Archive for the 'Addiction' Category

Recovering out loud

Jan. 13th 2016

Jeb Bush sets the standard for facing addiction

In your family as in mine, did side conversations occur during the holidays about cousins, in-laws or next-gens in rehab, relapsing or actively using? How about relatives or offspring of family friends fresh out of treatment – are they back at it? Of course these are all very quiet discussions; don’t tell anyone.

 

We don’t want to talk about it, do we? 

 

But Jeb Bush does. 

 

As a father, I have felt the heartbreak of drug abuse. My daughter Noelle suffered from addiction, and like many parents facing similar situations, her mom and I struggled too.

 

I never expected to see my precious daughter in jail. It wasn’t easy, and it became very public when I was Governor of Florida, making things even more difficult for Noelle. She went through hell, so did her mom, and so did I.

 

It’s very debilitating when you have a loved one who is struggling, and you can’t control it. You have to love them, but you also have to make it clear you cannot enable the behavior that gets them in trouble.

 

Showing a lot of courage, Noelle graduated from drug court. Drug courts use a restorative solution model involving multi-disciplinary coordination, including the judiciary, the prosecution, mental health specialists, social services and treatment professionals. I was the proud dad that saw Noelle finish that. She’s drug-free now.

 

Noelle was charged with forging a fraudulent prescription for Xanax and with possession of crack cocaine. Her parents chose not to use their influence to get her off. They were smart enough to realize that criminal charges could be used to force her into multi-disciplinary treatment with accountability for clean drug screens over many months – the proven formula for successful recovery.

 

Hearing from parents like Jeb helps us understand how Noelle recovered and “normalizes” addiction – making it just like any other illness. Unfortunately, most families aren’t as forthcoming as the Bushes and few follow through to see that consequences remain in place.

 

Common rationalizations counterproductive to achieving long-term recovery (and my responses) include:

  • It’s up to the addict to tell people. (But if s/he never does tell, people can’t be supportive.)
  • Let’s keep it a secret. (But addiction thrives in secrecy and withers in openness.)
  • I am ashamed to have an addict in the family. (But addiction is a disease. Is it shameful to have cancer?)
  • I need to let go. (But addicts need accountability. If not you, who will hold them accountable?)
  • I would never suggest alcohol/drug testing. (But testing leads to improve outcomes and early intervention in case of relapse.)

Facing addiction means talking about substance use and abuse and recognizing it is a chronic disease that can be prevented or minimized if families and their advisors work together. For most, however, even simple steps, like attempting to estimate the percentage of substance abusers or others with significant behavioral health disorders within the family, is fraught with controversy and rarely undertaken. And what is the tipping point – 20%, 30%? – sufficient to motivate action? In my family of origin, combining my parents, grandparents and siblings, our rate is over 50%. That’s 911 time in my book – and one reason I became a licensed alcohol and drug counselor.

 

Doing nothing or ignoring it is not a successful strategy and only leads to tragedy. It takes a village and thoughtful planning – before you find yourself in crisis – to have a chance against the power of the drug or the drink.

 

When parents talk openly about their experience, other families learn about what works for recovery. And their stories serve as cautionary tales for those in their teens and twenties.

 

Until we find the courage to move beyond our shame and our silence about addiction, unneeded relapse and avoidable deaths will continue to happen.

Worse than ever: Pain pills and heroin use

Apr. 28th 2015

More people are dying from opioid overdoses than traffic accidents, yet no one seems to notice or want to address it. As commented on in the April 17th issue of The New York Times, “Serving All Your Heroin Needs”:

 

Meanwhile, the victims – mostly white, well-off and often young – are mourned in silence, because their parents are loath to talk publicly about how a cheerleader daughter hooked for dope, or their once-star athlete son overdosed in a fast-food restaurant bathroom.

 

Look at the numbers: 24,000 deaths from opioids. While the pain pill machine goes about its business of producing more and more addicts, no one says a thing.

 

For parents who do stand up and speak, the response is underwhelming. I attended an event at a large suburban high school billed as a community forum to examine the problems of recreational drug use, prompted by the drug death of a 17-year-old. Her father, Tom, spoke very movingly and passionately about his loss, but the audience was almost devoid of parents.

 

Why? Is it fear of hearing a contemporary bare his soul about a parent’s worse nightmare? Is it hoping that ignoring the problem will make it go away – soon they’ll be off to college anyway? Who knows? But the absence of any passion – any demand for action – was striking.

Stimulant use among 26-to-34-year-olds doubles in four years

The Sunday Times had a second story, this one on abuse of ADHD medications, titled “Workers Seeking Productivity in a Pill are Abusing A.D.H.D. Drugs.” Stimulants like Adderall, Vyvanse, and Concerta are migrating from school settings to the workplace. They’re now in play in demanding professions:

 

These lawyers said they and dozens of young colleagues at their firms had casually traded pills to work into the night and billed hundreds of extra hours a year in the race for partnerships.

 

Overuse leads to rapid heartbeat, acute anxiety, hallucinations, sleep deprivation, and addiction. Just the type of professional you want working on your case or in your firm or client base. Outside of the workplace, these pills are “Mommy Crack,” great for staying thin and multitasking on the home front.

 

Again, this phenomenon starts in high school, where students sell pills or give them to friends to help with academic focus and performance. They’re great for answering the four or five extra SAT questions needed to break 700 and pulling all-nighters for studying and exams. Whether it be weed, alcohol, uppers, or downer, students in every high school know who is selling or providing drugs and drinks, but are unwilling to name names out of fear of being ostracized or to protect their sources.

Silence and indifference

In any case – at the parent or student level – we have created a culture of silence and indifference not seen since the AIDS epidemic. We are beginning to make the connection between binge drinking and date rape among high school and college students, but a similar connection must be made between pharmaceutical companies’ and doctors’ profits and drug dependence and deaths. In both instances, the big businesses supplying the alcohol and pills pay less than 5% of their collateral damage and can never atone for their increasing death toll.

 

Not to minimize the AIDS epidemic, but what we’re dealing with here is on a very large scale. The Band Plays On, with alcohol and opioid deaths exceeding 100,000 per year. When will enough of us join together to stop this growing tragedy?

Becoming addicted to pain pills

Perhaps understanding how opioid dependency develops will be the first step in generating more public support for taking on the drug industry.

 

For those of you unfamiliar with how someone becomes dependent on pain pills, here is how it happens. People have an injury, surgery, or dental work and are given a prescription for 30 pain pills. After just a few days, it takes more pills to obtain the same level of effect in dampening pain. Most patients learn to tolerate their pain and supplement with over-the-counter medications. But then once they near the end of their supply, there is the problem of stopping. Stopping abruptly leads to uncomfortable physical symptoms, so most people taper off. But addicts are not like most people, and they don’t stop.

 

The dependency cycle

 

The dependency cycle begins when a person ups the dose, decides it’s too uncomfortable to quit, or in fact likes the physical and psychological effects from the pills. These narcotics can give a euphoric sensation of withdrawing from the world. Users will continue to seek prescriptions until their doctors decide to cut them off. From there, they turn to doctor-shopping and online ordering, or worse.

 

Switch to heroin

 

Many users – or addicts – switch to heroin because it’s cheaper and more readily available. It also can produce a really powerful and pleasurable body jolt the first few times. This motivates the addict to “chase the high” – trying to reproduce the feelings from that first time by increasing the amount, potency, or by mixing with other drugs. Very dangerous and a big reason for all the deaths. A similar process occurs for other narcotics.

 

Over-prescribing

 

Painkillers are meant for acute pain, not chronic pain, as are most other drugs, such as anxiety or sleeping medications. But remember, this starts with the doctor handing out the initial 30-pill prescriptions or samples provided by Big Pharma, enough to hook some patients, as the drug companies know all too well. And it’s no secret that doctors are liberal with the scripts – even doling out Norco (acetaminophen and hydrocodone) by the handful to newly-postpartum nursing mothers. It’s hard to keep saying no when it’s always offered.

Transforming public opinion and policy

Attacking the supply side seems like a good first step, but that means overcoming deeply entrenched social stigma, leaving the shadows, and finding the courage to tell our truths – namely that these problems don’t exist in a vacuum. With opioid-related overdose deaths occurring every four minutes, we can no longer pretend that these “dirty” deaths are only happening to strung-out junkies living on the streets in the inner city. They are happening to us, our families, and our friends. Fortunately, new generations are stepping forward to start conversations aimed at transforming public opinion and policy.

To Tom, the father who spoke out at the community forum, you are not alone, and we will not forget your daughter.

