Thursday, February 14, 2013
Tuesday, January 29, 2013
In my use of this method with clients I have found that it doesn't for everyone, but usually it does work. People can usually tell within several sessions if it is going to work because they can feel the drive of the addiction lessening - once I see this, I know we're on the right track.
Mark Robinett, MFT 415-221-3182 firstname.lastname@example.org
Monday, December 3, 2012
The very first step of every 12-Step program begins with these words – an admission of powerlessness. For many people, that very first step makes participation in a 12-Step program very difficult and with good reason: powerlessness is an uncomfortable feeling and not one that most people seek out or admit to.
In fact, most of us spend a great deal of energy, time, and effort attempting to try to control things and other people in our lives. We work hard to try to create a life of happiness, as we should. However, these efforts often involve trying to gain control over something we don't have control of, like an addiction. Other times, the efforts involve trying to change or control other people who are in our lives. And understandably, because the people in our lives – their choices and behaviors – affect us; sometimes profoundly.
But when we stop and look at how effective our efforts are to bend others' actions to our will – when we really examine how well our efforts to control things go – we find that, in fact, we cannot figure out a way to make others be or do what we want. We discover that using all of our efforts to control someone so they don't cause us pain doesn't, in fact, protect us. As the program of Alanon says: we don't cause the behavior of others, we can't control it, and we can't "fix" it. Trying to do so simply makes our life feel unmanageable and increases our unhappiness.
Acknowledging that we are powerless is not about acknowledging that we are weak. Instead it acknowledges what is true, and allows us to focus on the things that we can control and the person who we can help: ourselves. Acknowledging the ways we are powerless also allows us to be more accepting of others, and to find a more peaceful way of being in the world and in relationships.
Security is mostly a superstition. It does not exist in nature, nor do the children of men as a whole experience it. Avoiding danger is no safer in the long run than outright exposure. Life is either a daring adventure, or nothing. Helen Keller
Samantha Smithstein, Psy.D.
Friday, August 17, 2012
Whether it's food, alcohol, or sex, there are a number of people who react strongly to hearing that someone has engaged in self-destructive behaviors because they are an addict by saying, "Don't use addiction as an excuse for your behavior! Take responsibility!"
This concept of an "addiction excuse" is relatively new, and while it captures the imagination of those who are hurt, angry, or frustrated by the behavior of an addict, or by someone who lacks basic understanding of addiction, it simply doesn't hold water for people who are addicts or those who work with people who struggle with addiction. People who speak about addiction as a "convenient excuse for bad behavior" or a "way to not take responsibility," don't comprehend what addiction is, and what the experience is like for the person who struggles with it.
Addiction is a psychological and physiological disorder. Even for "process addictions" such as those related to eating, sugar, sex, gambling, and stealing, there is strong scientific evidence that the neurological pathways related to dopamine are activated similarly to an addiction to cocaine. So addiction is not something made up by people to explain something away, it is a real condition, with both biological and psychological underpinnings.
For the vast majority of people who suffer from an addiction or impulse control disorder, acknowledging an addiction is one of the most difficult steps they will ever take. Most are in denial for years, believing in the "free will" that addiction naysayers speak about; addicts want to believe they are in control, and can stop any time they want. Many struggle for years to gain that control and feel deep shame when they fail, again and again.
Acknowledging an addiction, therefore, is an incredibly important first step. No problem can be solved if the problem is not acknowledged. Until someone admits, "I have lost control of this situation and can't stop myself," they cannot possibly be open to learning and working on the steps it takes to change their behavior. To the addict, acknowledging an addiction may be the most difficult, shameful, and scary step they take … but is also a crucial first step in saving his or her life. In fact, rather than being about shirking responsibility, acknowledging an addiction is the first step to taking responsibility.
As a society, we must stop shaming them further by telling them that acknowledging their addiction is an "excuse" and that they should "take responsibility for acting badly" and just feel ashamed. Instead, addicts must be supported in their first step and invited to take the many steps – psychological, physiological, spiritual, and emotional – that must take place for them to become well.
It may be that part of what people are reacting to is the overwhelming list of addictions that we hear about these days. People have begun to feel as if it is an overused term, and that there simply can't be so many people in our society addicted to so many different things. Sadly, this is also not something that is made up. It doesn't take much work to look around and see the sheer numbers of people who are addicted to food, shopping, electronics, alcohol, drugs, gambling, sex, and the myriad of ways available to us to avoid the profoundly beautiful but sometimes acutely painful process of being human.
Samantha Smithstein, Psy.D.
Pathways Institute for Impulse Control
Friday, June 22, 2012
What is the connection between desire and love? This question has been one that relationship scientists and couples therapists have concerned themselves with for a long time, but the answer has remained elusive.
