Psychoanalysis Is Addiction Treatment's Missing Piece

http://ericanorth.net, 2/20/2012

Sobriety doesn't guarantee a good life. By focusing on the whole person—not just the drug or drug use—psychoanalysis can help addicts grow in ways that go beyond recovery.

By Debra Rothschild PhD 05/29/13 Posted at http://thefix.com/content/relational-psychoanalysis-addiction-treatment-harm-reduction-therapy8424

Many people who suffer from addiction are told that psychoanalysis is the last treatment they should ever try. Psychoanalysis, which is psychotherapy that focuses on helping clients become aware of how their behavior can be motivated by factors often out of their awareness, can seem beside the point to people who are in crisis because of substance misuse. In addition, psychoanalysis historically involved several sessions per week for a period of years, incurring great costs of money and time; this reputation persists despite the fact that that is not how most psychoanalysts practice today. Because of this, and the fact that contemporary psychoanalytic approaches are not well known, the general public has many misconceptions and even mistrust of the process. 

The situation is often not much better among addiction experts. There is an unfortunate history of analysts asking alcoholics and addicts to lie on the couch and free-associate while their disease only progresses. Therefore, the negative reactions are not surprising. However, the truth is that psychoanalysis has always had enormous benefits to offer, and it can greatly enhance the chance for success in recovering from addiction. Yet because of mistakes by some analysts, the valuable contributions many others make are often neglected by treatment professionals.

As far back as Freudian times, psychoanalysis has been on the leading edge of enlightened, nonjudgmental approaches—the “analytic attitude”—to mental illness and, more recently, substance use disorders. Psychoanalytic theories about addiction date back to the 1930s, when addicts were blamed for their own fate; it was assumed that using substances was a “regression” to immaturity and all about indulgence or self-destruction. 

Foreshadowing what good clinicians believe today, psychoanalyst Sandor Rado, MD, wrote that “the study of the problem of addiction begins with the recognition of the fact that it is not the toxic agent, but the impulse to use it, that makes an addict of a given individual.” Accordingly, much of the addiction field now acknowledges that the object of study should be the individual rather than the substance.Certain substances are addictive for certain people (often due to their unique combination of biology, psychology and social circumstance). 

Edward Glover, MD, another 1930s psychoanalyst, was the first clinician to propose that people use substances in an effort to soothe or escape emotional pain. He said that drug addiction is not a regression but a “progression that performs a protective function” and that it is “frequently a successful maneuver.” This belief underlies today’s psychoanalytic understanding of addictive disorders, captured by the phrase “Self-Medication," which was coined by Edward Khantzian, MD, in a classic 1985 paper, “The Self-Medication Hypothesis of Addictive Disorders.” In this paradigm, addiction is removed of its stigma and those who are addicted are treated as individuals who use for their own reasons that need to be understood and addressed. It is acknowledged that often the addictive substance works (or once worked) in the short term to provide relief or enable a skill, and that it can be terrifying to give up. Analysts start from these premises in their work with substance use disorders.

Curiosity is a hallmark of psychoanalytic treatment: Analysts want to understand their clients as deeply as possible, and one goal of the process is to encourage the client’s curiosity about themselves. Treatment professionals often tell addicts that they suffer from “terminal uniqueness.” This is an attempt to help them understand that they are not alone, but also “not so special”—a message that can help some people step down from a narcissistic sense of difference from others and engage with others in the process of recovery. But it can also obscure a very important truth in treatment, and one that analysts are trained to be sensitive to: Each person is unique, and has a unique history and a unique set of needs, desires, fears, etc. If treatment is to be truly and lastingly successful, all of these aspects of their personality must be understood and addressed.

Addicts might be labeled “liars” less often if it was understood that one aspect of their personality does not always know what the other is doing.

This concept fits well with the “meet the patient where the patient is at” principle of Harm Reduction Therapy. In fact, there are many ways that harm reduction psychotherapy overlaps with psychoanalysis, especially Relational Psychoanalysis, which focuses on the importance of interaction with others in the development of personality and on the therapeutic relationship as the mechanism for cure. Both approaches recognize that treatment is not a one-sided affair but a relationship between two people to which both contribute. Goals are discussed, collaboration takes place, plans are made with mutual input. The clinician offers professional expertise but does not pretend to know the client, or what is good for the client, better than the clients know themselves. 

This “two person” model of treatment emphasizes the importance of the therapeutic relationship. It is not just the content of sessions that matters, but also the feel and the process. In other words, it does matter how the therapist and the client relate. Harm Reduction therapists often talk about the importance of respecting the client and trust as a foundation of treatment. Similarly, Relational analysts assume that what goes on in the session is part of the treatment. Being respected by the therapist, involved in treatment decisions and negotiating differences supports the growth of more mature, stronger aspects of the self.

By paying attention to the feel and the process, analysts can learn what their patients are unable to tell them directly. Many people who use substances have lost the ability to know, and communicate in words, what they feel. So, for example, if a patient suddenly starts missing sessions, they may be angry at or disappointed in the therapist. In this model, the therapist will do everything possible to make it safe to talk about. 

There are many ways that motivations that remain outside awareness can be discovered through a relational dynamic. For example, I had a client who could not take ownership of her desire to stop drinking. She kept telling me that she was getting sober because I would discharge her from therapy if she didn’t. I kept reminding her that wasn’t true. Then she said that it was only because her husband would leave her. That wasn’t really the case, either. Next she said that the only reason she didn’t drink was because she was on antabuse. I reminded her that she chose to take it. 

My patient could not talk about her lifelong sense of lacking agency and empowerment, but it came out in this process between us. Once I pointed it out, we could talk about it. The feeling that she had no control over anything in her life had of course contributed to her alcoholism, but she had never put words to it before. Now she was able to start dealing with it, and once she did that, she was able to start developing a conscious choice to stop drinking—and a stronger sense of self in general.