Moderate drinking: A destination or way station on the road to abstention?

Apr. 7th 2015

My comments on “The False Gospel of Alcoholics Anonymous” in The Atlantic

Gabrielle Glaser’s lengthy article in the April 2015 issue of The Atlantic, “The False Gospel of Alcoholics Anonymous,” (online as “The Irrationality of Alcoholics Anonymous“) is something of a misnomer, as its focus is on the failings of the treatment industry as a whole, including over-reliance on AA’s 12 Steps, interspersed with anecdotes from people interested in reducing or moderating their drinking. The dramatic tension in the article is between abstinence-based models (AA and inpatient treatment) and harm-reduction or controlled drinking models for people who may or may not meet DSM-V diagnostic criteria for alcohol dependence.

 

This is a common theme that crops up regularly in the media and is promoted heavily on the web – alternatives to AA that either teach people how to drink “normally” or offer narcotic medications as alcohol substitutes. While Glaser identifies several valid criticisms of the current system, the author’s focus is on promoting alternatives to abstention for people who very likely should be putting the cork in the bottle and leaving it there.

 

Here’s my quick take:

 

Moderation/Experimentation

Moderation/experimentation can be useful if there is an adequate assessment process (including drug testing and input from family members) and accountability in the event of failure. Unfortunately, Glaser overstates its benefits and understates its risks. In my view, it’s never appropriate for drinkers with severe disorders or co-occuring mental health concerns.

 

Drugs

We need to be clear what kind of drugs we’re talking about here. Drugs such as naltrexone that are not cross-addicting (unlike, say, Valium) can be helpful to some people in reducing their drinking or abstaining and are available at many treatment centers. But replacing addiction to alcohol with addiction to benzodiazepines should not be considered a success.

 

Treatment outcomes

In terms of recovery rates, programs for pilots and doctors have far superior outcomes to all other programs, and we should be talking about implementing their programs for all. Arguing about AA success rates and other treatment models for which there’s no data seems at best subjective, at worst pointless.

 

Alternatives to AA

Yes! Patients/clients should be offered material without references to God so they can participate in treatment center activities with their peer group. They should also be offered alternatives to AA meetings, such as Smart Recovery and Women in Sobriety. But let’s not forget that AA (and 12-Step programs) has worked wonders for a lot of people; there’s no need to completely trash it out. Additionally, from what I’ve seen, the article exaggerates AA’s role in most treatment programs.

 

Range of options in community-based settings

In an ideal world, a patient’s learning skills and preferences would be matched with a menu of treatment resources. With the ACA, many more options are in place, including groups for people who are thinking about stopping drinking. For example, in my hometown, two miles down the road from Dr. Willenbring’s office, Hazelden is building a brand new outpatient megamall. The one-size-fits-all criticism is now outdated in many communities.

A framework for evaluating addictive behavior

Whenever information is presented about someone with an apparent addiction, it’s important to understand the framework used to diagnose and assess the concern. My approach is grounded in medically-based information on the effect of alcohol or drugs on the brain, the American Psychiatric Association DSM-V Diagnostic Manual, and an evidence- or facts-based evaluation model, including drug testing.

The starting point for evaluating articles about drinkers or drug addicts

The starting point for sorting through these advocacy pieces, then, is the disease model for substance use disorders and contemporary “best practices” as applied to the four anonymous prototypes in the article: 

  • G. who used to drink a liter of Jameson a day but now does not drink and is taking Baclofen and Valium, as needed for anxiety.
  • Claudia who takes naltrexone and now stops at one drink.
  • Jean who was drinking a bottle of red wine a day and now has an occasional drink.
  • P who had as many as 20 drinks at one time, and by using naltrexone binges two or three times a month.

Brain changes due to drinking

Consistent with the mainstream medical perspective, the article reports that addiction results from changes in brain structure due to long-term excessive drinking:

 

Each time [a person drinks] the endorphins released in the brain strengthen certain synapses. The stronger these synapses grow, the more likely the person is to think about, and eventually crave, alcohol—until almost anything can trigger a thirst for booze, and drinking becomes compulsive. (p. 55)

 

While alterations in the brain can be seen through imaging, scans are expensive and not usually used in the diagnostic process. Instead, the American Psychiatric Association has developed 11 diagnostic criteria to assess the degree of substance dependence (brain alteration) in the DSM-V.

The DSM-V

The DSM-V assessment process uses 11 criteria with three levels of dependence based on symptomology: Severe (6+), Moderate (4-5) or Mild (2-3) alcohol use disorder. Keep these in mind when thinking about controlled drinking, for as the article reports:

 

Moderate drinking is not a possibility for every patient, and [Dr. Willingbring] weighs many factors when deciding to recommend lifelong abstinence. He is very unlikely to consider moderation as a goal for patients with a severe alcohol-use disorder. … Nor is he apt to suggest moderation for patients who have mood, anxiety, or personality disorders; chronic pain; or lack of social support.

 

The idea being that if the brain is altered sufficiently, it’s almost impossible to regain control at the 6+ level. These people are candidates for stop-drinking programs, whereas the moderate and mild drinkers are said to be appropriate for the doctor’s managed-drinking program using naltrexone.

Substance use diagnosis first, please

The first question anyone, including writers, should ask our four prototypes is:

 

What’s your DSM diagnosis? And then, what’s your status regarding related co-occurring disorders?

 

Current thinking is that people with a mild diagnosis may be able to control their drinking because their brains have not crossed the threshold to permanent alteration. However, people in the moderate category may not be able to consistently regain control, which brings up the harm-reduction/moderation debate in the treatment profession.

Harm reduction

We all know people who meet the moderate/severe category and want to continue drinking. P, for example, is using naltrexone to cut his binging down to three times a month. This type of harm reduction is viewed as a “win.”

  • However, for people like P, who meet the severe or moderate criteria, the risk is that they can revert to their old patterns, drink and drive, or hurt their family members.

Even with reduced drinking, they may still retain the emotional disorders associated with greater use (i.e., the dry drunk). Harm reduction then becomes a tolerated permanent status rather than a stopover on the way to abstention. Maybe not such a great win for P’s liver, spouse, children, or employer. But who knows?

Cross-addiction

J.G., who is now “not drinking,” is prescribed Valium for his anxiety. Anyone in the treatment field knows Valium is commonly used for alcohol detoxification because it hits many of the same brain receptors. It’s alcohol in a pill form and often used in place of alcohol by people who “don’t drink at all.” It’s odorless and easy to obtain over the Internet or through doctor shopping.

 

Replacing alcohol with Valium is simply substituting one addictive substance for another and is not considered abstinence as defined in the DSM-V or mainstream addiction medicine. But there are doctors and treatment centers that prescribe benzodiazepines (like Valium) to people with substance use disorders and claim their patients are in recovery – on maintenance therapy.

 

The author goes very light on this topic and does not even mention the very real possibility of cross-addiction. She also fails to note that Baclofen is associated with significant withdrawal symptoms and cautionary side effects and is in need of further study for use in treating alcoholism.

Addiction-certified doctors

The Valium script issue highlights the need for training on addiction in the medical profession. However, the number cited, 582, is incorrect, as there are over 300,000 members of the American Society of Addiction Medicine (ASAM), according to its website. With more addiction-savvy doctors, fewer patients will be prescribed benzos to help them control their drinking.

Assessment information: corroboration and BAC levels

One problem omitted from the article is the difficulty of assessing alcohol use when drinkers self-report in the absence of outside verification from family and friends or drug tests. Without such a system in place, moderation and experimentation can easily be a cover for continued excessive drinking and using. (For example, courts in Minnesota require three collateral sources.) “Trust but verify” through corroboration and random, supervised testing is state-of-the-art these days and would aid in determining whether Jean and Claudia meet the moderate, mild, or no diagnostic standard.

Experimentation/Controlled drinking

Drinkers in the moderate and mild category are said to be candidates for experimentation with or without the aid of naltrexone. By helping clients set behavioral expectations and then reviewing progress in meeting their goals, counselors can play a key role in building awareness regarding negative use patterns. This approach works particularly well with young adults.

 

This kind of “experimentation,” as discussed in the article, where people see if they can stop for a time, drink less, or drink on fewer occasions can be a good learning experience, as the author points out. It helps in breaking through the self-perception hurdle – over 90 percent of people with addictive disorder issues do not perceive themselves as having a problem – and it increases willingness to seek additional help when goals are not met.

