't addictive. Doctors prescribed these pills because they wanted happy consumers.

There are many ways to manage or cure pain--physical therapy, surgery, acupuncture, massage therapy, ergonomics, nutritional counseling to lose weight and yes, psychotherapy (because mental pain increases physical pain). But there's an old saying, "If your only tool is a hammer, every problem looks like a nail." Only M.D.s and a couple of other professions are licensed to prescribe pills, so that is what they do. They don't do physical therapy or acupuncture, and even among psychiatrists, few do psychotherapy anymore--they leave that job to non-medical therapists, because prescribing pills is more profitable. Primary care physicians and psychiatrists increasingly use only one tool--pills.

A good primary care physician refers patients to necessary adjunctive treatments, but many do not do these referrals, partly because insurance often doesn't pay for them, but also because many doctors want to believe that what they do is the "real" treatment. It's also what is profitable for them.

Opioids aren't the only substance causing an addiction epidemic. There has been a worldwide plague of addiction to benzodiazepines that has flown under the radar because it seemingly has not caused an epidemic of overdoses or crimes. But that's probably because there's no illegal alternative to "benzos." People don't overuse benzos and turn to an injectable street drug because such a drug doesn't exist. They also don't necessarily think of themselves as "high" on benzos. Although a  drug is classifiable as "addictive" based on whether it is likely to cause tolerance and dependence, the general public and perhaps some doctors identify addictive substances by whether they cause a "high." But life experiences can cause "highs." In the field of prescribing, the issue of concern should be whether the substance causes physical tolerance and dependence. What pills am I talking about? Benzodiazepines include Xanax, Klonopin and other commonly prescribed anti-anxiety medications. Other sedating drugs that aren't benzos, such as Ambien, may also induce tolerance and dependence.

A few years back I saw a new patient who appeared "strung out." She denied illegal drug use. I took a look at her list of prescribed medications, and saw that it included daily Xanax. I suggested she talk to her doctor about discontinuing this medication, and she told me that she had done so but that her doctor had advised against it, because, he told her, it would take her a year to taper off the medication. I've learned that this is indeed true, it takes patients months or years to detox/taper off such medications (detox from heroin takes about 8 days in an inpatient facility). Is such use of these medications, originally developed to treat severe anxiety, justified? I do not believe so. Panic disorder is often well-controlled with SSRI anti-depressants or a combination of SSRIs and psychotherapy. SSRIs may become less effective over a very long period of use, but do not create the kind of tolerance and dependence created by controlled substances.

But the worst epidemic of our time is the obesity epidemic. The culprit is the food and beverage industry, and few politicians have the courage to attack this industry. Junk food is more popular than opioids. The media directly benefits from advertising by the food and beverage industry, not from advertising for controlled substances (it may be illegal; I'm not sure). Yet the obesity epidemic kills millions more people than the opioid epidemic.

Other addiction epidemics of our time include video game addiction and online pornography addiction (a subset of sex addiction). The Wall Street Journal and other publications recently reported  about a study that found that a main reason for declining participation in the workforce by young males was video game addiction. Other studies have found evidence for sexual dysfunction caused by online pornography, and there's no question in my mind that online porn has contributed to a general cultural misogyny, stories of which I hear in my practice. I don't see any political crusades against video games or online porn. So far the general public seems to believe that these are harmless activities, and the companies that produce these products--some of which are multinational, powerful corporations--don't appear to answer to anyone.

Tuesday, October 31, 2017


Over the past year I had been experiencing the pervasive sense that large numbers of people in the US were going crazy. From neighbors, colleagues, patients and random persons on the internet I heard statements that sounded extreme in their despair, fear and rage. At times the statements entered the realm of clinical paranoia. I was told by left-of-center persons that America was full of Nazis, and by persons to the right that the "Left" was engaged in a purposeful campaign to destroy the Constitution and install a totalitarian regime. I blamed the media and our two main political parties for the incessant drumbeat of hysterical "news" stories, inflammatory language and demonization of others that fed this mass hysteria. But it turns out that the real story is even weirder: It was the Russians.