Many people who misuse substances have suffered trauma in their lives, and also many suffer trauma due to the stigma and hardships of being addicted. One hallmark of trauma is dissociation, or splitting and compartmentalizing various aspects of self. This psychological process has a very important implication for therapy: A different aspect (or “part”) of the person may be present in the therapist’s office than the part that emerges in a bar or at home or with friends. When the therapist and client make plans for the client to contain their substance use, the “part” who actually uses (often the hurting, scared or lonely part) may not be present and participating. The plans are being made, but only with the part that feels safe with the therapist and is motivated to change. 

Analysts make a great effort to invite all parts of a person into the therapeutic process. If more therapists recognized the powerful effects of dissociation and the importance of integrating all aspects of a person in treatment planning, failures to comply with the plans might occur less often and be less baffling when they do occur. Addicts might be labeled “liars” less often if it were widely understood that one aspect of their personality does not always know what the other is doing. 

By promoting the many insights and advantages of psychoanalysis in the treatment of addiction, I am not suggesting that we stop teaching tools for sobriety, coaching behavioral change, engaging spirituality or referring to self-help groups. No good psychoanalyst today would treat an addict or alcoholic without using cognitive-behavioral, medical-biological, social support, and other techniques. But at the same time, psychoanalysis should not be rejected because of past failures. It has much to contribute that will increase substance use treatment’s chance of success. 

When the focus is not specifically on the substance or even the substance use, but on the full individual, treatment can help nurture and support a sense of self as a strong, competent individual able to withstand challenges and live a happier life. Managing substance use is one—but not the only—very important part of this achievement.

Debra Rothschild, PhD, is a psychologist and psychoanalyst in New York City. She is also a credentialed alcoholism and substance abuse counselor, a clinical associate professor at the New York University Postdoctoral Program in Psychotherapy and Psychoanalysis, and a clinical supervisor at City College, Yeshiva University and Long Island University clinical psychology programs. She is on the executive board of the New York State Psychological Association Division on Addictions. She publishes and lectures widely on the integration of psychoanalytic thought with harm reduction psychotherapy and substance use treatment. 

Full article at http://thefix.com/content/relational-psychoanalysis-addiction-treatment-harm-reduction-therapy8424

The Microbiome and the Multiple Self

By Alexander Kriss, M.A.

This entry was originally published June 1, 2013 on inkblot.

© National Academy of Sciences, U.S.A.

Recent months have yielded increased discussion in popular journalism concerning one of the most significant discoveries in contemporary biology: the microbiome. This term refers to the trillions of microbes that live within every human being, a vast panoply of organisms that interact with our functioning in such a profound way that its alternate term is the "second genome." Emerging studies of the microbiome demonstrate a complex mutuality between us and living matter that is, strictly speaking, not us. Not only does this refute reductionist notions that "we are our genes" within the realms of biology and genetics, it fundamentally threatens dominant Western conceptions of the self. We are not autonomous beings but a colony of diverse life, a human-microbial collective. Additionally, disrupting the balance of these intertwined lifeforms (such as through the overuse of antibiotics) is increasingly thought to be deleterious to our health.

The idea that (mental) health is defined by a unified self has been a tenet of United States thinking since we first took a stance on the issue in the mid-20th century. Classical Freudian psychoanalysis emphasized incorporating disparate aspects of the psyche into a balanced and reality-based ego, and this aspect became reified during the reign of American ego psychology, as it appealed to our individualistic values that prized the idea that we are in full control of our destinies. From this perspective, health could be achieved in absolute terms when an individual (like the analyst) addressed all defenses against internal conflict to become a truly independent creature, free of neurotic illness and the societal, cultural, and interpersonal structures that caused it. Though this variant of psychoanalysis grew unpopular and has now all but faded away, the "Americanized" attitude toward mental health is alive and well. It is now represented by various interventions, including psychotherapeutic and psychopharmacological treatments, that promise quick and total results based on empirical evidence that is presented as objective and therefore irrefutable. Psychological problems are seen as unwelcome invaders that threaten our cohesion and should be eradicated in the same manner that we eradicate physical infection. However, the microbiome teaches us that this approach is reckless and often harmful, which in turn begs the question as to whether our basic cultural definitions of health and selfhood need revision.

Contemporary psychoanalysis in the U.S. has shifted dramatically from its earlier incarnations to incorporate many of the concepts stemming from object relations, interpersonal, and relational perspectives as well as Eastern philosophies, all of which tend to view the self as less solidified and more transient, or as a multiplicity of states and internalizations rather than a single ego. Within this framework we are not one self but a constellation of self-states that incorporates many ways of being, and that is dependent on context and the presence of others. Selfhood is therefore not fixed or even something to be "achieved," but a dynamic construction happening in the here-and-now. Relational psychoanalysis and attachment theory in particular argue that the striving for social interaction is a fundamental unit of human existence, and that the idea of an individual self existing in isolation borders on meaningless. (This concept, of course, has been present in non-Western thinking for millenia.)

Acknowledgment of the microbiome makes the idea of a deconstructed self even less plausible. After all, we are never truly alone. Though we cannot carry on a conversation with microbes, we are constantly participating with them. In the most basic physical terms, "we" are located not only in ourselves but in others (trillions of others!) with whom we have a symbiotic bond. Appreciation of this idea in biologic terms should make the concept that the self is intrinsically bound to other non-self entities (such as friends and family, communities, social structures, cultural values, historical trends, and so on) more palatable to the North American sensibility. Likewise, it ought to cast doubt on the "shoot first, ask questions later" approach to treatment, as our very notion of health shifts from purifying the self of pathogens to achieving a harmonious balance within a larger ecosystem that includes both the self and everything connected to it.

Anti-gay hate crimes on the rise: A call to the community

By Kevin L. Nadal, Ph.D.

The author (left) and boyfriend RJ Mendoza of the APICHA
Community Health Center with a message for all: ‘No Hate’

Posted: May 22nd, 2013 at http://thefilam.net/archives/11326

I first moved to New York when I was 24 years old and I was accepted into a doctoral program in psychology at Columbia University. Some college friends from my undergraduate university in Southern California were already living in New York and invited me to move in with them in a small two-bedroom apartment in the West Village.