 

As Glaser points out, these techniques, including prescribing Naloxone, should be part of the repertoire of outpatient clinics and individual addiction counselors these days. And, since most people who drink excessively are not alcohol dependent, an evaluation process is preferable to going directly to inpatient treatment, as can happen in the surprise intervention model.

Experimentation, to what end?

In my experience, people who “experiment” and fail don’t usually decide to increase their level or intensity of treatment, unless there is a written agreement in place or there is pressure from family or an income source (e.g., a trust or employer). In other words, insight alone is often insufficient to induce behavior change.

 

This leads to another concern: People don’t have alcohol and drug problems in isolation. It’s a family/community problem, and this larger group’s interests and opinions need to be taken into account as to how long they are willing to tolerate “failed experimentation.”

Treatment

When the topic of treatment effectiveness is raised, my starting points are the highly successful programs run by airlines for pilots and medical boards for doctors.

Outcomes – Best practices

The programs for physicians and pilots have proven outcomes of 74 percent continuous abstinence at five years and 92 percent at two years. Proven because the participants are drug tested over that time period. No other programs match these outcomes. The real criticism of the treatment industry should be its failure to apply the physician/pilot programs to all groups.

Treatment compliance/effectiveness

Patient failure to comply with treatment recommendations is a major cause of relapse. Is this due to lack of programs that appeal to clients? The system lacks incentives to encourage compliance? Or is alcoholism simply very difficult to recover from?

 

For the author, it’s lack of appealing programming. From my view, it’s lack of incentive-based contingency management approach. Reward systems can be very effective in treating even hardcore crack smokers. Again, its common knowledge that the medical boards and airlines (also DUI/drug courts) use therapeutic leverage to encourage treatment compliance, but this approach and these state-of-the-art programs are never mentioned.

$35 billion a year on substance abuse treatment – we need better outcomes

This is one theme of the article: What are we getting for all this money?

 

The better question is why aren’t treatment centers adopting the pilot/physician model for all patients? The long answer is that inpatient treatment centers tend to be their own program and economic entities. Until they are held accountable for outcomes, they will have little reason to ensure quality, patient-centered options exist in the pre- and post-treatment environment. Again, the ACA appears to be creating incentives for accountability.

Inpatient treatment

J.G. says he went to a center where they offered little more than AA. Being from St. Paul, I am not certain what place he is referring to. It is clearly not a Minnesota Model treatment center like Hazelden, which offers a full range of modalities, including CBT therapy, acupuncture, meditation, education on the disease concept, groups, and mental health-related services (by the way, it also offers naltrexone for craving reduction). He might have attended The Retreat, an AA-only program located in Wayzata, Minn.

Treatment centers promotion of AA and alternatives

Inpatient treatment centers provide a variety of programming during the day (see above), but their residences are organized on the basis of self-regulated peer groups, usually around the principles of AA. Patients are also asked to participate in actual AA meetings. That can be a problem for people who don’t like AA or the God part. Some, like me, join in, as it seems to help and is benign. Others object.

 

Treatment centers should adjust their programming to meet the needs of their patients, rather than vice versa. It is possible to modify the 12 Steps and peer-based activities to eliminate references to God so patients have a choice when participating in group activities. Offering alternatives to AA, such as Smart Recovery and Women for Sobriety, makes sense as well, although it requires staff that is sufficiently talented to oversee and help implement these support groups as an AA alternative.

Post-treatment referrals

To clarify, patients are referred to a range of post-treatment resources, including AA meetings. These include therapy and outpatient or aftercare support groups. Some people who don’t like attending AA only go to their non-AA activities.

 

As noted in the article, the quality and content of AA programs vary greatly. In my experience, AA works pretty well for middle- and higher-income males, but not for others (e.g., minorities, women, LGBT, the affluent, and the poor) who fare better in more targeted groups. But only a few of these specialized groups exist. I agree that clients leaving treatment should be offered options to referrals to AA.

A range of evidence-based options needs to be offered people seeking help

In an ideal world, a patient’s learning skills and preferences would be matched with treatment resources. The treatment profession is heading in that direction. Until the enactment of the ACA and Wellstone parity implementation, insurance companies underfunded non-residential services. But that is now changing for the better.

AA concepts originally for chronic, severe drinkers, or not?

The in-depth historical analysis in the article helps the reader understand why the 12 Steps of AA are so prevalent in treatment today and why abstention is the only recommendation for those who are “truly” alcoholic. From this analysis, the author argues that AA is a one-size-fits-all program and inappropriate for those with less severe patterns of drinking.

 

Having interned at a treatment center, I know that staff can use a generic approach for everyone, without regard to their individual circumstances. However, the Big Book is more flexible and in fact has a set of stories entitled “They Stopped in Time,” describing how people came into recovery before they hit bottom. Many drinkers seek help with moderate use disorders and find the Big Book and 12-Step model useful in becoming sober. It’s all in how you approach it – open-minded or closed-minded.

Lack of trained, well-educated staff

Unfortunately, rigidity in implementation occurs because it is so often based on the personal opinions of staff in recovery and AA volunteers. It is this off-putting attitude that is so offensive to many people, like Jean in the article, who then recoils from what might be helpful concepts. It also highlights the lack of professionalism in treatment centers – another valid comment.

AA’s value

AA’s value lies in providing a support group for people with a common problem: how to stop drinking and stay stopped. AA focuses on the present moment – today – versus remorse over the past and anxiety over the future; shame reduction; emphasizing the disease concept; and being accepted for “who you are.” AA also provides a relationship network so people can share personal stories, make connections and feel better. As to the latter point, we now know that intimate group-sharing releases positive endorphins. These are valuable, if not critical elements, in sustaining long-term recovery, which the author overlooks in her critique of AA.

Addiction as a “good habit gone bad”

In his book The Power of Habit, Charles Duhigg explains that habits are formed over time and based on rewards from engaging in specific behaviors. Due to changes in brain structure from long-term excessive drinking, alcoholics respond to craving by drinking, and their reward is the alcoholic buzz. To stop this compulsive behavior, mainstream treatment is designed to teach new, healthy responses to cravings and new rewards. (This, by way, is the also the core function of AA.)

 

The tension between the moderation model and abstinence model has to do with the different responses to stimulus and the reward.

  • Drinkers practicing moderation remain in the same stimulus-reward system where they want to take a drink with the resulting effect on their body and emotions (but with craving synapses hopefully dampened through naltrexone).
  • In contrast, those of us in the abstention model learn an alternative response to picking up a drink – say exercising, with the reward being increased self-esteem or an exercise-induced increase in endorphins.

Abstaining usually involves “transformational change,” in that the person no longer believes alcohol is necessary to live and adopts a new value system.

Marijuana: Family and advisor responses and recommendations

Mar. 31st 2015

Part II

As emphasized in Part I, it’s important to acknowledge the positive and enjoyable aspects of pot use to establish credibility with young adults. After all, they know many of us older folks smoked in our early days and we did indeed inhale, unlike one of our presidents.

 

However, to reiterate, marijuana’s downside is that repeated use impairs learning and executive/problem-solving brain functions. With many regular users chasing higher THC concentrations (up to 27 percent), being able to identify at-risk and dependent users becomes an imperative. Note that, in contrast, medical marijuana is effective at 9 percent THC in very small quantities (two or three times a day) – one way to identify those truly in need of pain relief vs. those gaming the system.

The survey says

Another important part of any discussion with young adults is putting marijuana use in the context of other substance use, including alcohol.

  • Surveys show within a two-week period, 13 percent of college students had 10+ drinks in one night and 5 percent had 15+ drinks in one night.

Potheads are quick to point out this comparison (binge drinking at 18 percent vs. regular pot use at 9 percent) while also noting the difference in post-use effects – namely no vomiting or hangover. But let’s not fall into the trap of arguing which type of substance is superior. Going down that rabbit hole with Alice (a.k.a. your client, son, or daughter) leads you to a land of never ending rationalizations and justifications.

 

By the way, these drinkers and smokers are two separate groups, so the total for male students with substance use symptomatology is at least 27 percent. Add in the one in nine in 2013 who used Adderall without medical supervision and smaller numbers using other drugs, and you can understand why we keep harping on the fact that this problem can no longer be ignored.

 

A recent New York Times article on 12 hospitalizations due to ingestion of “bad Molly” on the Wesleyan campus led police to discover 600 Xanax and at least 15 other prescription drugs in room searches. Noted one expert at Columbia College:

 

“Where did this kid get such a bizarre collection of drugs? … It’s very frightening, because these drugs can cause fatal reactions.”

