The National Council on Alcohol and Drug Dependence (NCADD) is promoting their 32nd Annual Alcohol Awareness month this April. The theme for this year encompasses the idea of drinking as a rite of passage. This immediately makes me think of a case that I have been following regarding a fraternity at Penn State and the alcohol-induced death of one of its pledges. While there are many issues in this case that can be picked apart and examined, I feel that alcohol, as a rite of passage is central to what occurred.
The Meadows will host Recovery Comedy with Kurtis Matthews on December 31 at The Meadows to entertain patients and staff. This event is not open to the public. Using his struggles with infidelity, alcohol and drugs to enrich his material, Matthews makes audiences laugh while inspiring them to be better people.
In 1984, Matthews began his stand-up career at the Improv in Hollywood. That same year, he also embarked upon his own journey in recovery from alcoholism after an automobile accident that resulted in his second DUI and jail time. Touring alongside such renowned comedy veterans as Bill Hicks and Sam Kinison, Matthews learned the joys of making people laugh, as well as the challenges of staying sober while doing so.
"We know being in treatment during the holidays can be difficult and the holidays overall can often be a challenge to those in recovery," said Sean Walsh, The Meadows Executive Director. "At The Meadows we not only want to assist our patients and family members to ensure this will be the first of many healing and healthy holiday seasons, but also to remember the power of laughter and learning to incorporate fun into recovery."
The Meadows is an industry leader in treating trauma and addiction through its inpatient and workshop programs. To learn more about The Meadows' work with trauma and addiction contact an intake coordinator at (866) 856-1279 or visit www.themeadows.com.
For over 35 years, The Meadows has been a leading trauma and addiction treatment center. In that time, they have helped more than 20,000 patients in one of their three inpatient centers and 25,000 attendees in national workshops. The Meadows world-class team of Senior Fellows, Psychiatrists, Therapists and Counselors treat the symptoms of addiction and the underlying issues that cause lifelong patterns of self-destructive behavior. The Meadows, with 24 hour nursing and on-site physicians and psychiatrists, is a Level 1 psychiatric hospital that is accredited by the Joint Commission.
In my third year of medical school, I was mentored by a brilliant surgeon who routinely pontificated about the virtues of his profession, with clear intent to dissuade me from entering psychiatry. On one such occasion, he disrupted my tense and halting approach at a long abdominal incision with the question: "Do you know what makes a surgeon great?" I looked up from the patient's pale, still body - scalpel still poised. "It's not the suturing; you can teach any monkey how to sew." (That didn't boost my fledgling surgical confidence.) He went on to say, "When you open someone up, it rarely looks like the textbook. It's messy, unpredictable. Great surgeons effectively respond to each new situation as it arises... they adapt."
Although this gifted surgeon didn't dissuade me from the practice of psychiatry, I was persuaded to believe that effective treatment of the body and the mind requires an ability to adapt to each new situation as it arises. Most people enter The Meadows with some idea of their underlying problems and what they want to accomplish in treatment. However, as people give themselves to the recovery process, often the mental and emotional landscape changes in unpredictable ways, presenting new challenges and new opportunities for healing and growth. The following case history highlights the dynamic unfolding of one patient's experience at The Meadows and some of the treatment modalities that were adaptively employed on the patient's behalf.
Susan, as I will call her, was a 32 year-old, single, female from Denver, Colorado who was referred to The Meadows by her outpatient therapist. She initially reported symptoms of anxiety and depression that had contributed to significant problems in her close relationships and work performance as a financial consultant. She identified pervasive feelings of uneasiness and tension, with debilitating spikes of episodic panic and fear. Also, she noticed that her self-confidence was very low and that she was uncharacteristically tearful, emotional, and sad. After discussing her condition at length with her psychiatrist at The Meadows, they both agreed to explore the symptoms further before deciding if a medication was necessary.
Forming relationships of trust with peers and providers allowed Susan to acknowledge that her symptoms of depression and anxiety were partially related to worsening addictive behaviors with alcohol, food, and sex. She admitted to a life-long struggle with binge eating, excessive dieting, and shame about her body. She also shared that, after ending a ten-year, co-dependent romantic relationship in the months prior to admission, she immediately turned to compulsive sexual encounters via phone, internet, and night clubs. With the help of her outpatient therapist, she was able to reduce her sexual acting-out, but she then turned to excessive and reckless use of alcohol. Her life had become unmanageable.