Recently, researcher Jim Pfaus, professor of psychology at Concordia University, co-authored a study published in the Journal of Sexual Medicine that set out to use brain imaging to try to shed some light on the differences and similarities between sexual desire and love.
It turns out that love and desire activate specific but related areas in the brain. The researchers found that two brain structures in particular, the insula and the striatum, are responsible for tracking the progression from sexual desire to love. The insula is a portion of the cerebral cortex folded deep within an area between the temporal lobe and the frontal lobe, while the striatum is located nearby, inside the forebrain.
Love and sexual desire activate different areas of the striatum. The area activated by sexual desire is usually activated by things that are inherently pleasurable, such as sex or food. The area activated by love is involved in the process of conditioning by which things paired with reward or pleasure are given inherent value. That is, as feelings of sexual desire develop into love, they are processed in a different place in the striatum.
Somewhat surprisingly, this area of the striatum is also the part of the brain that associated with drug addiction. Pfaus explains there is good reason for this. "Love is actually a habit that is formed from sexual desire as desire is rewarded. It works the same way in the brain as when people become addicted to drugs."
This habit has its pros and cons. For some, the experience can turn into an addictive process, whereby they seek out, again and again, the experience of falling in love, unable to form a long-term relationship bond. For most, however, the habit of love activates pathways in the brain that are involved in monogamy and pair bonding, and is connected to parts of the brain that are more abstract and complex – so that the experience of love is not as dependent on the physical presence of someone else. Another way of understanding it would be that desire and love are on a spectrum that evolves from integrative representations of sensation to an ultimate representation of feelings. Thus they are not the same thing, but are intimately connected.
According to Pfaus, cognitive neuroscience has given researchers a deep understanding of where intelligence and problem solving sit in the brain, but there is still a lot to discover when it comes to love. He hopes that studies such as his will not only give us a map of where these experiences are located in the brain, but perhaps more importantly deepen our understanding of how these feelings and experiences – so central to our existence as humans – grow and evolve.
Samantha Smithstein, Psy.D.
Pathways Institute for Impulse Control
Tuesday, March 27, 2012
This question is a good one, as there is no obvious ending point for psychotherapy – it isn't like a course of antibiotics, or a broken bone, when the ending of treatment can be prescribed. With psychotherapy, the ending has to do with 1. the goals of the therapy (which can grow and change), 2. the ability of the therapist to adequately address those goals and 3. the ability and/or willingness of the patient to do the work necessary to complete the goals.
Let's address each of those questions individually.
1. Have I achieved the goal(s)?
This question is an interesting one. Often, people come into therapy with acute problems which tend to improve after a while, sometimes within several months. If the goal was to address these acute problems, there can be a perception on the part of the patient that therapy has done its work and they are therefore done. That is certainly one way of looking at it but is it a good enough reason to end therapy?
Often the improvement someone experiences is because they have been able to identify the problem, learn new communication skills, and experience being heard through nonjudgmental inquiry and feedback from the therapist. They learned their part in their problem and/or the psychological impact of the problem and have been able to begin to talk freely about the problem.
However, several months, or even a year, is usually not long enough to address the underlying vulnerabilities that led to the acute problems in the first place. This makes the person highly vulnerable to repeating the acute problems in the future. It is also not typically long enough to create a lasting change, so that the person may find that they are coping better but they have not made the deeper changes that address their orientation to life, work, or relationships. If the goal is to have fewer symptoms and feel generally better, that goal might have been met, but if the goal is to have a broader understanding of themselves and a shift of perception enough to implement lasting change, they may not be.
Take, for example, the case of Marty: Marty came to therapy to try to figure out why she was so burnt out in her chosen field as a creative director in an advertising agency. Her goal for therapy was to get back her passion and excitement about her work. Through therapy she discovered that it wasn't really her work that was the problem. She and her husband were parenting three teenagers and had very little time for themselves and each other. Her therapist came to feel that an underlying issue was Marty's lack of self-care, and began to work with Marty on it. Marty discovered it wasn't that easy. It was easy to support her husband to go swimming and get back to his passion for woodshop. But for some reason she couldn't seem to sign up for yoga, painting and ask her kids to pitch in more. Slowly her therapist suggested that perhaps they needed to look a little more closely at her childhood growing up with an alcoholic mother and father. Marty was willing to consider adding this to her goals and realized that she was never very good at taking care of herself, she was good at surviving in an out of control alcoholic family. After a few months she was able to sign up for yoga and a few months after that she signed up for weekend painting class.
As in the example above, deeper work often means a revision of the goals. Sometimes it means that the therapist and patient do not have shared goals – the therapist may see the potential for greater change and the patient may not be interested (see #3). But often as the patient and therapist work together they come to see that there are goals that were not initially apparent.