Why do people succumb to propaganda and why can't they see that they are being manipulated? There are many factors:

Conformism: Humans are social animals and want to "belong." If a group of people with whom someone wants to associate insists on a shared belief system, many people will adopt the beliefs even though those beliefs have no basis in fact. The strong need to "belong" will override logical thought processes.

Displacement: Persons with histories of abuse or neglect in childhood deal with anxiety, anger and even outrage, but may be unable to connect those emotions with their childhood experiences due to wanting to protect the images of their family members. Instead, they direct their fear and outrage toward public figures or groups or imagined groups. It is emotionally convenient to fear and hate those you don't personally know.

Self-esteem: Many people revel in a belief in their own moral superiority. By aligning themselves with what they see as a virtuous or righteous position and condemning others who disagree, they feel better about themselves.

What can counter these dangerous tendencies? Here are some tips:

1. Learn history. The better educated and older people I know demonstrated less susceptibility to the propaganda, and not just because they don't use Twitter. It's that they (we) have seen it all before, and what we haven't seen personally we have read about. Propaganda and popular hysteria are nothing new. There have been waves of mass hysteria throughout history, often with atrocious, catastrophic or genocidal results.

2. Use logical analysis to assess claims made by groups, including established groups. It doesn't matter who made the argument or published the news story if it doesn't make sense.

3. Listen to your gut instincts. If something seems fishy, it probably is. If you can't put the pieces together, maybe it's because they don't fit. Ask yourself: Is something missing from the story? Does the story seem too bad or too good to be real?

4. Live a healthier lifestyle: Acknowledge your childhood traumas, build your self-esteem in healthy ways and seek friends who don't demand that you agree with their political beliefs. Talk to different types of people and listen to them.

Tuesday, October 24, 2017

Harvey Weinstein Heads to Rehab

Yesterday I read that Harvey Weinstein is checking into a facility for treatment of "sex addiction." Is repetitive sexual harassment or sexual assault a form of sex addiction? 

Sex addiction, like any addiction, is a repetitive, compulsive behavior. The hallmark of any addictive behavior is that it is experienced as being outside of the person's control. A common self-test for addiction is to try to stop the behavior for a period of time. If you find that you are engaging in the behavior after you told yourself you wouldn't, this could be a sign of an addictive disorder. Simply making something a habit is not itself  a sign of addiction. If the behavior is under the person's control, an addiction has not been established regardless of how dysfunctional the behavior is.

Sex addicts typically either frequent prostitutes, pick up random strangers for sex on a regular basis, or spend hours masturbating to online pornography. Some also compulsively attend peep shows and strip clubs. Eventually they start to realize that they are spending enormous amounts of time or money (or both) on their sexual activities, and perhaps endangering their health or even their lives. At this point an addiction has been established, and sometimes, people seek help.

Based on the publicly reported evidence, Weinstein appears to have exercised great control and planning in his harassment activities. Subterfuge and the assistance of allies appear to have been involved in the various scenarios that have been reported. The cost of hiding the behavior appears to have been calculated. This type of planning and execution is rare in addictive behaviors, because, as I said, the hallmark of addiction is that the behavior has spun out of control. In addition, on a deeper psychological level, addiction is about a regression in which the person unconsciously grants power to a substance or behavior, enacting a dominance/submission dynamic in which the addict is the submissive. In Weinstein's case, it's obvious that the dynamic went the other way in his encounters with young actresses and models.

If it's not an addictive disorder, is it possible that Weinstein has a different clinical disorder? It's possible and perhaps likely, but it may be one that it is extremely difficult to treat. Pleasure in exercising control and dominance over others is sadism, a psychological phenomenon that is rarely treated because sadists don't seek help. I'm not aware of any standard treatment protocols for sadism except perhaps psychoanalytic therapy to resolve early childhood traumas and conflicts, but, as sadists are rarely interested in such treatment, there isn't a lot of evidence regarding outcomes. Sadism is often a component of antisocial personality disorder (also called sociopathy or psychopathy) and this disorder is notoriously difficult to treat. Confrontation and limit-setting may be the only ways to address sociopathic behavior. People, like other animals, respond to negative consequences for behavior.