In response to this additional information, Susan was reevaluated by the medical doctor to monitor and treat any symptoms of alcohol withdrawal. She spoke with the dietician so that the treatment team could better understand the nature of her disordered eating patterns and could help her establish an eating and wellness plan. In collaboration with her primary therapist, Susan set clear limits on her use of communication devices and her interactions with fellow peers, so that she could effectively address her compulsive tendency to rely on unhealthy relationships. Susan was also encouraged to attend 12-step meetings and to make use of important mind-body activities, such as yoga, tai chi, and meditation.
Although Susan had acknowledged a history of sexual trauma during the intake process, she was unsure of its significance in her life. Starting in the second week of treatment, she participated in a unique five-day experiential form of therapy that specifically addresses childhood trauma and early family relations. For the first time in her life, she began to see how her mother's tragic death at six-years-old led to years of depression and social-withdrawal on the part of her father. She was able to see herself as a scared and lonely child who tried not to worry her already distraught father, even when she was molested by the babysitter at nine-years-old. She discovered that during those lonely years, food was a trusted ally, but by the time she reached her teen-age years, food had become the enemy and she was at war with her own body.
As Susan's second week of treatment came to an end, years of shame, anger, and self-hatred gave way to profound sadness and grief. Long-held defenses began to relax, and as a result, she touched into another source of pain and sorrow connected to a date-rape in her early twenties that resulted in miscarriage. With guidance from peers and providers, she realized that this additional trauma and loss had contributed to soaring alcohol use and plummeting self-worth. In response to Susan's evolving treatment needs, she was offered several visits with an individual therapist trained in Somatic Experiencing to specifically address her adult trauma-related symptoms. Also, her focused work in 12-step recovery during the third week became more meaningful as she explored further the links between her past trauma and her addictive behaviors.
As a result of many lectures and hands-on practice regarding interpersonal communication and boundaries, Susan felt prepared to engage in family therapy with her father and two sisters during the fourth week of treatment. Relying on the inner-child work from her second week, she was able to talk openly with her family about the bewilderment and loneliness she felt after her mother's death. For the first time in her life, she shared the deep emotional pain associated with her experiences of sexual trauma, her ten-year, unhealthy relationship, and her addictive behaviors. Susan's family members responded with concern, but also with an outpouring of love and acceptance. Together, she and her family received information and practical tools to move forward in a way that could support Susan's recovery and a healthier family system.
As Susan entered her fifth week of treatment, she was invited to participate in a special grief workshop to specifically address lingering feelings of loss and pain regarding her mother's death and her miscarriage. Also, after weekly meetings with her psychiatrist about her particular condition and possible treatment options, she decided to start a medication for symptoms of depression. Several discussions with her providers, discharge coordinators, family, and outpatient therapist resulted in an aftercare plan that fit her therapeutic needs. Susan finished her treatment with a new lease on life - ready to face old challenges and embrace new opportunities.
Of course, there are additional elements of The Meadows' treatment program that are not discussed here and not everyone's experience is like Susan's... but that is the whole point; the human psyche rarely conforms to overly-simplistic, textbook universals and treatment often unfolds in unpredictable and complex ways. As my mentor suggested, this requires that treatment professionals recognize and adaptively respond to situations as they arise. This means that providers must have the appropriate training and therapeutic techniques to effectively respond to the dynamically changing landscape of each person's recovery process. The Meadows has a proven track-record of providing this kind of treatment.
When Adolescence Doesn't End at the Same Time Adulthood Arrives: REHAB Treatment for Young Adults
Bonnie A. DenDooven, MC, LAC
Ad·o·les·cence is defined as a period or stage of development, preceding maturity. But what happens when chronologically your son or daughter becomes an adult and emotionally they are still locked in immature, self-destructive patterns that you thought they would out grow?
For a therapist working with young adults and their families, REHAB is a process of untangling the mystery of maturation gone wrong. Getting young adults sober from drugs and alcohol is just the tip of the iceberg. Unless the underlying issues are addressed, the young adults are precariously at risk to return to the immature habits that put them at risk to start with.
Karen Horney, pioneer psychotherapist who focused on the struggle toward self-realization, held that basic anxiety brought about by insecurities in childhood was fundamental to later "character development". (Footnote 1) In other words, some anxiety and some insecurity are needed to produce maturity, much like the baby chick in an egg needs to press against the adversity of the hard egg shell in order to emerge strong and capable from the hatching process.