 

Great question. The answer is everywhere. This type of use by different groups – the drinkers, smokers, and stimulant freaks – is prevalent on all campuses and upon graduation will either become part of your client base or potential work force. 

Evaluation

Clients come to us suggesting we evaluate a young adult to see if there is substance dependence. But good luck conducting an assessment based on self-reporting. All we hear is minimization and excuses. Reports from concerned family members are rejected as overreactions or one-time “experimental” events. When marijuana comes up for discussion, the attitude is “It’s legal or should be legal.” Without objective external evidence, convincing a young adult to cut back or seek help can be fruitless, particularly if they have access to trust funds or are employed.

 

Be aware that for an evaluation to be accepted in court in our state, at least three outside collateral sources are needed to verify information about the subject’s drug use. Identifying and then even suggesting talking to these collaterals can be contentious, to say the least.

 

As mentioned in Part I, by understanding marijuana’s effect on the body and why people like it, family offices and advisors can tailor an approach that focuses on education, establishes behavioral standards and performance expectations, and puts policy in place for family members.

Recommendations

For the office, drug testing is the most reliable and prudent approach to ensure you are not putting your reputation and fiscal integrity at risk. If a person wants to smoke dope or use other drugs, they can work at a coffee shop, but not for you or the families and clients who rely on you.

 

For your clients, there are two complementary tools: education (scientific advances, including brain scans) and behavioral expectations and standards.

 

Education: the science of brain scans

Showing younger generations how brains of pot smokers compare to the brains of non-smokers is an excellent educational tool. When accompanying accurate information on how weed affects the body – both the fun and unfun sides – scans can be persuasive. Another tactic is to find a respected family program, like Hazelden’s, where teenagers and their parents can learn more about substance dependence and how it is linked to brain changes.

 

Behavioral expectations and standards

Aside from the educational approach, the critical piece has to do with behavioral expectations and standards. Start with solid baseline information on aptitude, skill level, and any learning concerns. Assuming you or the parents you are advising have this information, assess whether there are underperformance or behavioral concerns that warrant evaluating the reason for the differences between expected and actual results. This may require educational or other testing to explain the disparity.

 

As you continue on, it’s necessary to come to an agreement or otherwise establish goals for the young adult in question. It is through a thoughtful goal-setting process with measureable standards that dysfunctional behavior can be identified, particularly if there is some indication drug testing is a necessary part of the process.

 

Note the connection to the Social Impairment diagnostic criteria for substance use disorders:

 

Social Impairment is the second grouping of criteria (Criteria 5-7).

  1. Recurrent substance use may result in a failure to fulfill major role obligations at work, school, or home.
  2. The individual may continue substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.
  3. Important social, occupational, or recreational activities may be given up or reduced because of substance use. The individual may withdraw from family activities and hobbies in order to use the substance.

Setting measureable goals and expectations can provide the factual basis to support findings relating to social impairment, an area of vulnerability for pot smokers. When facts become apparent, it’s a good time to introduce drug testing. Tests can now be justified to parents and families who might previously be concerned about an unwarranted invasion of privacy.

 

present in an alcoholic as you would in someone whose drug of choice is marijuana. For example, take impairment criteria 3 and 10, more common to binge drinkers:

  1. The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects.
  2. Tolerance is signaled by requiring a markedly increased dose of the substance to achieve the desired effect or a markedly reduced effect when the usual dose is consumed.

The people consuming 10-15 drinks in one sitting will have a high tolerance and spend a great deal of time recovering from the effects of doing so. Each drug presents its own set of challenges and impairments. By DSM standards, one is not better or worse than another. Disordered use is disordered use.

Three points

1. Take action or problems will get worse
Don’t let under performing, slacker, next-generation family members meander through their formative years without a plan to investigate drug or learning concerns. (Otherwise they become dependent – in the full sense of the word – 30-, 40- and 50-year-olds.)

  • Of course, this assumes the family office and governance documents contain expectations as to performance.

If not, and each branch handles these issues individually, you will be an observer of the long-term effects of drug use and living proof of affluent “falling generations.”

 

2. The code of silence

Don’t expect siblings, cousins, or friends to blow the whistle on heavy pot smokers (or other drug users or drinkers, for that matter). There is a fierce unwritten code not to rat out substance users.

  • If you do hear something, follow it up because it usually means the person of concern is in way over their head.

However, even if the information is persuasive, you will need to determine if it carries the same weight with the deciders (i.e., parents or grandparents) before you proceed. They will often either be in conflict or more concerned about reputation and succession, and thus eager to shoot down stories from their heir’s friends.

 

3. Cross-addiction

Simplistically, the brain reacts to most drugs in the same way. It doesn’t distinguish between weed, alcohol, coke, and other substances in terms of their addictive nature. So when someone comes out of treatment and says, “They told me I can’t do vodka, but I can have beer and weed,” that’s a lie. Ask them to sign a release so you can see their discharge summary with their diagnosis. This type of misinformation is a lot more common than you would imagine.

Not going away

We hear from our friends in Denver that home prices are skyrocketing due to an influx of younger folks of independent means who seem to be moving in so they can enjoy legal bud. Who knows if this is fact or old folks’ imagination, but what we know is weed is not going away. It’s going to be more pervasive and impactful on communities, including the families we serve and the people we employ. Doing nothing is not an option.

Marijuana: The fun side, the downside, and why family offices and advisors should take note

Mar. 19th 2015

Part I

Fully or partially legalized in many states, a solid majority of teens and young adults believe marijuana should be universally decriminalized, viewing weed as a relatively harmless drug in comparison to alcohol. Its use is widespread among affluent young in high school and college. For example, at one local school I hear students toke up to obtain a better grasp on abstract concepts in their advanced physics class.

 

As of 2013, one in 11 male college students are daily smokers. With marijuana use and acceptance on the rise, we advise diffusing this momentum with facts on how it affects the brain (both positive and negative) and a behavioral-based management strategy.

Why bother worrying?

As pot becomes increasingly legitimized across the country, now is a good time for family offices to get up to speed on the implications for clients and office operations. You might think, “Why bother?”

  • And, indeed, that is a fair question if your approach is to oversee investments, disburse and account for income, advise on estate planning, and leave personal conduct issues up to the individual.

Marijuana can be viewed as just another substance that clients may choose to use as part of their lifestyle. Some regular smokers even tend to be “laid back” and therefore less time-consuming and demanding compared to other clients.

When it becomes a problem

Conversely, other regular smokers may be more difficult to deal with in family meetings.

  • They ask disruptive questions and go off on tangential trains of thought.
  • They are susceptible to harebrained investment schemes, being easily talked into being the deep-pocket “lead partner” to show their family they can be successful – despite being chronically high.
  • You may also have unhappy grandparents when they discover their beloved granddaughter is moving to Colorado to raise goats after they “invested” several hundred thousand in her private school education.

So identifying the source of this behavior, understanding what marijuana does to a user and why so many find it so appealing may be helpful in responding to these unhappy senior family members. If your office or family leadership is also concerned about encouraging young adults to develop competitive skill sets and lead productive lives, as well as avoiding addictive behavior patterns, then I suggest you read on.

Consuming THC – the delivery system

THC is marijuana’s primary psychoactive ingredient. Levels today can exceed 25 percent, as compared to 3 percent in the ’90s. And as users ingest higher concentrations of THC at more frequent intervals, the chances of addiction and other disorders increases. In addition, there are many other psychoactive chemicals (cannabinoids) that are fine-tuned through plant breeding to create different strains to increase potency and appeal to consumer tastes.

 

Note that CBD and related cannabinoids are cultivated for their medicinal properties, lack any noticeable psychoactive affects and are generally sold in pills or other edibles. Exception: Pot for treating pain has THC, one reason why so so many young adults carry generalized pain diagnoses in medical marijuana states.

 

There are four stairways to heaven:

 

Burning: pipe, joint

  • Hits the lungs in minutes, lasts about two hours, but is an irritant.

Vaporizing

  • Solves the irritation problem and is hard to detect. Oil can go into an e-cig chamber.

Eating

  • THC is processed through the liver, resulting in a delayed high.

Dabbing

  • Placing concentrated hash oil against a heated surface and inhaling the smoke. These extracts have up to 90 percent THC levels and result in a rapid and very intense high.

