alcohol abuse


I attended a lecture today about addiction where the lecturer claimed that the American Medical Association requires that a phenomenon meet the following criteria to be considered a disease:

1) It must be progressive

2) It must manifest identifiable symptoms

3) It must occur chronically in affected individuals

4) It must be fatal if left untreated

That makes some things obvious diseases. Cancers, for example. There are many things that we consider diseases that do not fit these criteria, though. I believe that obesity, for example, is not officially considered a disease because it is not fatal. It’s correlated with many fatal conditions but isn’t fatal on its own. Most mental disorders fail to meet this criteria too. Anorexia is fatal if untreated, but anxiety disorders, dissociative disorders, ADHD, learning disorders, conduct disorders, psychotic disorders, and dissociative disorders and many others are not. There is a pretty good case to make for  alcoholism and some other addictions meeting these criteria. Disorders that are associated with suicidality, too, might qualify, like severe depression, and possibly “gender identity disorder,” though GID may not be progressive and so fail the first criteria.

I just went to my first Alcoholics Anonymous meeting. It was the closest one I could find using a Google search–a few blocks from my house, maybe a four minute ride, in a house that I’ve passed hundreds of times. I didn’t expect that. I probably would have guessed that there were something like five or ten AA meetings in all of Eugene and Springfield, but when I searched “Eugene 12-step meetings” I immediately had a list of one hundred and seventy-eight meetings within 15 miles of my zip code. One hundred and thirty-four of those were AA, most of the rest were Narcotics Anonymous, and some were Gamblers (4) and Overeaters (10) Anonymous. They happen every day of the week, from early in the morning until late at night. This movement is huge. No one knows exactly how big because there is no registry, no dues, and the meetings are self-organized, but there were 10 people at my meeting, and this was Halloween night. If 10 is average, that’s something like 1,800 attendees per week, though there is certainly lots of overlap–people attending multiple meetings. Still, that’s a lot of people sitting in a lot of meetings, and that’s in an area with a population of about 200,000.

It was interesting to be so outside of my normal social bubble. I was nervous to go, and nervous when I got there, but everyone was super nice. There were 6 boomers, 2 X-ers (including me), and 2 millenials. I guessed a few were middle class and the rest working class. I’ve been working class my whole life, but these days my social circle is mostly upper-middle, with thin skin and clean hands. My eyes were drawn to the “mechanic hands,” with grease practically tattooed into the grooves of the fingers, and the rough, thick faces of hard lives. We sat in a circle, introduced ourselves, and started reading from Alcoholics Anonymous, the Bible of AA. We each read a paragraph and then passed to the next person. About half of us had what sounded like a grade-school reading level, another reminder of the thin slice of society I live in, so highly educated.

The story was about a rich alcoholic, who failed to get sober in the US and went to Carl Jung in Europe, who also failed to cure him. Apparently, after some effort, Jung told him something like “I have never had any success helping your type of drunk. Sometimes a spontaneous spiritual epiphany can do the trick, and I have been trying to produce that in you, but have failed. You are a hopeless case.”

The format was that anytime anyone felt moved to speak, they would pipe up: “I’m so-and-so, and I’m an alcoholic” and then tell their story or make their comment on the reading. I found it moving to hear their stories and even just to cop to being alcoholics. There was clearly power behind that ability to admit powerlessness. One woman shared about how her life before sobriety was “insanity,” not only in that she was constantly miserable to the point that she felt like her life was “hell,” but in that “What I thought or what I decided about drinking had no impact on whether I drank that day.”

A lot of the readings for my Modern Issues in Addiction class are critiques of the 12-step model, the “disease model,” of addiction. The in-vogue model in post-modern circles like my Couples and Family Therapy program is the “harm-reduction model,” which is secular, so it requires no spiritual epiphany to reorganize the addict’s behavior, and is not aiming at abstinence, but at reducing the damage done by the addiction. One reason harm-reduction is appealing is that you are allowed to count positive outcomes that fall short of abstinence; isn’t it a victory if someone who used to get drunk every night now gets drunk just 3 nights a week? Yes, I think so. Another reason harm-reduction is appealing is that God, even as vaguely defined as it is, is such a dicey topic, hard to manualize for therapy, hard to justify getting behind for us multiculturalists, not wanting to offend the atheists or the theists who have another word for God. The AA God has a male pronoun, for God’s sake. So unhip. It’s hard for us to get behind a program that is not for everyone.