In 1969, a publication changed how we treated children. The "Self-Esteem Movement" was birthed when psychologist Nathaniel Brandon published a widely received and highly acclaimed paper called "The Psychology of Self-Esteem" and argued that "feelings of self-esteem were the key to success in life". (footnote 2) A 40-year craze of self-esteem building began then. This craze changed how parents and teachers treated anxiety and insecurity in children. The "Self-Esteem Movement" encouraged parents and teachers to remove as much anxiety as possible from the lives of children. Suddenly it was NOT okay to give 1st, 2nd, and 3rd place trophies for fear that some child would feel less than others. Teachers put away red markers previously used to grade papers because it might make students "feel bad". Parents began a chorus of constant praise and admiration such as "You're so smart!", and "You're so pretty!";, and the killer, You've got so much potential". Research now shows that by age 12, children no longer believe these overworked compliments and see these compliments as an attempt by adults to manipulate them. (Footnote 3) Worse, the self-esteem movement created children who may have high self-esteem but who cannot tolerate any form of anxiety or insecurity. Without tolerating basic anxiety and insecurity they cannot produce character in themselves. Teenage use of drugs and alcohol to medicate the anxiety and insecurity is leaving us with a generation of addicts who live by the cognitive distortion, "I should never feel bad."
In the therapy room, when working with immature young adults (ages 18-29), it is easy to detect patterns. The newest research on addiction indicates that attachment disorders underscore addiction, but what does that mean? Karen Horney wrote about how the authentic self emerges. She described three classifications of how we relate to others. It is in our relationships with others where authenticity or the lack thereof shows up. To see attachment disorders in action, therapists watch how young adults: (1) Move toward people, (2) Move against people, or (3) Move away from people.
In essence, it is a simple and brilliant way to look at this thing called attachment disorder and to prepare therapeutic interventions that are effective. In the close conformity of the REHAB environment, these reactive positions of relating to others become visible, and set patterns readily emerge in the day-to-day required activities. Following are the three categories and ten patterns
Attachment style of Moving toward People:
Pattern 1: The need for affection and approval; pleasing others and being liked by them. The feelings of peer pressure are too powerful to resist and results in CODEPENDENCY and trauma bonding to unhealthy "friends" Young people can become just as addicted to "the lifestyle" of the drug world as they are to the chemicals.
Pattern 2: The need for a partner; one to love and who will solve all problems - the emphasis is that "love will solve all problems". This results in love addiction and sexual promiscuity with either an inability to disengage from abusive relationships or the inability to be without a relationship. These are the REHAB residents who strike up romantic or sexual liaisons in treatment.
Attachment style of Moving against People:
Pattern 3: The need for power; the irresistible urge to bend the rules and achieve control over others. While most people seek strength, an immature young adult may be desperate for it.
Pattern 4: The need to exploit others; to get the better of them. To manipulate, operating from the underlying belief that people are there simply to be used staff splitting and using humor to control a room (they are just an audience). People become objects and the immature adult operates without empathy.
Pattern 5: The need for social recognition; and limelight. The immature young adult manifests as desperate for recognition; they posture before staff, lie, cheat, and steal in order to be the center of attention, or become the clown and the butt of their own joking, never taken seriously. This need is an act of moving against people because it connotes beating others out for attention.
Pattern 6: The need for self respect; an exaggerated need to be valued can result in an overly inflated ego and a young person who is not in touch with their own limitations and unable to see their own character defects. This pattern forms Narcissism and self-blindness.
Pattern 7: The need for achievement; though virtually all persons wish to make achievements, some are desperate for it. Some are so driven for success, that they sacrifice relationships, health, and sometimes integrity for it. The paradox is that achievement is an elusive line that seems to move just as soon as a goal is met. The success never satisfies.
Attachment styles of Moving away from People:
Pattern 8: The need for self-sufficiency; taken to the extreme, some are independent to the point of becoming "needless and want-less". ISOLATION and LONELINESS ensue, along with an inability to live among others interdependently.
Pattern 9: The need for perfection; while many are driven to do things well, some young adults display an overriding fear of being even slightly flawed. This perfectionism causes "Fear of Shame" to become a driving force in their life, causing them to quit tasks they enjoy if they can't be the BEST.
Pattern 10: The need to contain; some find a need to restrict life to within narrow borders - to live as inconspicuous as possible. The ultimate result of an extreme of this pattern are ANOREXIA and DEPRIVATION. We find young people who have gravitated toward living alone and homeless. They find it difficult to rejoin others in the REHAB community.