2. Is my therapist capable of helping me achieve my goals?
This is also a very important question and one that can be difficult to assess. Sometimes people encounter frustration with their therapist and feel they must leave – that they are not done with therapy but done with that therapist. This very well may be an accurate assessment on the part of the patient: even if people seek specialists for their particular problem, or they get a recommendation from someone who they know, not every therapist can work well with every person – there needs to be a "fit" for the therapy to work. Additionally, some therapists are more skilled than others.
However, often people underestimate their therapist and leave instead of working with their therapist to see if the frustration can be resolved.
Take, for example, the case of Sue and Dave: Sue and her husband Dave brought their child to a therapist because they had reports from school that he wasn't doing well academically and were concerned that their son had an emotional issue that was causing him to lose concentration. Sue and Dave luckily saw an adult & child psychologist, Dr. Lee, who not only specialized in mood disorders but also in learning disorders. After an initial evaluation the psychologist told them that he felt their son didn't have mood based learning problems, rather he suspected the neurological based learning disorder dyslexia. Initially Sue and Dave were upset by this thought, and felt Dr. Lee was the wrong therapist for their son. However, after discussing it further with Dr. Lee they agreed to testing and discovered Dr. Lee had been correct. Dr. Lee was able to work with the family to help them accept the diagnosis, including the depressed feelings Dave initially experienced as a result. Dr. Lee was able to support Dave to work on all his feelings and now both Sue and Dave are involved parents and advocates for their son, and their son was able to receive the help that he needed.
Often, the therapist and patient can work through the impasse together and the process itself can be a very effective part of the therapy.
3. Am I willing and/or able to do the work necessary?
This final question is crucial. The process of therapy is intense and powerful. Often when people find their symptoms are (temporarily) alleviated, they feel incredible relief, and this feeling of relief allows them to feel the possibility of wellness. Typically, as they continue in therapy, they then begin to feel uncomfortable. The therapy process begins to take a deeper look into the person and his or her life. Unpleasant feelings can emerge, such as feelings of dependency, or a deeper unhappiness. More subtle thought distortions, relationship patterns, or acting out can begin to be revealed, and all of this can be frightening or make the patient feel worse. This is a common time when people have the urge to leave.
Take, for example, the case of Tony: Tony came to therapy after his partner discovered Tony's compulsive sexual behavior involving internet pornography, multiple affairs and frequent encounters with prostitutes. His partner had told Tony if he didn't get help to stop his behaviors, she would leave and take their three kids with her. Tony was motivated to change, got into an intensive outpatient treatment program, joined a twelve step program and his wife joined a support group. Tony was hugely relieved that things started to calm down at home and he and his wife were finally able to communicate without painful arguments. Six months into the therapy, Tony had a very deep session with his therapist acknowledging he thought he'd been depressed since his mom died when he was eleven years old. A week later Tony came to therapy stating he was confident he was over his problems and decided after six months of no longer acting-out in his sexual compulsivity he was done. His therapist asked him if he thought he'd touched on something very painful when he had brought up his mother and that he had more work to do to grieve her loss and look at the corresponding depression he'd had since that time. Tony disagreed and in a couple of days sent her an email stating he would not return. His therapist called him back and told him that her door was always open to him and encouraged him to consider a final session for closure. Two months later he returned to therapy and said his wife had caught him again on an internet pornography site. His twelve step sponsor said he was still in his addiction and he needed to get additional help of therapy to get and stay sober. He acknowledged he wasn't done and indeed was really just getting started. Tony later learned that when he had been in so much pain remembering his mother, it wasn't his sober adult mind doing the thinking and acting, it was the addict defensive part of his mind that was telling him to run and hide from therapy. That was a part of his mind that had developed to help him survive a traumatic event when he was young but it was no longer helpful – it was self-destructive.
People spend a large portion of their lives acting without knowing really why or where the action is coming from. Part of the goal of therapy is to develop a mind that can think "real thoughts" versus automatic responses, awareness of feelings and ability to tolerate them, so that conscious decisions can be made and intimacy can be created. The discomfort – experienced as frustration, irritability, restlessness, sadness, pain, anger, unhappiness, etc – can be an indication that the real work can begin – the work of discovery and healing. The deeper problems are now within reach and are available to be explored and resolved.