I was a naïve Californian, who had just completed a two-year tenure in Michigan, and I didn’t really know much about my neighborhood. When I told people where I was moving, I usually said that it was where the “Friends” characters lived or where the tenth season of the “Real World” was filmed.

However, when I actually moved to the Big Apple a month later, I quickly learned that the neighborhood where I would spend the first three years of my New York life was the home of the Stonewall Inn and the mecca of the LGBTQ (lesbian, gay, bisexual, transgender, and queer) Rights Movement.

Perhaps I didn’t know much about Stonewall because I was still in the closet. While I had been living a “secret” life as a gay man for most of my life, the lingering pressures of coming from a Catholic, Filipino family prevented me from ever coming to terms with my sexual identity.

I didn’t tell many people that I was gay — not my family in California, not my family that lived off the last stop of the F-Train in Jamaica, Queens, and not even my roommates who I shared a wall with. I wasn’t ready. I was afraid I wouldn’t be accepted. I was scared that I would lose everything (and everyone) in my life.

But somehow, everything changed.

I started exploring my neighborhood and began to frequent some of the local gay bars. I began to meet all kinds of LGBTQ people -– particularly gay men, transgender women, and even a few drag queens. At least once a week, I would go to the Stonewall Inn on Christopher Street, the same place where the LGBTQ movement began over 30 years prior when a bunch of brave transgender women and gay men fought back against a police raid.

My favorite nights at Stonewall circa 2002 were the “Hip Hop Nights;” I would enter a room where a bunch of gay and queer men of color were bobbing their heads to the sounds of Biggie Smalls and Jay-Z. For the first time in my life, I felt like I belonged. I could be a person of color and gay at the same time, and it was okay.

I made several friends in the West Village, and I even met a few lovers. It felt so free and invigorating to hold another man’s hand in public for the first time in my life. I felt safe. I felt proud. It was time for me to come out of the closet.

Eleven years later, a few things have changed. First, over time, I had lived in two other LGBTQ-friendly neighborhoods in Manhattan: Hell’s Kitchen (which is adjacent to Times Square) and Chelsea (where I currently live). I graduated from my Ph.D. program, wrote a few books, and eventually became a tenured professor. And most importantly, I finally met the love of my life, and we have been unofficially living together for the past nine months. I plan on marrying him someday and I am proud to be a resident of a state where that would be legal.

However, lately, I haven’t been so proud of my state or my city.

In the past three weeks, there have been a string of hate crimes against gay men in Manhattan, and one resulted in death. On May 5th, a gay couple was attacked in broad daylight outside of Madison Square Garden, right after a New York Knicks game, while a different gay couple was assaulted a few days later, a few blocks away. A gay man was attacked while leaving a bar in the West Village, and another gay man in Union Square was punched in the face and robbed. With all of these incidents, the assailants were heard yelling homophobic slurs, right before — and while — they assaulted their victims. 

On Thursday, May 16th, I attended a protest, in front of Madison Square Garden, right before a Knicks game. With the theme of “Queers Take Back the Night, ”over a hundred LGBTQ people and allies stood silently with signs as Knicks fans entered the arena. Some passers-by respectfully walked by, while many snickered or scoffed at our presence.

A few LGBTQ leaders spoke passionately on a megaphone, and the nonviolent group walked with their signs and flyers down 8th Avenue. For some, it was important to educate people about the string of anti-LGBT hate crimes and for others, the purpose was to reclaim the streets they once viewed as safe.

Apparently, the peaceful protest didn’t work.

On May 18th, shortly after midnight, Mark Carson, a 32-year old, gay African American man was walking with a friend in the West Village, when a group of men began to verbally harass them with homophobic taunts. One of the men followed the pair and shot Mark Carson in the face; he died shortly after.

Less than 24 hours later, I attended a candlelight vigil in honor of Mr. Carson, located right where he was killed. Several hundred people were in attendance, and I heard the phrase “It could have been any of us” throughout the night. On Monday night, a more organized rally was held to honor Mr. Carson. While I personally could not attend, I was there in spirit with the thousands of people who marched in the West Village and held signs that read “Stop the Hate!” and “Marriage means nothing if we are being gunned down.” Leaders of the LGBTQ community, politicians, and even members of Mr. Carson’s family spoke.

Sadly, this protest didn’t work either.

A few hours later in the East Village, a gay man was attacked after disclosing to an acquaintance that he was gay. A few more hours later in Soho, a gay Latino couple was the verbal target of anti-gay slurs, right before they were physically assaulted. These last two incidents bring the total number to seven anti-gay hate crimes in a span of 20 days. Perhaps we need to do more than just protest and rally.

Some members of the LGBTQ community want to fight back, by taking self-defense classes or arming themselves. Others want more police presence in LGBTQ neighborhoods, and others want to organize “safety by numbers” programs. While I can see some merit in some of these responses, my recommendation is simple: 1) Talk about these issues, 2) Don’t assume, and 3) Take a stand.

We have to start talking to our family members, friends, and acquaintances about what is happening. Post on your Facebook and Twitter pages. Send emails to listserves across the country, but also to your personal networks. While there is some coverage on mainstream news sources, most people are unaware of what is happening. Tell people about what happened to Mark Carson, so that his death is not in vain. It is way too common for LGBTQ people (particularly transgender people and LGBTQ people of color) to be victims of heinous crimes and for their names to be forgotten. I will not forget Sakia Gunn, Stephen Lopez Mercado, or Lorena Escalera, and we cannot forget Mark Carson either.

Secondly, don’t assume anything. In the past couple of weeks, I have had lots of conversations with friends who say things like “Things like this don’t happen in New York.” But, they do. It is quite common for my boyfriend and I to hear homophobic slurs as we walk down the streets of Manhattan. It wasn’t too long ago that a man in Hells Kitchen shoved me and called me a “faggot” as I walked by holding my boyfriend’s hand. Luckily nothing else happened, and after these past few weeks’ events, I am thankful that nothing did.