Brain scan information[i]

From brain scans, we now have a good understanding of how pot affects various areas of the brain and the ensuing feelings:

 

In your brain:

  • Basal Ganglia: Controls many of the brain’s reward system, the part that makes you feel high
  • Amygdala: Responsible for paranoia and anxiety in smokers
  • Hypothalamus: Gives stoners time warp and munchies
  • Hippocampus: Pot mimics a temporary brain lesion, which is why smokers can’t recall so much of their high
  • Cerebellum: Nexus of motor control, especially coordination and timing, becomes sluggish under effects of cannabis
  • Brain Stem: Charged with autonomic functions like breathing and heart rate, devoid of cannabinoid receptors, which is why virtually no one fatally overdoses on pot

The last fact, that THC does not lead to overdoses, is one reason why potheads believe weed is far superior to alcohol.

 

In your mind:

  • Euphoria: The brain’s reward circuit kicks into action and intensifies feelings – usually a pleasurable experience.
  • Dysphoria: Opposite effect, for those already anxious, fearful, or worried about the increasing heart rate. Reported by 40-50 percent of users.
  • Distortion Perception: THC’s affect on the amygdala and release of dopamine induces state of absorption, can make things more vivid, and result in sound and visual distortions.
  • Time Lag: THC speeds up internal clocks so stoned people overestimate how much time has passed while high.
  • Memory Impairment: Short-term memory affected due to neural interactions and modifications.

Oh, to be back in college, or not!

 

Similarly we, have a good understanding of the physiological impact on the body:

  • Dry/cotton mouth: Lagging salivary gland response time slows the secretion of spit.
  • Bloodshot Eyes: With lowered blood pressure, capillaries in the eyes widen and blood fills the void. Dilated pupils can also make it difficult to focus on nearby objects.
  • Increased Heat Rate: In as little as 10 minutes, heart rate can spike to 160 and stay elevated for a few hours.
  • Drowsiness: THC can interfere with REM and stage-four sleep for up to five days.
  • The Munchies: Causes the hypothalamus to produce enzymes that increase hunger and messages that let your body know you’re full.

THC is stored in fat cells and is released into the blood stream for two to four weeks or more, depending on amount and intensity of prior use – one reason why professional athletes flunk drug tests while in training camp.

Have a real conversation

The best way to have a real conversation about pot is to acknowledge what’s good about getting high: It lubricates social interactions, dissipates boredom and stress, and enhances perception and euphoria. Just saying it’s all bad does not resonate with younger people and causes most to end the conversation or stop listening to the lecture.

 

For some, the not-so-good aspects include amplified anxiety, lack of motivation, and expense. Allowing people to express these experiences while also talking about the enjoyable aspects helps take the conversation to a deeper, more nuanced level.

 

For regular users, one in six teenagers and one of 11 adults become substance-dependent, with many adolescents seeking help when psychosis takes hold. With the brain developing into the mid-20s, young people who smoke early and often are more likely to have learning and mental health problems due to structural changes in the amygdala (processing memories and emotions) and the nucleus accumbens (decision-making and motivation).

 

As one expert, Dr. Hans Breiter, noted:

 

If I were to design a substance that was bad for college students, it would be         marijuana.”

 

It’s also bad for office staff as THC can impair focus, working memory, decision-making, and motivation for about 24 hours. Not exactly the qualities family offices and advisors are specifying in their job descriptions.

 

As with alcohol, moderate marijuana use among young adults might be professionally and socially acceptable. But its side effects and legality call into question how families and family offices should treat it. So as recreational marijuana use becomes legalized, de facto legalized or decriminalized in more states, it’s crucial for families and family offices to be proactive when dealing with their psychoactive offspring and clients. In Part II, we’ll talk more about how to go about this and what approaches and policies are most effective, including education and setting behavioral standards and performance expectations.

 

[i] The following information on the science of the weeds impact on the body is taken from a December 2014 article in New York Magazine titled “Your Grandmother’s Guide to Pot.”

 

Recovery dilemmas: Should I stay or should I go?

Feb. 19th 2015

Wealthy, famous, powerful, and addicted

A dilemma is a situation in which somebody must chose one of two or more unsatisfactory alternatives.” Also called a “quandary,” “tight spot,” or “Catch-22.”

 

Many affluent addicts in treatment find themselves in “recovery dilemmas.” These dilemmas stem from conflicts between how we were raised and what we learn is needed to achieve a sober life. These can be presented as choices between actions to take, but I think they really are better described as emotional conflicts between staying in our comfort zone (existing attitudes, behaviors, and social norms) and the fear of trying something new and unknown.

 

The following are common dilemmas those of us with wealth, fame, status, or power encounter when trying to transition into recovery.

 

(Where do we see ourselves when reflecting on these dilemmas?)

 

Shame re: money/status vs. talking about the issues

Money is very confusing to children. They enjoy the material benefits that come with wealth, even though such benefits are unequally distributed among socioeconomic groups. When children are taught it is wrong to think of themselves as superior, those teachings are easily converted into feeling guilty and thinking they are “bad” for enjoying their privileges. Because children think in black and white, this thought process leads directly to shame and a more fragile sense of self.

 

In treatment, we tell ourselves: “I can’t talk about this – both the pleasure from having money and the opposite – the shame from enjoying our privileged status.”

 

The antidote to this disease is honesty. Will our shame keep us sick? Will it keep us from talking?

 

High expectations vs. the disease concept

The burden of high expectations, coupled with much criticism by adults and a never-good-enough educational system, makes it very difficult for us to accept that our behavior stems from having a disease. Instead, we view the problem as the failure to control drinking or use.

 

The resistance to the disease concept also makes it difficult to seek family support: “I never knew my nephew was a heroin addict until he died of an overdose.”

 

Where am I with my beliefs as they relate to control vs. accepting I have a disease?

 

Expected behavior vs. recovery activities

There is a narrow range of acceptable behaviors in all areas (e.g., career, speech, friends, social activities, hobbies, etc.), and many of us in the moneyed class fear deviating from the “norm” and being rejected by our social/business class or by our parents.

 

It’s the “save your face or save your ass” dilemma: “I can’t give up doing what others expect of me. But then I can’t recover that way, either”.

 

Recovery requires taking risks, redefinition of self, and hanging out with others on the same path.

 

Outward appearances vs. internal feelings

Parental absence, isolation, and “don’t trust anybody” rules can lead to shy and lonely adults. This comes across to as being a “snob” or as “not one of us,” particularly in groups. Sadly, this is usually the opposite of what the person intends to communicate.

 

Another result is a superficial sociability, which is also off-putting. These kinds of interactions may be attempts at intimacy, but the truth is that those raised in wealthy culture often do not know how to express feelings. We are at loss to do so: “I feel so cut off, so alone.”

 

Can we talk about why we are unable to talk?

 

Controlled emotions vs. empathy

Repression and control of feelings for us are the social norm (but it’s OK to give reasoned criticism). In trying to show no pain, many often feel no pain. Other times we feel the pain but don’t express it, leading to the same problem.

 

This makes it difficult to empathize with others in groups and form relationships based on expressed feelings: “I feel no emotions.”

 

Stick with the basics: sadness, anger, fear, and joy. Can we be angry about losing our only way of coping? Or is that too embarrassing?

 

What shows is what matters vs. it’s what’s inside that counts

The emphasis on the positive public/social image prevents us from acknowledging the private and personal effects of use and the harm to family members. This attitude often allows the addiction to become so embedded, it is almost impossible to recover. The effects on children are devastating. But “What will they think of us?” predominates.

 

Why wait to address the problem until the overdose, the car wreck, or the cirrhosis goes public? Besides, many people know anyway.

 

Concealing WFSP attributes vs. being real

Limiting what information we share helps avoid resentments but creates an incomplete or misleading “protective” identity in treatment and recovery. This concealment comes at the price of dishonesty and the stress of managing information.

 

We tell ourselves: “I just try to fit in. I won’t talk about the money. It doesn’t matter.”

Can real progress happen with a big piece missing? True acceptance of our disease rarely occurs when so much energy goes into controlling information and the perception of others.

 

If the whole me is not out there, the whole me can’t recover. The missing part will stay in addiction. Worrying about whether they like me won’t get me sober.

 

Limited relationships vs. recovery relationships

Associating with people from similar social or economic backgrounds limits access to meaningful relationships with the whole spectrum of the recovering community. Reality checks offer perspective and balance. Staying within our social set may keep us away from the resentments of others and the feelings of guilt and isolation from being privileged and different, but avoiding these reactions comes at the price of learning about the real world.

 

We must be careful not to try to manipulate our world for the sake of personal comfort: “I don’t relate to those people.”

 

Rejoining the human race around the commonality of shared disease is part of the recovery process. Trusted counselors and peers help teach us how to benefit from group interactions and 12-step meetings.