Samantha Smithstein, Psy.D. & Elizabeth Corsale, MFTPathways Institute for Impulse Control
Friday, February 3, 2012
The majority of people's problems are caused by the fact that they are disconnected with the rest of creation. (C.S. Lewis)
We came to believe that a Power greater than ourselves could restore us to sanity. We made a decision to turn out will and our lives over to the care of God as we understood Him. (Steps 2 and 3 of the 12 Steps of AA)
In his correspondence with Bill Wilson, co-founder of Alcoholics Anonymous, the psychologist Carl Jung stated his opinion that craving for alcohol was really "the spiritual thirst of our being for wholeness." In their book on Maharishi Ayur-Veda, Transcendental Meditation, and treatment of addiction, authors David O'Connell and Charles Alexander state that in addition to genetics and physiology, "addiction arises from the 'mistake of the intellect,' known as pragyaparadha, in which one perceives one's self not in terms of the wholeness of pure consciousness (the Self), but rather as a highly limited individual personality burdened with conflicting impulses and feelings, cut off from the wholeness of pure consciousness."
In an article titled "The 12 Steps: Building the Evidence Base" that appeared in the May 2009 issue of Addiction Professional magazine, Valerie Slaymaker, Ph.D., reviewed a series of studies examining the role of spirituality in addiction treatment. In the introduction to her article, she acknowledges the difficulty of defining spirituality.
"Spirituality is a difficult concept to study scientifically," she states. "Ask 10 people how they define spirituality and you will receive 10 different answers. To some, spirituality implies a connection with the metaphysical, whether that is a traditional concept of God or a nontraditional concept of a higher power. To others, spirituality is intertwined with religion and formal, organized practices such as church attendance and group prayer." That said, spirituality has become an integral part of many forms of treatment for addiction. "Despite differences in conceptualization, and challenges with measurement," Slaymaker state, "scientists have begun to examine spirituality's role in recovery from alcohol and drug dependence."
Slaymaker found that studies suggest that people with a spiritual belief system are less depressed, less anxious, and less suicidal than non-spiritual people, and that they are better able to cope with stressful and traumatic events. Those who incorporate spirituality into their daily lives through meditation, prayer, and other spiritual practices report having a more positive outlook and an overall sense of satisfaction with life.
Dr. Slaymaker also pointed to research that compared individuals in treatment for alcohol use who relapsed with individuals who maintained abstinence. Although all participants demonstrated significant initial increases in spirituality scores (measured by spiritual experiences, gratitude, tolerance, humility, and other factors), those who relapsed showed significant declines in spirituality scores in a three-month follow-up. Still other research highlighted by Dr. Slaymaker has shown that higher spirituality levels directly relate to improved treatment outcomes and life satisfaction.
Many people have a negative experience of religion. Throughout the course of human history, people and cultures have committed horrible deeds in the name of religion, and individuals have preached messages in the name of religion which have turned many away from the concept of God or spirituality. Still others have never been exposed to a healthy spiritual community or tradition, and are bereft of regular practice that gives them the spiritual experience they need. In addition to contributing to depression, anxiety, and other mental health issues, this lack of experience can contribute to a spiral into addiction, just as gaining regular spiritual experiences can help lead the way out.
So how does one cultivate a more spiritual life? There are many paths to expanding spiritual connection, some formal and others not. Twelve Step programs, organized religion, some forms of therapeutic treatment, meditation, and yoga are all more formalized paths. Going for a hike in the woods is not. In his letter to Bill Wilson, Carl Jung address it by stating his opinion that "The only right and legitimate way to such an experience is that it happens to you in reality, and it can only happen to you when you walk on a path which leads you to a higher understanding. You might be led to that goal by an act of grace or through a personal and honest contact with friends, or through a higher education of the mind beyond the confines of mere rationalism."
In addition to psychologists, other scientists have articulated the importance of spirituality. Francis S. Collins, MD, head of NIH, has written about his views on God and how spirituality fits with his experience as a doctor and scientist. "Science is not threatened by God," he writes, "it is enhanced." Albert Einstein wrote about how living without an expanded consciousness is like living in a prison. "A human being is part of the whole called by us universe, a part limited in time and space," he wrote. "We experience ourselves, our thoughts and feelings as something separate from the rest. A kind of optical delusion of consciousness. This delusion is a kind of prison for us, restricting us to our personal desires and to affection for a few persons nearest to us. Our task must be to free ourselves from the prison by widening our circle of compassion to embrace all living creatures and the whole of nature in its beauty. The true value of a human being is determined by the measure and the sense in which they have obtained liberation from the self. We shall require a substantially new manner of thinking if humanity is to survive."
However one cultivates it, the cultivation of a spiritual life must be conscious, purposeful, and regular to be effective. While the rigorous separation of church and state in the US gives everyone a right to pursue their own path of connection to something more expansive then our own self, this leaves the task of finding that path up to us. And find it we must.
Like the air, God's grace is available to us. It is permeating every fiber of Being and the Being of the entire universe. When we take our attention to that Being, finer than the finest, then we establish ourselves on the level of God's grace. Immediately we just enjoy. Life is Bliss! (Maharishi Mahesh Yogi)
Samantha Smithstein, Psy.D.
Pathways Institute for Impulse Control