I’ve also had a lot of conversations with friends who say things like “I don’t think I know any homophobic people.” When I ask if they’ve talked about homophobia with their brothers, cousins, or friends directly, the common response is “No.” Of course we don’t want to believe that anyone in our lives is homophobic (or racist, sexist, etc.), but unless we talk about their views directly, we really don’t know.

When perpetrators of school shootings or serial killings are arrested, most people claim that they didn’t know the person was hateful, sociopathic, or mentally ill. When a person commits suicide, a lot of people will say they didn’t know the person was depressed or suicidal. And this is why we need to ask.

Finally, take a stand. Tell people that homophobia and transphobia is unacceptable. When people use biased language like “That’s So Gay” or “No Homo,” point out how those words are wrong and hurtful. When we allow these microaggressive, anti-LGBTQ behaviors to continue, we create an environment where people believe it is acceptable to hate or discriminate against LGBTQ people. And if these hateful environments persist, the violence will continue.

I share all of this with you because I don’t want to be afraid to hold my boyfriend’s hand in public. I don’t want to feel unsafe again. I don’t want to live my life in fear. And I don’t want to go back into the closet.

But I need your help. 

Dr. Kevin Nadal is an associate professor at John Jay College of Criminal Justice. His second book, “That’s So Gay: Microaggressions and the LGBT Community,” was published in February. 

Full article http://thefilam.net/archives/11326

“Shortcomings of a Psychiatric Bible”: A Revealing New York Times Editorial?: author: Jeremy D. Safran

The May 12 New York Times editorial titled: “Shortcomings of a Psychiatric Bible” is both revealing and distressing.  After briefly discussing the recent National Institute of Mental Health (NIMH) decision to replace DSM-5 with their new Research and Diagnostic Criteria as a guiding framework for funding future research, the editors conclude with the following assertion: “The underlying problem is that research on mental disorders and treatment has stalled in the face of the incredible complexity of the brain. That is why major pharmaceutical companies have scaled back their programs to develop new psychiatric drugs; they cannot find new biological targets to shoot for. And that is why President Obama has started a long-term brain research initiative to develop new tools and techniques to study how billions of brain cells and neural circuits interact; the findings could lead to better ways to diagnose and treat psychiatric illnesses, though probably not for many years.”

http://www.nytimes.com/2013/05/12/opinion/sunday/shortcomings-of-a-psychiatric-bible.html

This conclusion reflects an unquestioning acceptance of what has become the received wisdom that further advancement of our understanding of both the etiology and treatment of mental health problems is completely dependent on our ability to accurately map out the associated brain chemistry and neural circuitry. This belief is in keeping with the disease model of psychiatry which holds that psychological problems are no different in kind than diseases such as cancer or tuberculosis, and that both the underlying causes and relevant targets for treatment are biological in nature.  This assumption was also one of the important factors that led to the major revision of the Diagnostic and Statistical Manual for Metal Disorders (DSM-3) by the American Psychiatric Association in 1980 that laid the groundwork for the forthcoming fifth edition of the DSM that the NIMH is now abandoning because its lack of validity. NIMH is assuming that the failure to find relevant biological targets for psychiatry to focus on is the byproduct of a diagnostic system such as the DSM which cannot be assumed to reflect the way in which “nature is carved at the joints.” What they are failing to consider is the possibility that  a  more fundamental problem is the assumption that the underlying causes and relevant targets for treatment are exclusively biological.

It is one thing to  hypothesize  that psychological and emotional problems are associated with changes at the biological level (e.g., specific patterns of  brain activity or levels of neurotransmitters) or that  symptom remission is  associated with biological changes   It is another, to assume that the underlying causes of psychological problems are always or exclusively biological in nature. While it may be the case that biological factors play a more significant causal role in some psychological problems (e.g., schizophrenia) than others, the assumption that the major causal factor (and thus the appropriate target for and level of intervention) for mental health problems is always biological is a form of simplistic reductionism. Nevertheless, it appears that the disease model of mental illness has become the dominant narrative in our culture – a narrative that the editors of the New York Times apparently accept in an unquestioning fashion. Some readers may assume that an article such as “Shortcomings of a Psychiatric Bible,” which is signed by the editorial board of the New York Time reflects the newspaper’s official position on the topic. If they do I hope they are mistaken.

Shortcomings of a Psychiatric Bible

A version of this editorial appeared in print on May 12, 2013, on page SR10 of the New York edition with the headline: Shortcomings of a Psychiatric Bible.

http://www.nytimes.com/2013/05/12/opinion/sunday/shortcomings-of-a-psychiatric-bible.html

Patients and parents concerned about mental illness have every right to be confused. The head of the federal agency that finances mental health research has just declared that the most important diagnostic manual for psychiatric diseases lacks scientific validity and needs to be bolstered by a new classification system based on biology, not just psychiatric opinion. The hitch is that such a biology-based system will not be available for a decade or more.
Dr. Thomas Insel, director of the National Institute of Mental Health, posted his critique of the manual in a “Director’s Blog”on April 29 and expanded on his reasoning in a recent interview with The New York Times. He was critiquing a forthcoming revision of the American Psychiatric Association ’s Diagnostic and Statistical Manual of Mental Disorders, the first major reissue since 1994. Although there have been controversies over particular changes in diagnostic descriptions, he said, the new revision involves “mostly modest alterations” from its predecessor.
The psychiatric association’s diagnoses are mostly based on a professional consensus about what clusters of symptoms are associated with a disease, like depression, and not on any objective laboratory measure, like blood counts or other biological markers. The mental health institute says scientists have not produced the data needed to design a system based on biomarkers or cognitive measures. To fill the gap, the agency started a program two years ago to finance research in biology, genetics, neuroscience, cognitive science and other disciplines with the ultimate goal of helping scientists define disorders by their causes, rather than their symptoms.
The underlying problem is that research on mental disorders and treatment has stalled in the face of the incredible complexity of the brain. That is why major pharmaceutical companies have scaled back their programs to develop new psychiatric drugs; they cannot find new biological targets to shoot for. And that is why President Obama has started a long-term brain research initiative to develop new tools and techniques to study how billions of brain cells and neural circuits interact; the findings could lead to better ways to diagnose and treat psychiatric illnesses, though probably not for many years.
Meanwhile, the diagnostic manual remains the best tool to guide clinicians on how to diagnose disorders and treat patients. Consensus among mental health professionals will have to suffice until we can augment it with something better.