In a REHAB environment, a young adult is forced to display every coping skill they have ever engineered. For many, it is the first time they are in close quarters with so many people 24-hours a day. If their tendency is to move toward and enmesh and give away their soul in order to deal with the anxiety, we see it in the friendships they form and as a failure to confront others out of fear of rejection. If the tendency is to move against others to cope, peers will react to them- against postures are offensive and conflicts with ensue.A tendency to move away from others manifests as depression, rage and laziness.
The best REHAB treatment centers are those that know how to manage, not eliminate, the anxiety and insecurity, in fact many activities are designed to increase the anxiety. Activities are planned to strategically intervene on the coping defenses above. As the defenses are exposed and the resident is taught to tolerate anxiety and feelings of inferiority, gradually the immature self begins to grow more confident and merges into a whole and complete self. This new self has character and is capable of navigating the adult world. The alternative is to stay immature, without a confident self, and to medicate with drugs and alcohol or other self-defeating behaviors.
Bonnie A. DenDooven
Bonnie A. DenDooven, MC, LAC is a former business owner-turned-therapist. The author of the MAWASI© for therapy and healing of financial disorders and work disorders. She is a former primary and family counselor and assistant clinical director for Dr. Patrick Carnes at The Meadows. Bonnie was schooled in Gestalt therapy and is a member of Silvan Tomkins Institute of Affect Script Psychology, an advocate of Martin Seligman Positive Psychology, and a champion for the initiative for VIA Classification of Strengths and Virtues (jokingly referred to as the "un-DSM").
Footnote 1: Neurosis and Human Growth: The struggle toward self-realization, 1950
Footnote 2: http://www.chabad.org/blogs/blog_cdo/aid/1073778/jewish/Why-Hasnt-the-Self-Esteem-Movement-Given-Us-Self-Esteem.htm
Parents of young addicts suffer the aftershocks of trauma long after the addict has entered REHAB and begun recovery. The Family Member PTSD Scale © Note1 which assesses family members of drug addicts for SHOCK, ISOLATION, VICTIMIZATION, SHAME, OVER-RESPONSIBILITY, LACK OF HOPE, and GRIEF, as well as for other symptoms of Post-Traumatic Stress Disorder (PTSD) or Complex Post-Traumatic Stress Disorder (C-PTSD), is the first tool to use when starting to work with families of addicts. The scale was designed to determine the degree of trauma and the residual effects that trauma has had on parents and siblings. There are stages of unresolved trauma which must be known before beginning family reconciliation.
Examples of some of the typical SHOCK questions on the scale that parents of addicts endorse include: "I am numb from dealing with the crisis of addiction" or "I am shut down emotionally and do not respond like I used to" or "I have flashbacks of incidents that happened in our family when we were dealing with active addiction" or "When the phone rings late at night, I sometimes still experience startle, fear and vivid memories."
Most families have some form of PTSD. A parent who found their child collapsed in the bed or bath nearly dead from an overdose, who experienced a surge of adrenalin to handle the emergency, and never processed the crisis, is frequently haunted by vivid recollection, and nightmares. The nightmares can last for years. For many parents, the long battle with trying to save their teenager's life has resulted in C-PTSD. C-PTSD was first described in 1992 by Judith Herman in her book Trauma & Recovery. It is a psychological injury that results from protracted exposure to prolonged interpersonal trauma with "loss of feeling in control", "disempowerment", or "feeling trapped," which parents suffer knowing they are responsible for underage children in grave danger. The key difference between PTSD and C-PTSD is the concept of "protracted exposure."
All previous family models for working with addiction have approached the family system from the point of view as if addiction began with adults and was passed down generationally. Today we are seeing a very high percentage of first-generation addicts, and the devastation to relatively normal parents when their children turn to drugs is incomprehensible. We have begun to work with families using a different model from the traditional model of family systems theorists of 20 years ago. Once the addict is admitted to REHAB, an immediate assessment for Post Traumatic Stress (PTS) of parents and siblings of these young addicts is begun. Some form of relief from the PTS symptoms is the most immediate need of family members. For some parents, the admonition to just "start working on your own issues" feels like a slap in the face. When the very first advice parents get from treatment center staff are things like "look at your enabling" or "look at your codependency" or "go find an ALANON group and work on your own stuff", some are offended and further traumatized by the lack of empathy for their current state of SHOCK.