 

The experience of control vs. the experience of consequences

We are used to exercising power over our environment (control). We make decisions and watch as things happen. However, our consequences remind us that we are not in control. Rather, it is consequences that make the disease a reality. Recovery cannot be controlled, but we can allow ourselves to feel what recovery is like for us.

 

Exercising self-will, thought, and direction is useless for addicts and alcoholics when we want to use: “I know what to do to stay clean or not drink” is a common delusion.

 

How does it feel to be an addict without a drug or drink? What does if feel like to be powerless? Once we let go and begin to experience recovery as it happens, we understand we were never in control.

 

The problem (social) drinker vs. the alcoholic

Affluent culture downplays alcoholic and addicted behaviors, using terms like “problem drinking,” “having a good time,” or saying we “deserves to relax.” The predominant role alcohol plays in social settings and the expectations regarding drinking reinforces concepts of normal use that are, in fact, alcoholic. The point here is naming the behavior and use as addictive.

 

The serious drinker or drugger will socialize with others using at the same level, hide use, and develop dependent business associates, assistants, and family members to avoid being identified as alcoholic or drug addicted: “If I am an alcoholic, so are all my drinking friends.”

 

Who will call it as it really is? And once called, who will stick with it?

 

Public behavior vs. private behavior

If the problem is defined or caused by a public incident or social disgrace, it’s easy to focus on the behavior that caused the incident/disgrace, rather than the big picture. By the time the latter comes into play, there is usually severe emotional, mental, and spiritual degradation.

 

Solving the problem becomes eliminating the public behavior, rather than true recovery: “I will make sure they won’t see me drunk or high again.”

 

The trick here is to move beyond public behaviors or incidents to private/personal conduct, emotions, and mental status – to define us as addicts/alcoholics. Without this transition, motivation to recover is tough to sustain.

 

Looking different vs. identifying with others

Due to the protected environment and lack of consequences resulting from money, power, and status, it can take a long time for use to hit home. That is why we come into treatment sicker than many others. But the tragic irony is that so many of us believe we are better off and different than others in treatment who have experienced serious consequences.

 

This is an illusion is fostered by the ability to maintain outward appearances during heavy drinking and drug use when others cannot: “Who are these people?”

 

The inability to identify with others compromises our learning from them and asking for help.

 

Without money, influence, or friends to cushion our consequences, what would we do for our drug or drink? What would we look like?

 

Pseudo-recovery vs. true recovery

Pseudo-recovery is running a program that looks good to the outside observer. We are socialized to focus on the externals, hang out in the right places, and show no perspiration. Too often the question is, “How should I behave in recovery?” Not, “What do I need to do for recovery?”

 

What does it mean to be in recovery? Who knows the answer?

 

Silence vs. talking (the isolation trap)

We are trained to present everything as fine – at the expense of ignoring personal difficulties and withholding information. But if we don’t talk about issues, we can’t get help. Our counselors/peers are then unable to provide relevant feedback and advice, thus reinforcing our sense of isolation and hopelessness.

           

I can’t talk about these things with my counselor.” Actually, “won’t” is a better word.

 

We are not unique. We fit an all-too-common pattern. Our counselors have heard similar stories many times. The choice is to trust and talk or continue using.

 

Class expectations vs. commitment

The attributes of having money, status, and power and what they bring become ends in themselves. Recovery requires committing ourselves to something we care about outside of our lives that is not based on money, etc.

 

Who am I without my money, status, power, fame, and image?

 

Material success vs. self-esteem

Luxury, money, power, and fame are not fulfilling. Often we lose our sense of inherent value and set out to distinguish ourselves from others by developing false pride base on our name, wealth, or connections, instead of true esteem derived from deeds.

 

People equate material success with well-being: “Look at all I have, I can’t be an alcoholic.” “Look at how well I am doing, I can’t be in relapse.”

 

Rather the opposite is accurate. Early recovery is about limiting our materialistic trappings, resisting contact with outside voices that reinforce the material, and working a comprehensive program as our first priority.

 

Recovery is finding well-being in the non-material activities.

 

A life with WFSP vs. reality

We often are too insulated and lack accurate information about the world. This allows problems and feelings to become magnified and intensified out of proportion. Correction occurs through contact with regular people, particularly those in AA.

 

On the opposite side of this coin, mentoring by others with similar backgrounds has powerful impact because we can no longer use the excuse that money makes us different and, therefore, we can ignore advice on recovery. (This attitude also may be why we don’t want to hang out with our peers in recovery from similar backgrounds – they can call us out.)

 

Are we open to risk exposure to learning opportunities?

 

Institutional power vs. personal inadequacy (pseudo-power)

Often we exercise institutional, professional, or family power, but on a personal level we feel inadequate because we may not have lived up to our own expectations or our values. To compensate for these inadequacies, we can turn to pseudo-power (the arbitrary, self-serving use of power): “Talk to so-and-so. They’ll tell you I can’t do what you are recommending.”

 

But pseudo-power does not work in recovery. This kind of attitude or the actual use of parents, agents, or other outside forces is not going to keep us clean. Some other solution must be found.

 

Are we willing to sit with our feelings of inadequacy long enough to take at look at their origins?

Many tough questions

These are tough questions that many of us face when no longer using and when ignoring them is no longer an option. When people ask “What’s going on?”, often we are mulling over these and similar quandaries in our minds, trying to figure out whom we trust enough to talk them over without being judged or scorned. Should we test the waters with some trial balloons, jump right in, or keep quiet (and keep suffering)? There are no easy answers here in ambivalence land – where staying in the middle of the teeter-totter is only a temporary solution.

Why don’t they change?! – Evaluating the therapeutic environment vs. blaming the addict

Feb. 12th 2015

Wealthy, famous, powerful, and addicted

This phrase – “Why don’t they change?!” – expresses the frustrations many counselors and family members experience when we enter treatment, complete our stay, and then struggle with relapse.

 

  • They tell us we don’t understand the first step, meaning we are unable to talk about or accept our powerlessness over drugs or alcohol or we believe we can control our use of alcohol or drugs by saying, “I’ll do a better job next time.”
  • We also are described as “running our own recovery program” and “unwilling to ask for help or take direction.”

Counselors will say in their treatment meetings that we have not suffered enough or need to go back out and use again so there will be more consequences. Their thinking is that with more consequences, we will admit to powerlessness over use and listen our counselor.

 

In my view, the answer to “Why don’t they change?” lies as much with counselors and the protocols used to treat us as within us. After all, we are the ones who need help, and to reject us out of hand is anti-therapeutic, to say the least – especially given the amount of money charged upfront for treatment. If we seem stuck, resistant, and likely to relapse, a far better approach is to evaluate the treatment setting and see if the right conditions exist to promote change.

Safety and trust

People – even those of us with wealth, fame, status, or power (WFSP) – generally do not change unless they feel safe and trust in their surroundings and counselors enough to risk new behaviors and shed old attitudes.

 

In my experience, there is far too much labeling of us by treatment center staff as uncooperative and far too little self-examination and acceptance of responsibility on the part of counselors and staff for how they can help promote change.

 

This means assessing why change is not happening and how the situation can be modified to help us take the risks and make the emotional shifts necessary to begin recovery.

Accessing emotions

Another impediment stems from the current treatment model, which emphasizes education and information. This is based on the idea that by reading and thinking about addiction, we will be inspired to stop using. To the contrary, we need an approach that builds trust and accesses our emotions – one that is based on relationships with empathetic counselors. While we may be motivated to enter treatment, once there, we need a supportive environment to create the conditions necessary to encourage us to adopt new behaviors.

 

To aid our discussion of these conditions, I developed the accompanying chart (below) with the client in the middle (that’s us), the counselor on the outside, and the interactions between the counselor and client that promote change (in yellow). For the client, there are four factors that set the stage for the change process (in blue) and four counselor attributes needed to encourage us to change. This chart helps in assessing where the blocks are to the change process.

Screen Shot 2015-02-12 at 12.02.45 PM

Conditions for Change for the Client 

  • Safety
  • Time
  • Space
  • Commitment 

Interactions Promoting Change 

  • Content
  • Personal Reflection
  • Dialogue
  • Coaching 

Counselor Attributes Supporting Change 

  • Conviction
  • Real
  • Compassion
  • Integrity

Conditions for Change

The client; the client’s family, social, and business relationships outside of treatment; and the counselor determine these four factors. For example, time can be influenced by how long the client is expected to remain in treatment or spend in recovery activities after treatment. Space is both a function of whether the client is expected to do business or communicate with family and friends while in treatment, as well as whether the client intends to do so or focus on treatment. In contrast, safety is very much influenced by the environment and counseling staff.