A version of this editorial appeared in print on May 12, 2013, on page SR10 of the New York edition with the headline: Shortcomings of a Psychiatric Bible.

No More Addict "Abuse"

The new DSM-5 is the object of an ongoing smackdown by critics for everything from its minor changes to its very existence. But there is one major change that addiction treatment providers can applaud.

By Dr. Richard Juman, 05/08/13 Posted at http://www.thefix.com/content/DSM-5-abuse-dependence-substance-use-disorder8423 

The DSM-5—the revision of the Diagnostic and Statistical Manual of Mental Disorders due out May 22—has already sparked a firestorm of criticism in the mental health community. On Monday the National Institutes of Mental Health (NIMH) made the stunning announcement that the manual displays "a lack of validity" and that the organization will stop funding research that uses DSM symptoms and diagnoses in favor of research focused on the biological underpinnings of psychiatric disorders. “As long as the research community takes theDSM to be a bible, we’ll never make progress,” NIMH director Thomas R. Insel told The New York Times. “People think that everything has to match DSM criteria, but you know what? Biology never read that book.” This brain-biology vs. clinical-symptom struggle will, no doubt, play out in fascinating fashion in the coming years.

As for addictive disorders, not much will change, despite the fact that since 1994's DSM-IV there has been an incredible amount of scientific research and practice devoted to addiction and addiction treatment resulting in a rich debate about the nature and meaning of addiction. Consider these questions:

• How is addiction, which involves the repetition of maladaptive patterns, different from other forms of compulsive behavior? 

• Which of several competing and compelling theoretical frameworks best defines addiction? As the use of a substance (alcohol, heroin, etc.)? Or as a “a primary, chronic disease of brain reward, motivation, memory and related circuitry,” the position of the American Society of Addiction Medicine? Or as a disease that is the result of a “hijacked brain,” as Nora Volkow, MD, the director of the National Institute on Drug Abuse, is fond of saying? Or as a maladaptive remedy for dealing with other overwhelming psychological conditions and early traumatic experiences?

• Is abstinence the best approach for most people in recovery? Or are more recent evidence-based treatment approaches like harm reduction and gradualism?

Don’t expect to find answers to these questions relating to the “grand unified theory” of addiction in the DSM-5. 

Instead the bible of psychiatry offers the same diagnostic criteria in use for the last two decades, albeit slightly reworked—for example, the addition of “cravings” and the deletion of legal problems. Yet if these specifics are not especially controversial, the more general changes in the “substance use disorder” diagnosis already strike many mental health providers as problematic. (Some of these changes are described in recent articles in the Professional Voices series here, here and here.) One change is that for the first time a “behavioral addiction”—gambling—is included as an addictive disorder. But in my opinion, none of the changes are so dramatic as to have a major impact on practice.  

Amidst all the criticism, there is one change worth celebrating because it is of great importance to the treatment community and, more important, to all those who have suffered from addiction: It eliminates any rationale for diagnoses containing the word “abuse” (for example, “alcohol abuse,” “substance abuse,” etc.) or for any psychiatric term at all that describes a person with a substance use disorder as an “abuser.” Let’s make sure that with the DSM-5’s stamp of approval we finally get “abuse” out of the lexicon!

This opportunity has presented itself because the DSM-5 redefines psychiatric illnesses as operating on a continuum as opposed to the previous binary categories of “abuse” and “dependence.” An example of this trend outside of the addictive disorders that has received much media attention is theDSM-5’s elimination of Asperger’s Syndrome as a diagnosis, replacing it with a "mild" version of "autism spectrum disorder." 

Similarly, substance use disorders are no longer diagnosed as either, on the one hand, “substance abuse” or, on the other, “substance dependence”—terms that have often been applied clinically as differences of degree rather than kind (as intended). Instead, a diagnosis of substance use disorder will be made on a spectrum of “mild,” “moderate” and “severe.” For example, a person previously diagnosed with “cocaine abuse” will now have a diagnosis of “cocaine use disorder, mild”; a person previously diagnosed with “alcohol dependence” will now get “alcohol use disorder, severe.”

Let’s make sure that with the DSM-5’s stamp of approval we finally get “abuse” out of the lexicon!

The term “dependence” has, in practice, been misunderstood and misused: Rather than indicating severity, it has been linked to the physiological processes of “dependence,” “withdrawal” and “tolerance.” These biomarkers of addiction make a great deal of sense in diagnosing certain substances such as opioids, alcohol and benzodiazepines, which do in fact result in a user becoming physically dependent. But the term causes much confusion because not only do people who are misusing, say, opiate-based painkillers, and who become addicts, develop dependence; so do patients who take these medications exactly as prescribed. So equating “dependence” with “addiction” is inaccurate. The inaccuracy and confusion are magnified when “dependence” is applied to substances such as cocaine or marijuana, where tolerance and withdrawal symptoms are rare. “Tolerance” and “withdrawal”—clearly defined physical responses to addictive substances—remain diagnostic criteria, but “dependence” is gone.  

In my view, “substance abuse” has never been a useful concept with which to discuss addiction or its diagnosis. Physical, sexual, child and domestic abuse all describe situations in which one person is victimized by another; that dynamic does not pertain to “substance abuse,” where, if anything, the “abuser” and the “abused” are the same person. Instead, describing addiction as “abuse” flows from our long history of stigmatizing and blaming those who suffer from addiction. The words we use to describe a person are inextricably bound up with the way that person is perceived and treated, and people with substance use disorders are still largely described and treated as criminal or morally defective.

The shame and stigma attached to the label “substance abuser”—a term that allows no distance between the person and his behavior—can make people reluctant to seek treatment, thereby causing worse outcomes, including death. “Substance abusers” also experience isolation, discrimination and other social and economic barriers; they are often denied medical services, government benefits and employment opportunities. Eliminating the word “abuse” alone will not right these wrongs, but it can help redefine addiction for the general public as a clinical disorder rather than a moral failing.