"The most painful thing that we see parents dealing with," says April Lain, M.Ed, L.L.S.A.C, who has facilitated over 360 family workshop sessions integrating young adults back into their family of origin, "is the confusion of being told to disengage and leave the addict on their own - the concept of ALANON of "detach with love" is healthy but can be confusing. Parents are sometimes even made to feel guilty for continuing to seek help for their adult children who are caught in the grip of addiction, when intervention is required." She goes on to say, "I tell these parents not to feel guilty for seeking help. If you saw a stranger standing out on the ledge of a 14-story building about to jump off, wouldn't you at least call 911 and try to save their life? If you would do that for a stranger, why not for your own son or daughter who is standing on the proverbial window ledge and their life is in great danger from drug and alcohol use?" For parents who are in the trenches strategizing interventions, they are still on the battle ground. The adrenalin is still pumping. Lives are at stake.
The PTSD/C-PTSD approach to dealing with families is cutting-edge and compassionate. Without fail, along the way, the family members have suffered severe abuse from the addict. Abuse comes in several forms: Overt, Covert, Stealth, Structured, and Impulsive.
Overt abuse is clear-cut and easily recognizable and easy to describe. Cursing, name-calling, fighting, and verbal threats are overt and obvious. If your beloved son or daughter is standing in your kitchen threatening you with a knife, it is obviously abuse and is easily describable to others. If your teenager is throwing things or kicking holes in doors, you have evident visible damage. If you have bruises, broken lamps and you've started to put locks on your bedroom door out of fear, you are dealing with overt, tangible abuse.
On the other hand, covert abuse by an addict revolves around the addict's need to assert and maintain control over his/her parents or brothers and sisters. Covert abuse may not be visible to others such as to the non-custodial parent in divorced families, or with grandparents or schools and even police or coaches who continue to see the addict as charming. These "outsiders" will say, "Oh, you are making a big deal out of nothing." Or, "They will grow out of it, quit nagging them." Covert abuse is emotional and manipulative. It takes advantage of trust and costs parents their self esteem and confidence. Covert abuse is made all the more painful because others do not see the emotional damage - they only see a seemingly "crazy person" who is dealing with the aftermath of addiction.
Stealth abuse such as gaslighting is a form of abuse where the truth gets denied so often and so convincingly that the parent starts to believe they are going crazy. It is the deliberate use of false information to make others doubt his or her own reality, doubt their own memory, and not trust their own perceptions. (The term gaslighting comes from a 1944 film called "Gaslight" starring Ingrid Bergman. Her charming new husband deliberately attempts to drive her crazy, i.e., gaslighting.) Many parents report a feeling "like I was losing my mind".
Sometimes addicts manifest what is known as a patterned (or structured) abuse. That is someone who abuses everyone around them, not just parents but other children, friends, authority figures. The abuse is predictable- everyone gets a fair share. Other addicts are more unpredictable and impulsive with their abuse - they are nice at times and then they strike "out of the blue" in a flurry of chaos. One never knows when the rage fit will hit.
Bessel van der Kolk, in his "Assessing and Treatment of Complex PTSD" identified depression, lack of self worth, problems with intimacy, inability to experience pleasure, satisfaction, or to have fun, as symptoms of C-PTSD. There are no reliable statistics of the number of marriages that do not survive dealing with a child addict, but it appears it could be as high as 20 percent. It is complicated because other factors might have impacted the marriages. The emotional toll is very high on the family.
Drugs and alcohol have taken a foothold on our younger generations on an epidemic scale. Validating the stress that the families have endured is the first step for starting to work with the family. Helping the family to recognize the PTSD characteristics of their reactions, helping them to heal and finally, helping the addict to feel and show empathy for how the trauma has impacted those who love them- that is the work of a REHAB Family Counselor.
Bonnie A. DenDooven
Bonnie A. DenDooven, MC, LAC, a family workshop therapist at Gatehouse Academy, is a former business owner-turned-therapist. The author of the MAWASI© for therapy and healing of financial disorders and work behaviors. She is a former primary and family counselor and assistant clinical director for Dr. Patrick Carnes at The Meadows. Bonnie was schooled in Gestalt therapy and is a member of Silvan Tomkins Institute of Affect Script Psychology, an advocate of Martin Seligman Positive Psychology, and a champion for the initiative for VIA Classification of Strengths and Virtues (jokingly referred to as the "un-DSM").