 

Safety

Treatment should foster an open environment in which it is safe to speak up without fear of reprisal, retaliation, or personal rejection. This includes:

  • No sharing of information with outsiders.
  • No reactions of resentment, envy, or awe.
  • No asking for money, favors, or a personal relationship.
  • Hearing what is said, not making it “off limits” because it doesn’t fit preconceived ideas about what is supposed to be said in recovery (i.e., talking about how money and privilege has impacted our life and addiction).
  • Setting boundaries.

Safety allows trust to develop. With trust comes the opportunity for honesty.

 

Time

We must allow time for the process of recovery. Getting over the physical affects of drugs and alcohol has little to do with recovery. Living a sober life means:

  • Recognizing the mental, emotional, and spiritual impacts of the disease.
  • Working on changing behavioral patterns from using to “normal.”
  • Learning to have personal relationships based on intimacy.
  • Establishing boundaries with non-WFSP.

These tasks rarely are accomplished in an in-patient program. The usual 28 days in treatment merely provide a foundation for continuing the process in the community.

 

Space

Treatment is supposed to create the space to reflect on core issues where we transition from our heads and into our hearts – where it is OK to feel confused. Having the space to recover means:

  • Getting away from it all.
  • Limited business transactions.
  • Minimal relationship calls.
  • Not using money or prominence in a way that separates us from others.

Allowing space is part of our recovery journey as we begin, over time, to gain insight and feeling into the layers of our experiences.

 

Commitment

Are we willing to do what is necessary for recovery? Committing to the process includes:

  • Recognizing we don’t have the answers.
  • Staying the course without knowing the outcome.
  • Asking for help.
  • Allowing counselors to “encourage” our efforts.

Part of commitment is the courage to try new ways of interacting with others – to engage in trial and error.

Interactions Promoting Change

The counselor’s role is to engage in interactions leading to a change of perspective and, subsequently, behavior. The perspective change may occur during therapeutic encounters or later when we have an opportunity to process our experience. Thus, desired counselor attributes include the ability to communicate and interact with us in ways that support internal change.

 

Content (Information)

This includes what counselors know about the clinical needs and childhood experiences of the affluent, wealthy, and prominent (and how it is different for men and women). By knowing actual content, counselors build trust with patients. Examples:

  • Secrets
  • Lack of consequences
  • Being special
  • How money affects relationships
  • The connection between money, prominence, position, and addiction
  • The resentments and misconceptions of others

And most importantly: how this has impacted our lives.

 

Personal Reflection (Feelings)

Pain and emotional turbulence leads to change. There are countless ways we experience confusion regarding our addiction:

  • This is not how I planned my life.
  • What has happened to me?
  • How did I get here?
  • Why can’t I stop using?
  • Will I ever feel better about myself?

Counselors should be mindful of childhood issues (i.e., where is the pain?) and, for the newly successful, the fear of failure and feeling like a fraud.

 

Dialogue (Intimacy and Honesty)

Through honest discussion, counselors should be able to identify some of the challenges and dilemmas we face in the treatment setting in terms of relating to other patients, staff, and AA attendees. These obstacles can include:

  • Isolation vs. connection
  • Living in images vs. being real
  • Comparing differences vs. seeing similarities
  • Money and fame vs. recovery and humility
  • Remaining static vs. starting the process of insight

Coaching (Model Interactions)

Counselors are tasked with understanding where we are in terms of time, safety, space, and commitment to being in treatment and recovery. The counselor can help suggest words to use and ways to communicate with other patients, staff, and in meetings, such as:

  • Describing life experiences in ways that reduce distractions over details but still convey the meaning.
  • Owning one’s own bottom.
  • Setting boundaries (e.g, saying “no, I am here for treatment, not loans, tickets, or autographs.”).

Counselor Attributes

We often have very low trust levels in helping professionals, as well as the general public. This low trust level results from exploited relationships by counselors and apparent friends. Most of us have developed a “radar” to distinguish between people who are being genuine and those who are presenting a false front (exception: when we are using or with skilled manipulators). Counselors must be absolutely comfortable with their feelings about money and status, and if they cannot treat us without resentments, disrespect, or genuine empathy, they should not take us on as patients.

 

Conviction

Counselors must have confidence in what they are telling their patients and have faith that the information will promote recovery. If they think we do not really have specialized clinical needs, we will pick up on this attitude. Here’s what’s necessary for a counselor to be effective and convincing:

  • They need to walk the walk (and not speak negatively of us when we’re not present).
  • Focus on recovery.
  • Believe what they say.

Real

Putting on a false front to impress a patient or hide insecurities about having a patient who is very wealthy or famous is all too common. We easily see through the façade. Keeping it real includes:

  • No images
  • Humility
  • No hidden agendas

Compassion

An effective counselor needs to understand that money and prominence are barriers to recovery and that every person’s “story” is valid, despite the circumstances. Showing compassion means:

  • Hearing what is being said – not thinking “I wish I had that problem!”
  • Listening without judging.
  • Understanding the difficulties of recovery unique to the patient’s situation.

Integrity

Counselors are here for the patients, not the other way around. Too many times we become a source of vicarious pleasure for the staff. This becomes self-evident and destructive to the counselor-patient relationship. Integrity depends on the following:

  • Boundaries
  • Privacy
  • Focusing on the problems and issues that brought the patient to treatment

Trust comes from integrity, when we can see that the counselor is not focusing on who we are, what we have, and what we’ve done.

The professional’s therapeutic task

Recovery requires effort and commitment on the part of the patient and the counselor – neither can be held solely responsible for the success or nonsuccess of treatment. It’s true that many of us with WFSP show up to treatment with self-imposed limitations and expectations, but it’s a therapeutic task on the part of the professional to convince us to stay, encourage us to let go of our old habits, and to trust the process. But as we all know, trust is hard won, and we need the appropriate conditions. It’s on us to remain open to treatment, and it’s on the professionals to be worthy of our trust.

 

Not many treatment centers are up to the challenge of creating the conditions for change discussed here. But once a safe and trusting treatment environment is established, it’s up to us to choose to venture into the uncharted territory of recovery and say goodbye to our using lifestyle, friends, and ways of thinking.

 

Upcoming blogs will delve into dilemmas that inhibit our ability or willingness to commit to recovery.

Recovery ambivalence: a rich man’s son

Feb. 2nd 2015

Wealthy, famous, powerful, and addicted

I might start off by giving the experience of a man whom I have not seen for two or three years. His experience so well illustrates the nature of the problem with which we have been dealing. This man was a rich man’s son. …

 

Well, he did a conventional amount of drinking, and that went along nicely a number of years, and then he found he began to get drunk, very much to his own consternation. …

 

I have indicated, I think, that he was a person of character, and great force of character. Therefore the question immediately arises in everyone’s mind: “Why didn’t he stop?” But he did not. … [L]ittle by little, matters got worse and he began to go from one hospital or cure to another.

 

And the very strange thing is that while this is going on, many of us seem to all outward appearances to be sound and able citizens in other matters. Our minds waver, and we wonder what in thunder is the matter.

 

This quote from Bill Wilson’s presentation at the Rockefeller dinner in 1940 introduces the second section of our “Wealthy, famous, powerful, and addicted” series: Ambivalence!

 

After previously exploring barriers to quitting drinking and drugging or entering treatment, we now turn to the next challenge: ambivalence about whether we actually want to stop using and commit to recovery.

 

Do we truly want the drug-free lifestyle, or would we rather return to substance use – although modified, “under control,” and less visible?

 

Ambivalence commonly occurs after detox, once the drugs are out of our system. We’re already feeling so much better – relieved to have dodged that bullet. But our emotions are raw, and our coping mechanisms and reliable friends are gone. Now what?

The internal tug of war

A tug of war starts with competing voices in our head, as the enormity of the task sinks in. Having money or connections heightens the challenge, providing so many options for figuring out how to get away with it, to deceive ourselves, family, and friends, and to return to our old ways of being. And the shame of falling from high places and ever regaining our standing, combined with the shame of being an addict, makes it all the more difficult to choose to face the reality of our lives.

 

Aside from this internal debate, there are many external pressures – family, social milieu, profession, business, media, etc. – that bear on us when contemplating embarking on a sober life. In the book, The Power of Habit, the author points out that we have limited amounts of energy to learn new behaviors. If we are dedicating a great deal of this energy to fending off external forces that cue using triggers or distract us from our chosen path, we don’t have enough left to win the internal battle.