Now that “dependence” and “abuse” are no longer in the DSM, we treatment professionals should lead the way in ridding the word "abuse" from our terminology and talk. Stop using it with patients, colleagues or family members. Get the word out of the marketing materials of your facility or practice. And when you hear others use the term, point out that it’s time to let it go, and why.

Let's also insist that the powers-that-be at the national agencies that provide research and treatment leadership consider the affect that these changes in the DSM-5 will likely have on their agencies. Now that “abuse” is leaving the building, maybe it’s time for the word to be removed, literally, from the front of real brick-and-mortal buildings, like the National Institute on Drug Abuse (NIDA), the Center for Substance Abuse Treatment (CSAT), the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the Substance Abuse and Mental Health Services Administration. Hint: The word “addiction” also starts with the letter “A.”

Richard Juman is the coordinator of "Professional Voices," a weekly feature on The Fix designed to provide a forum for addiction professionals to discuss critical issues in addiction theory, treatment, policy and research. He is also a former president of the New York State Psychological Association and a longstanding member of its Addiction Division Executive Committee. His email is dr.richard.juman@gmail.com; he tweets at twitter:@richardjuman.

Full article at http://www.thefix.com/content/DSM-5-abuse-dependence-substance-use-disorder8423.

Fix Event Spreads New Hope on Opioids

Presenters from Physicians for Responsible Opioid Prescribing and CASAColumbia engage doctors on the drug epidemic of our time.

By Ben Feuerherd, 02/26/13 Posted at http://www.thefix.com/content/the-fix-opioid-conference91331

Addiction to prescribed opioids has become an epidemic in the US, as The Fix has frequently reported. Who’s to blame? It’s the addicts who “doctor shop” and misuse their prescriptions, right? Not quite—after all, if you're a doctor shopper, you're probably addicted already. The doctors who prescribe drugs like Oxycontin to chronic pain patients, and the pharma companies that falsely billed such drugs as “non-addictive” for chronic use, have had large parts to play.

In an effort to spread awareness of the problem and the possible solutions, The Fix sponsored a lunch presentation for physicians at the Yale Club in New York last Saturday, co-hosted by the National Center on Substance Abuse at Columbia University (CASAColumbia) and Physicians for Responsible Opioid Prescribing (PROP). “There is no objective national effort...[to address the epidemic]...this leads us to conclude it’s up to the medical professionals,” said Susan Foster, CASAColumbia’s director of policy and research analysis, during her opening talk on the prevalence of the problem.  

Leading psychiatrist Dr. Andrew Kolodny, chief of psychiatry at Maimonides Medical Center in New York and president of PROP, then gave a riveting presentation on the root causes of America's opioid epidemic, and the vital need for change in prescribing practices. Every US state has seen an alarming rise since the late '90s in fatal opioid overdoses, Kolodny showed us, and most who die were introduced to the drugs by a prescription. With doctors having to rely on self-reported information about patients' pain levels, we've actually arrived, said Kolodny, at the point of "de facto legalization of heroin." But most doctors haven't been prescribing opioids for chronic pain maliciously, he stressed; the drugs' manufacturers successfully presented them as "non-addictive" for such use, and doctors began prescribing them out of compassion. Now we know better.

In the final talk, Fix contributor Dr. Andrew Tatarsky, director of the Center for Integrative Psychotherapy for Substance Misuse, founder of the Center for Optimal Living and a founding member of the Division on Addiction of New York State Psychological Association, stressed the importance of the doctor-patient relationship in dealing with the problem, and the value of a holistic approach. And he urged the audience of primary care physicians to address the stigma associated with addiction. Various stereotypes about addicts can contribute to over-prescribing, he said, but"Everyone is vulnerable to substance misuse." Tatarsky also noted various possible alternative treatments for chronic pain, including relaxation techniques, yoga, exercise and diet. 

The event—in which Dr. Richard Juman, the former president of the New York State Psychological Association and the coordinator of The Fix's Professional Voices strand, played a major role—was designed to “engage primary care physicians to address addiction,” as Susan Foster summarized. It appeared to be working: The doctors stayed on long after the end to ask follow-up questions on how they should apply what they'd learned about opioid addiction to their practice. Attending GPs like Dr. Vincent Esposity and Dr. Jeff Trilling, for example, told us that the chance to meet "like-minded people" within their community was valuable to them, "because the resources just aren’t there.”  

Full article at http://www.thefix.com/content/the-fix-opioid-conference91331

Appily Ever After: A Smartphone Shrink

By JUDITH NEWMAN, The New York Times

Published: April 5, 2013

When I was a kid, my favorite toy was the Magic 8 Ball. There was something immensely comforting about asking this little gizmo a question (“Will I find true love?”), shaking it and then seeing the answer that would bubble to the top of the screen: “Outlook good.”

As the world became more complicated and full of anxieties, many of us traded our Magic 8 Balls for therapists and self-help gurus. (“Will I find true love?” Answer: “First, you need to learn to love yourself.”)

But now a proliferation of psychology smartphone apps — with names like BreakkUp, iStress and myinstantCOACH — purports to help us live happier, less anxious lives. As Mark McGonigle, a therapist in Kansas City, Mo., who invented the app Fix a Fight, puts it: “Electronic devices don’t have to drive us apart. They can bring us together.” Which sounds so good. A few bucks and a lot of squinting into my phone: that certainly beats a $300-an-hour psychiatrist, right?

But can an algorithm iron out the kinks in our existence? Will I be able to get my kids to do their homework, or calm down, or simply get my husband to stop nagging, all by following the protocol of these apps? I decided to test them against the stressors of my own less-than-peaceful life: work, cranky husband, twin 11-year-old boys.

Over the course of two weeks, I did a lot of screen tapping — just as I used to spend hours shaking that Magic 8 Ball — and discovered the pleasures, and frustrations, of making my smartphone my shrink.