Wednesday, October 18, 2017

Mass Culture and the Normalization of Pathology

Yesterday I wrote a post about the psychological defense mechanisms often used by trauma survivors and others, and how these defense mechanisms might prevent awareness of traumas and crimes. But are psychological defense mechanisms the only reason why people don't address sexual harassment, sexual assault, and related issues? Of course not. Our culture supports the minimization and rationalization of sexual harassment and violence against women and normalizes the oppression of women People don't complain about, or sometimes don't even notice, what they consider "normal."

Repetitive presentations of violent or degrading images in tv shows, movies, video games and in online pornography trigger the use of the defense mechanisms I noted in yesterday's post. Today's youth (I'm using "youth" expansively to mean persons under 45) have grown up with pornography, reality tv shows in which people are deliberately humiliated, and violent imagery in television that wasn't permitted or just didn't exist 40 years ago.  Repetitive viewings trigger dissociation, separating the viewer from his or her emotions. The viewer stops experiencing the normal feelings of disgust and fear that these images would otherwise generate.  Unfortunately, the use of these defenses then becomes a habit. The individual who routinely uses dissociation in order to view tv, video games or pornography without disgust and fear then becomes unable to recognize violence and humiliation perpetrated on others in real life. Violence and humiliation become "normal." The dissociation doesn't just destroy empathy for others; it can also lead individuals to deny their own victimization, because they are dissociated from (disconnected from) their own emotions.

The notion that women's bodies are a commodity for men's entertainment has been normalized, including in persons who don't view online pornography or violent films. The commodification of women is an old practice and has only gotten worse in recent decades as it has become more generally acceptable and out in the open. As a psychotherapist who works with men and women, I hear things that most people don't, and have come across more than a few examples of how people who would generally be considered liberal or worldly or even feminist still can accept the notion that women's bodies are for men's entertainment. Here are some vignettes, all from the past 8 years:

1. A man who worked in sales told me team meetings were sometimes held in strip clubs. I pointed out to him that this was done to exclude women or make them feel uncomfortable. He looked surprised. This hadn't occurred to him. He didn't disagree with me; he simply hadn't thought about this possibility.

2. I was working with a man who I thought might have a problem with online pornography. I decided it might be important to find out what type of porn he was viewing. It turned out he mostly looked at women giving men blow jobs. I pointed out that these images represented a woman doing something for a man. A look of horror came over the man's face; he considered himself a feminist and didn't want to think of himself as someone who thought women should serve men. Yet he hadn't noticed the pattern in his choice of pornography and pondered what it might mean.

3. A man told me workers at the social service agency where he was employed had a get-together at a local Hooter's. I found this odd considering that many women work in the social services field. Apparently, women are now so dissociated from their own femaleness that they can watch other women degrade themselves in a low-wage job to obtain tips, and not feel uncomfortable.

The reality of women's oppression is also obfuscated by the invention of euphemistic phrases or new definitions of words. "Casting couch" and "sleeping her way to the top" have now been revealed to mean "raped and silenced with job offers." For decades women and men alike have been brainwashed by these euphemisms to believe that women initiated these encounters or at the least agreed to them in advance.

More recently, the word "choice" has been confused with the word "empowerment." The words aren't synonymous, as many choices are not empowering. I find that when I point out examples of internalized oppression or capitulation to oppressive systems, the person to whom I am speaking sometimes will tell me that the behavior can't be an expression of internalized oppression or defeat because the person "chose" to engage in the behavior. But people also "choose" to commit suicide. They choose to shoot heroin. These aren't examples of empowerment. In addition, many so-called choices are not made freely. The 12-year-old girl in East Africa who "agrees" to be genitally mutilated is not making a "choice." And yet, I found out recently that the ACLU--supposedly an organization that supports freedom--supports the "right" of persons in the US to "practice" this form of torture and disablement because it is their cultural "choice." We are well into the realm of Orwell's "1984" with this type of re-definition.