Outside forces

While future blogs will explore this internal struggle, this one focuses on the many ways outside forces undermine recovery, essentially tipping our ambivalence over to the dark side. Having seen this happen over and over again, the remainder of this blog aims to support those of us exposed to these pressures.

 

From brain scan research, personal experience, and observation, we can answer Bill Wilson’s question of what in thunder is the matter with this rich man’s son: a level of external pressure that can make attaining a sober life near impossible.

 

We now know that using drugs repeatedly over time changes brain structure and function in fundamental and enduring ways that persist long after the individual stops using. Core areas of the brain are reprogrammed so that in the presence of “environmental cues,” we will want to use mood-altering substances. Even after long periods of abstinence, brain scans show that the “craving” areas of our brains light up in the presence of alcohol and drugs in ways unique to us addicts.

 

Too often parents, employers, or media all pay lip service to supporting our recovery, but their behavior belies their verbal encouragement. In reality, we are supposed to go off to treatment and then return to our normal lives – just not drinking or drugging. It’s easy for us to buy into this scenario, as we long for acceptance and try to get back into their good graces, rather than focus on the danger our old life poses to our hard-won “days” of new freedom.

 

How many times have I heard:

 

“My family/law firm/production company/business wants me back, or there will be repercussions.”

 

Or how about:

 

“If I don’t go to my family’s vacation home in Hilton Head for the annual reunion, my parents will cut me off.”

 

Sad, ignorant, and perverse, yes – but all too frequent. We are expected to pick right back up as if nothing happened. Whether self-imposed or required, premature exposure to our “craving cues” leads to relapse.

‘Do you mind if I have just one?’

How many times do friends and relatives ask that question at cocktail hour or when out to dinner? While we have no choice but to tolerate other people drinking in our presence, why drink at all around a friend or loved one in early recovery?

  • Show some respect for what we’ve been through and for the power of the disease.
  • For families where drugs and alcohol have caused so much harm to so many, set an example.

After 19 years of saying “Go right ahead,” on my birthday, I finally said, “Yes, I do mind.” It felt liberating.

Navigating the social scene

At larger family functions, where alcohol flows freely, often 30 percent or more – depending on your definition of substance dependence and how self-serving the answer is – are alcoholic. (Excluding those dependent on pills or weed.)

  • How about the great uncle spotted with a tall glass filled with vodka at the holiday party?
  • Or the cousin with pinpoint pupils toasting his father?

What’s that? Nobody wants to know. The senior leaders who can set an example or chart a different course turn a blind eye. Then they ask where you are. Sayonara – that’s what I say, but many feel we must remain and endure.

 

For those of us encouraged to maintain our social connections, friends ask us to join them, telling us they’ll make sure we only drink Pepsi. As an added bonus, we can drive them home! Or we can join them at the 19th hole or country club lunch and drink Perrier. Yeah, right. And then they wonder why we are drinking “again.”

 

Some of us also face our friends, family, and colleagues inserting themselves into our recovery program/plan.

  • How about the mother who wanted her daughter only to attend high-end AA meetings?
  • Or the producer who pressures his newly minted 28-day graduate movie star into attending the media tour, promising a sober companion?

In these instances, we are treated as commodities to save face or earn money – they don’t appreciate that this is a life and death matter.

No wonder

We are supposed to say nothing, fit in, and resume our old lives. No wonder there is so much relapse. No wonder people are convinced treatment is a failure. Do you get it? Our external environment – our social life, family, and economic pressure – works against us.  Even when we learn new responses to these “cues,” our brain unconsciously registers them. Our will to stay clean can collapse, and we succumb to our internal voice that says, “Hey, this time it will be different. This time I can handle it.”

 

I will say this to you, dear readers:

 

For families with loved ones in early recovery, gladly join in abstaining and finding enjoyable activities to engage in that do not involve going to bars and parties. Reorient your life to one that supports sobriety. Do this for several months, and for the next few years don’t drink in the presence of your loved one. Consider having at least one alcohol-free social event at family gatherings and setting time aside for a 12-step meeting.

 

For those of us with “the problem,” it really helps to have an intermediary – a savvy person who can fend off outside pressures and explain that recovery is the top priority for now. This intermediary can be the one to tell our friends and family to leave us alone, to focus on healing from our disease, and of course to vociferously object to any reprisals for putting our health first.

Preparing the next generation

Jan. 27th 2015

Rethinking advice for parents

A recent article in The New York Times by Ron Lieber with the headline “Growing Up on Easy Street Has Its Own Dangers revealed the shocking news that many adult children of the moneyed class are not self-sufficient functioning adults. The article states:

 

There is an emerging consensus among academics that children of the affluent have higher rates of depression and anxiety and elevated levels of substance abuse and certain delinquent behaviors.

 

OMG! If this is news to you, what planet are you living on?

 

Ever since the ’60s, members of wealthy families have been self-reporting high rates of addiction, behavioral health disorders, abuse, and generalized dysfunctions in memoirs. Aside from personal stories, Joanie Bronfman’s 1987 dissertation, The Experience of Inherited Wealth: A Social-Psychological Perspective, documents what is common knowledge among the next-generation affluent: Yes, Houston, we have a problem!

 

But almost every wealthy family, when asked, will not admit to significant concerns about substance use disorders or underperforming, economically-dependent younger generations. Those of use on the inside – either because we are in recovery or in the helping professions – see a reality that is far different than the public façade. Not only are there high levels of substance dependence, but increasingly, financial conflict with parents and trustees stemming from the inability to independently sustain the lifestyle and social standing experienced as children.

Great expectations

As commented on in the New York Social Diary (your link to society), over the last 20 years there is the growing phenomenon of new wealth supplying their children with an endless supply of money to live the high life and impress their friends. While this assures those of us in the recovery business an endless supply of clients, old money’s younger generations feel enormous social pressure to compete and maintain prominence.

 

This group, having grown up in an environment of surplus, expects to live in a similar manner as adults and be supported by family money in doing so. Their parents often inherited in their 40s or even earlier. But now, with increasing longevity, the next generations are facing shortfalls and not happy about it. Lacking the skills or inclination to earn significant incomes in the job market, they are pressuring parents and trustees to pony up. While resorting to violence is obviously an extreme measure, cutting off access to grandchildren and threatening litigation with the attendant disclosure of family secrets is becoming more common.

 

Few take responsibility for slacking off in high school and college and consequently failing to develop marketable skills or spend within their means. Accepting a lower social profile or adopting a reduced standard of living is not an option. Resentments surface and demands increase, often fueled by excessive alcohol and prescription medication abuse.

Reaching a crisis level

We continue to identify substance abuse and behavioral disorders as the No. 1 risk to wealth preservation and next-generation well-being. While drinking and drugging have always been part of high-end culture, intensifying external social and media influences are leading to increased use and at younger ages. It’s beginning to reach a crisis level; parents are overwhelmed and outgunned, and we are not using our expertise to help them respond.

 

In my view, the primary task for family offices, advisors, and professionals is to support parents in setting limits, requiring accountability, and limiting communication tools, as well as being role models rather than peers. Advice on involving the younger group in philanthropy, family meetings, and business/economic exercises is secondary and can detract from the more important goals of learning life skills, developing academic and career interests, and differentiating from “the family.”

 

Let’s devote 2015 to assisting our clients in educating themselves on the risks to their children and responses that allow them to successfully navigate an increasingly hazardous culture.

Between 30 Rock and A Hard Place: The Rockefeller-AA Connection

Jan. 16th 2015

As Bill Wilson observed early on, while the well-off are welcomed in AA, many do not stick around for long. That may be due to the widespread resentment expressed by members of the recovery movement, including those in the helping professions.  Having experienced this resentment firsthand, I decided to write Between 30 Rock and a Hard Place in hopes that a detailed recounting of the vital role John D. Rockefeller, Jr., played in supporting Bill and Bob in the early years might make AA a more inviting place for the affluent.

 

Based on my reading of this history, without JDR, Jr.’s support during the early years, the AA movement would have either failed or, at the very least, taken many more years to become self-sustaining.  My e-book provides a comprehensive review of JDR, Jr.’s role in the development of the 12-step movement and details how his support of Bill and Bob is one of the first examples of entrepreneurial philanthropy.

 

I might add that the affluent can and do recover by participating in AA if they are careful about disclosing personal information and maintaining firm boundaries so that “dual relationships” are minimized.


The e-book is available on Amazon as a free download for a limited time! Click here to download now.

Posted by Bill Messinger | in Addiction, Substance use disorders, Wealth | No Comments »