Fix a Fight

“Communication: it’s the sine qua non of a good marriage,” says Fix a Fight’s Mr. McGonigle and, you know, everyone else.

My problem: It is tax season, so my husband and I are barely speaking. He is the kind of person who likes his receipts carbon-dated. I am not the best record keeper. Let me rephrase that: I am not a record keeper. We’ve been having the same panicky discussions for years, usually right before we go to sleep. They go like this.

John: “Did you see that you are getting Comcast dividend checks? I thought you sold that.”

Judith: “I’ll find out tomorrow.”

John: “Oh, and do we have enough money in the checking account?”

Judith: “For God’s sake, shut up. I can’t take it anymore. You know that when I’m tired I don’t want to think about money.”

The process: My reaction is not, strictly speaking, what Fix a Fight would advise. The app instead shows how a fight is really a “golden opportunity for intimacy” if you process the emotions correctly. This involves: naming your feelings, identifying with your partner’s story, taking responsibility for your actions and describing how the fight will be different next time.

So, John and I identify our feelings (anxiety is big on his list, exasperation on mine) and are instructed to explain our positions to each other.

John: “Why are you typing this discussion into your phone?”

Judith: “Never mind, just talk.”

John’s feelings: “It’s all your fault, because it would be the simplest thing to hold on to your pay stubs.”

Judith’s feelings: “I want a divorce.”

Unfortunately, John and I never made it to the next steps because by that time we were already sleeping in separate rooms.

Conclusion: My failure is not the fault of the app. It seems a sound approach, if you have two people willing to concede some ground. This was not going to happen.

MoodKit

My problem: On the moodiness scale, I wouldn’t say I’m Sybil, but I wouldn’t say I’m June Cleaver, either.

The process: MoodKit, devised by two psychologists, is one of those whiz-bang apps that has so many things going on, you think you need a tutor just to learn how to use it. That puts me in a bad mood — which I can then track in my daily mood tracker. Other things I can do: read the 150-plus mood-lifting activities like “create something,” “choose your friends wisely” (Who has time for friends? I’ve got moods to track), “identify and write down three things you appreciate today.” And so forth.

Something called Thought Checker also invites me to write down a situation that bothered me, then gauge how strongly I felt, on a scale of 1 to 10, at which point I am told how I may be distorting my feelings.

For example, I was annoyed that my son didn’t greet me when I returned from a business trip, his eyes being glued to his beloved Knicks game. When asked, “What thought or concern was going through your mind when you started to feel this way?” I replied, “He is a little ingrate.”

Then I was given a choice of my possible distortions: “all or nothing thinking,” “blaming,” “catastrophizing,” etc. I decide that I am “personalizing,” telling myself an event relates to me even when it may not. I am told to try to find another way to think of the incident.

I know the correct answer is: “It was an exciting game, and he’s only 11.” My answer is still: “He’s a little ingrate.” I mean, it’s not as if he had a bet on the game.

Conclusion: I may be moody, but I’m not a grudge holder. So by the time I got through many of these exercises, I’d either calmed down or forgotten what was upsetting me in the first place. I did rather enjoy tracking my moods for two weeks, and while I could give you a detailed account, they could be summed up thus:

Children home from school for a week: bad mood. Family vacation during which children don’t want to leave the hotel room and pool: really, really bad mood. Everyone returns to school and the normal routine: who needs Zoloft?

Conclusion: The kit gets kudos for irony. It requires so much time to chronicle your life, you can’t really do it if you have a life.

ParentSmart

More of a reference guide than an interactive app, with advice divided into categories: actions, behavior, development, values. It asked me to enter information about my two children, keep track of their activities and devise “wish lists” — which consisted of nothing from my sweet autistic son, Gus, who wants to be allowed to watch buses all day, and about 500 requests for a Tim Tebow jersey from Henry, who has never met a piece of Jets sports paraphernalia he doesn’t love.

My problem: Oh, so many things to choose from here. But I decide to try out ParentSmart’s advice on interrupting, which my children do almost constantly. One day, when I was in the middle of a pressing phone conversation, my kids had instructions not to interrupt — instructions that did not go over so well because, when you’re 11, there are many, many things that constitute a news bulletin. On this particular day, it was the fact that there were window washers hanging outside our window, which elicited repeated cries of, “Mommy, Mommy, Mommeeeee.”

This is the kind of incident that makes my head explode. I read the advice about being proactive: teach your children not to interrupt unless there is an emergency. Talk through specific situations so that they understand what is and isn’t an emergency. Someone is hurt — emergency. I can’t find the yellow crayon — not emergency. Be consistent. If none of this works, whack them with this smartphone.

O.K., I admit I added that last sentence. ParentSmart’s advice is sound and common-sensical. I gave it a try. Apparently in my pre-app-enlightened state, I had assumed that what was and wasn’t an emergency was pretty obvious by age 11. I was wrong. Now, after much discussion: brother putting aluminum foil in the microwave — emergency. Men hanging from platform out the window — not emergency.

Conclusion: There do seem to be fewer interruptions in my household, at least when I’m on the phone. Not interrupting one another’s conversations? Well, maybe by the time they’re 30.

Unstuck

A bells-and-whistles iPad-only app by a San Francisco consulting firm that leads you through a series of exercises to help you get out of whatever rut you’re in.

My problem: I can’t seem to write today.

The process: First, I have to choose three adjectives to tell Unstuck how I’m feeling now. I pick “Overwhelmed, Uninspired, Unmotivated,” which pretty much sum up my entire life. The machine continues to interrogate me: What am I doing while I’m stuck? What thoughts am I having in this stuck moment?

This is where we get to the how-to of the whole exercise. I need to “believe in a new way to commit.” I am given useful tips to get the job done: chop it up into little tasks. Do one thing today; consider the extreme of what could happen if I don’t get it done.

O.K., I still haven’t started, but I have my marching orders.

But wait, there’s more. My iPad still wants to talk to me with a section called “Get to the Root of It” and continues hammering me with questions.

“I worry my work won’t be good enough,” I write.

“Why is that?” the machine asks.

“Because my parents were so critical,” I answer.

“Why is that?” the machine asks.