The overwhelming presence of mass media and entertainment media in people's lives has been a boon to those who want to entrench sexist notions. Media and entertainment companies are still mostly run by men, and these men have used media to shape and alter people's emotions and perceptions. Through the control of images and the manipulation of language, violence and oppression have been normalized.

Tuesday, October 17, 2017

Normalization of Pathological Behavior, Part One: Psychological Defense Mechanisms

Since the Harvey Weinstein revelations, I've been thinking about the normalization of pathological behavior. This is a common phenomenon in our society and in most societies.

This article in The New York Times summarizes the reasons why women often don't report sexual harassment--mainly, that they fear retaliation. There are other factors, however, that make people in general turn a blind eye to harmful and pathological behaviors. These include psychological defense mechanisms such as denial, rationalization and dissociation, effects of mass culture, and deliberate propaganda by vested interests that uses rhetorical tricks to minimize atrocities. I'll address psychological defense mechanisms today.

Psychological defense mechanisms serve to ward off anxiety by distorting reality. In rationalization, the mind invents "reasons" why something happens that aren't really logical, but serve to distract from an unpleasant or frightening reality. In dissociation, consciousness is altered so that an experience isn't perceived at all in daily consciousness, but may be acted out unconsciously, or remembered while in an altered state (such as hypnosis). Denial is a phenomenon in which "the existence of unpleasant realities is disavowed; [it] refers to keeping out of conscious awareness any aspects of external reality that, if acknowledged, would produce anxiety" (Kaplan and Sadock, "Synopsis of Psychiatry," 2007 edition). Denial and dissociation are closely related.

The mind resorts to defensive maneuvers in order to preserve physical health. Overwhelming stress can cause great damage to the body--altering hormones, damaging the immune system, interfering with sleep and worse. The survival instinct will undermine the mind's ability to accurately perceive reality in order to avoid the physically damaging effects of overwhelming fear.

People who have been victims of rape or other traumas not infrequently experience dissociation. Aspects of the trauma may be blocked from conscious awareness.

Sometimes trauma survivors invent "reasons" why the incident occurred (rationalization). As the general population is made aware of behavior such as Weinstein's, others may also engage in denial or rationalization. People don't want to believe that another human could be that horrible, and perhaps especially, when that human is the same gender as they are. It's too frightening.

The way to overcome denial, dissociation and rationalization is to speak about the crimes and traumas. Overwhelming evidence eventually destroys the use of distorting defense mechanisms, in all but the psychotic.

Wednesday, October 11, 2017

Raising Resilient Children

There have been a plethora of books and articles written in the past few years about the lack of "resilience" among members of "Generation Y" (people born from approximately 1985 to 2000), what has caused it and what to do about it. But now, the millenials are starting to have their own children. How can they avoid the mistakes of their parents? Here are some tips:

1. Have more than one child and make sure that siblings aren't more than 3 or 4 years apart in age. I know this might not be feasible for all parents, but it is worth mentioning, because the advantages of siblings outweigh the negatives, and the advantages are significant.

 Although some studies in the past indicated that only children have higher achievement, some studies also found a greater incidence of drug addiction among only children.

People who grow up with siblings learn crucial skills of negotiating, sharing, advocating and taking turns, earlier and more consistently than only children do. More importantly, a sibling close in age is a "buddy" who provides peer identification, which is important for personality development. Only children often feel lonely because school friends and play dates aren't a substitute for a sibling, and worse, when the parental marriage is dysfunctional, an only child can become a parent's best friend, an unnatural situation that interferes with personality development and in the worst cases leads to incest.

Although I've heard stories of dysfunctional sibling relationships (including abuse), the majority of my patients who have siblings have benefitted from those relationships. Siblings too far apart in age often don't function as siblings, however, with the older sibling often taking on a quasi-parental role that may not be appropriate.

2. Allow your child to engage in unstructured, unsupervised play. It really is true that hovering parents interfere with a child's developing sense of autonomy. Let young children play by themselves (or with siblings) in their rooms, and let school age children play by themselves in the backyard, if you have one.