“Because they were Jewish,” I reply.

“Why is that?”

“Because they don’t believe Jesus Christ is our savior.” I feel my iPad is getting a little personal.

Then the machine triumphantly concludes: “This is what is really holding you back: because they don’t believe Christ is our savior.”

“So what are you going to do about it?” the machine asks.

“Uh, convert?” I tap.

Then the machine smugly asks: “Did this tool help you get unstuck?”

Conclusion: I spent about an hour and a half learning that I am Jewish, which does, in fact, explain a lot.

Simply Being

My problem: After spending so much time puzzling over my moods (the getting-my-marriage-working mood, the getting-my-children-in-line mood, the getting-through-all-the-mood-apps mood), I need something simple to improve my moods.

The process: Simply Being is exactly what it sounds like: a tape of 5, 10, 15 or 20 minutes (you choose), with a woman’s voice that’s calm-trending-to-coma and saying things like: “This is a time to do nothing, but simply be. Letting go of everything you’re doing, letting go of everything you need to do, simply be aware of everything going on, right now, in this moment.”

You know why this is relaxing? Because I’m not being asked to do anything. I’m sitting as someone whispers in my ear to sit down and shut up. (You can listen to the voice with music or nature noises in the background, but the recording’s a little dicey, so you find yourself thinking, “What did she say?” as she’s drowned out by a roaring ocean.) Of course, I could never find more than five minutes at a time to do this. I never got around to the 20-minute option. Still, it was five minutes well spent.

Conclusion: This app almost puts me to sleep — and in my world, that’s a very good thing.

Here’s the thing about all of these devices: They require thought. Lots and lots of thought. Thinking is what I do all day long. I needed something that would turn my mind off, not on. Something that would let me, however temporarily, ignore all of life’s problems, not confront them. Which is why you can find me pecking away, every night, at Words With Friends. Do you know how many two-letter words there are in the universe? I do! Ask me.

There is no easy solution to a life of stress and anxiety, of course. But out of all of the apps I tried, well, did I find at least one that does exactly what it says it does?

As my Magic 8 Ball says: “Signs point to yes.”

For the full article, visit: http://www.nytimes.com/2013/04/07/fashion/appily-ever-after-the-smartphone-as-shrink.html?pagewanted=1&ref=psychologyandpsychologists&_r=0

Love letters and kindness may improve mental health

By Lorna Stewart

Health Check, BBC World Servicehttp://www.bbc.co.uk/news/health-21900202
"You matter to me. In a way I cannot explain, you matter to me. And you, you are a marvel... you and all the parts of you."

It's not the kind of thing you normally write to a complete stranger.

But after graduating from college and moving to New York City, Hannah Brencher was feeling anxious and depressed. She found herself not wanting to be around other people and "just really unravelling".

Then she started writing love letters to strangers and leaving them all over the city. The first letter she left on a train simply addressed: "If you find this letter then it's for you."

Since then she has left letters in libraries and cafes, and even hidden them around the United Nations building.

"What I noticed was that my sadness and loneliness got backburnered," she told the BBC. "I found something that allowed me to take the focus off of myself."

Unexpected kindness

Hannah and her More Love Letters campaign are part of a growing number of organisations shouting about the beneficial effects of random acts of kindness for givers as well as receivers.

It might sound a bit like new-age nonsense to some people, but new research suggests being kind might actually be good for your mental health.

A study published in the journal Emotion reports that performing acts of kindness may help people with social anxiety to feel more positive.

Dr Lynn Alden and Dr Jennifer Trew, from the University of British Columbia, asked volunteers with high levels of social anxiety to commit multiple acts of kindness on two days a week over a four-week period.

"Sometimes people would give a small gift to somebody, or picking somebody up from work, visiting sick people, thanking a bus driver. They were actually fairly small acts," explained Dr Alden.

They were small acts perhaps, but ones which had a much bigger impact.

Challenging beliefs

More standard treatment for social anxiety disorder is cognitive behavioural therapy (CBT) adapted specifically for people who fear they will do or say something embarrassing in a social situation.

As part of this therapy patients are encouraged to face their fears about social contact, by putting themselves into a situation they would normally avoid or initiating conversation with new people.

In Dr Alden's experiment a comparison group of anxious volunteers were asked to perform small "belief-challenging" tasks similar to these therapeutic ones.

Just like the kind acts group, this group were also increasing their levels of social contact, engaging in unfamiliar behaviour, and paying attention to others' responses; all things which have been suggested to be important components in overcoming social anxiety.

At the end of the four weeks, participants in the kind acts group avoided social situations less and also reported increased relationship satisfaction. Performing kind acts appeared to have a bigger effect than CBT-like behaviour tasks.

Dr Nick Grey, consultant clinical psychologist and clinic director at the Centre for Anxiety Disorders and Trauma in London, was initially wary of the idea that performing kind acts might have therapeutic value for patients with anxiety disorders.

"I hadn't seen the paper and I was sceptical from the title to be honest. But it's a good paper and comes from a well-respected team.

"I don't think that's ever going to be a therapy in and of itself, but it could well be the kind of activity that could be integrated as part of a broader treatment."

Dr Alden suggests that acts of kindness might be an initial step in a longer therapeutic pathway.

"Engaging in kind acts may help the person to get out and encounter other people and then we can use other techniques to help the person change their beliefs about themselves."

But she urges caution about performing acts of kindness chosen by someone else or just to impress others.

"I think it has be done in such a way that the individual has a sense of autonomy. They are performing the act because they want to and not because it's required by the group."

Continue reading the main story

The kindness offensive

A London-based initiative called the Kindness Offensive have been organising give-away events and encouraging kind acts since 2008.

They hold the world record for the largest ever random act of kindness for distributing 39 tonnes of goods in one day.

"It's practically impossible to do an act of kindness without feeling good about yourself," said the aptly named David Goodfellow, one of the founding members of the group.

"If you can make someone's day a little bit better it will actually make your day a little bit better."

• The Kindness Offensive
• For the full article visit http://www.bbc.co.uk/news/health-21900202