3. Send your child to sleep-away camp if you can afford it. Do this when your child is 11 or 12 years old. Sleep-away camp can be a way for only children to get some of the benefits that children with siblings get. A good sleep-away camp offers challenging outdoor activities that build confidence.

4. Remember that academic achievement alone doesn't guarantee success in life. The Unabomber went to Harvard. Prestigious academic degrees don't guarantee mental health or social functioning. I have found that many of my patients who are the children of immigrants were kept home after school to study, study, study. The end result is often anxiety disorders and worse. Just today I read an article in The New York Times about the skyrocketing rate of adolescent anxiety disorders, with one teen profiled  taking 3 Advanced Placement classes as a high school junior. I don't understand why this is allowed by the school, much less by the parents.

5. Be a role model of mental health. The best way to be a good parent is to be a healthy parent. Parents with untreated depression or those who engage in substance abuse tend to have emotionally disturbed children. Nine times out of ten, when I worked with children, I found that there was either abuse or neglect going on or a parent had an untreated disorder. Unfortunately the media sometimes give the impression that children's emotional disorders are purely genetic, purely socially constructed,  or unfathomable, and this isn't true.

Sunday, September 24, 2017

What is Co-Dependency?

I've discovered many people do not know what the word "co-dependency" means.  It's a somewhat complex clinical term.

"Co-dependency" was coined in the addiction treatment field to describe a phenomenon observed among family members of alcoholics and addicts. Treatment professionals and others noticed that spouses of addicts and alcoholics frequently were high-functioning individuals, but that they often helped the addict/alcoholic cover up their addiction and "enabled" the addiction through "caretaking." These "enabling" and "caretaking" behaviors sometimes allowed the addict/alcoholic to continue their addictive behaviors past the point where they might have been forced to change, had they been on their own. These observations led to a belief among treatment professionals and others that family members of addicts needed their own treatment.

"Enabling" and "caretaking" can take a variety of forms. The spouse/partner might make excuses for the addict/alcoholic to employers, "explaining" that the person is "sick" and can't come to work, for example. If the addict/alcoholic is fired from employment, the co-dependent may take on additional work to make up the difference, instead of demanding that the addict/alcoholic stop the addictive behaviors and find a job.  The co-dependent in some cases may even facilitate the addiction by keeping alcohol in the home or by driving the addict/alcoholic to social events or perhaps even the liquor store. Why do people engage in these behaviors?

A theory began to emerge that the co-dependent was "dependent" on the spouse's addiction the same way that the addict/alcoholic was dependent on the substance. By comparing her/himself to the addict/alcoholic, the co-dependent could feel superior. The care-taking behavior was seen as making the co-dependent feel important. In some cases, the co-dependent behavior led to a "martyr complex," in which the co-dependent believed that he/she was a valiant and long-suffering individual. Underneath  these behaviors and beliefs there is typically a lack of self-esteem. Treatment for the co-dependent involves helping the person get in touch with his/her feelings of low self-worth, and guiding the person to finding productive ways to raise their self-esteem instead of through comparing themselves to a dysfunctional person whom they need to remain dysfunctional in order to fulfill this purpose.

Because so many alcoholics and addicts are men, for a long time the stereotype of the co-dependent was that of a wife. However, it's been my observation that more men than women have co-dependent traits, and that these traits are often normalized in men--the "White Knight" who rescues a damsel in distress, or the man searching for an "Angel with a Broken Wing." We are so familiar with these characterizations that we may think of this as normal male behavior. Needing to feel superior is a sign of low self-esteem, and just because it may be common in men doesn't mean it isn't pathological.

Even though the co-dependent may "help" the dysfunctional partner or family member, the relationship doesn't serve anyone's interests. It enables the dysfunction and stresses the co-dependent. The dysfunctional person often starts to resent the co-dependent, sometimes sensing consciously or unconsciously that the care-taking behaviors are a form of control.

Anyone who has a close relationship with an alcoholic or addict should seek their own counseling. Any man who searches for an "Angel with a Broken Wing" as a partner should take a serious look at his own feelings of insecurity and inadequacy.