The critiques of the 12-step model have all been theoretical critiques of theory–a form which is quickly becoming my least favorite form of writing. If you have a theory you want to critique, please use data to do so. Please build your counter-theory on data. That would be lovely. The trouble is, the data does not contradict the 12-step model. The summaries of evidence I’ve read (which were written by the critique-ers) basically say that 12-step programs work at least as well as harm-reduction programs, however you measure outcomes, and they work significantly better for addicts who are religious.

The God part of the program was clearly a key part for the folks in my meeting. Two men told harrowing stories about their pre-sobriety days that focused on their denial of their problem. They would go to meetings but they didn’t really “get it” and things got worse and worse. Both described turning-point moments that turned on a prayer. One night, one said in anguish simply, “God, help!” The other said, “Oh, God, I will do anything.” And suddenly they knew that they had a real problem, and that they were personally powerless against it.

I have a difficult time relating to the concept of a second-person God–it’s hard for me to believe anything I can’t directly experience–but I think there is something real and useful going on here. It reminds me of what it’s like to sit in Vipassana meditation. I sit and systematically observe the sensations in my body. It seems as if I have some control over what part of my body I’m focusing on, but I don’t seem to have any control over what sensations I experience in that part of my body. I look and feel what is there, and what is there is given. I am learning to relinquish control over the things that I cannot control. I am practicing not reacting against what is given. And really, how I react is also mostly not in my control, also part of what is given, so I sit with the intention of allowing reality to happen and watch. Suffering is part of the reaction. If I have pain in my body and I react against it, that is suffering. If I have pain and I don’t react against it, that is just pain, which is radically different. And the difference between reacting and not reacting, I think, is grace. It’s my willingness to sit and pay attention, and grace. This is not so different from an alcoholic turning their life over to God. It’s like the serenity prayer, which we said:

God, grant me the serenity
To accept the things I cannot change;
Courage to change the things I can;
And wisdom to know the difference.

When we went around the circle introducing ourselves, each person (just like in the movies) said their first name and that they were an alcoholic. When it came to me I said “Hi, I’m Nathen, and I’m new here.” I was a little nervous about it, but they seemed to like that fine and said “Hi, Nathen!” with just as much enthusiasm as they did for the others.

I’m not an alcoholic. I don’t like alcohol. The first swallow can be pretty interesting, especially if it’s expensive stuff, but after that it starts tasting like something you would scrub your sink out with. I think I inherited that from my mom’s side of the family. That’s how you can tell the Pikes from the in-laws at a family reunion: The in-laws are drinking, the Pikes are not.

I can relate to compulsive behavior, though, mostly around food. And when I say food, I mostly mean sugar. (I seriously considered going to an Overeaters Anonymous meeting for this project instead of AA. I think that I didn’t because I (unfairly, I’m sure) imagined the real food addicts staring at me, maybe hating me in my effortlessly thin body.) At times, I can relate to the woman who said it didn’t matter what she thought or decided about drinking. I can make what feels like a very serious decision not to eat any more cookies today, for example, and then find myself rationalizing my way back to the package. Or ice cream, chocolate, pretty much anything sweet. I can remember sitting, my stomach already feeling kind of bad, looking at a half-eaten bag of chocolate chips, and realizing that I was going to finish those chips. It didn’t matter that I would feel terrible. It didn’t matter that I would have trouble getting to sleep. They weren’t even tasting that good anymore. But I was going to eat them all. I find that disturbing. I think of myself as the kind of person who can and does make decisions and follow through, all the way. That is the kind of behavior psychologists call “ego-dystonic,” or counter to the conception of the self.

So I had my moment of feeling like I was in the right place. It was Halloween night, and they had a big container of candy on a table in the middle of the circle and said, “Help yourself!” It was all crap, in the sense of my intention for this year, “Do not eat crap.” I saw that immediately. I was not hungry, but I wanted some candy. I thought, “I should probably eat a piece or two of that candy to take part in the culture of this group.” I took and ate two Reese’s Peanut Butter Cups–probably my favorite of the crap-class candy–during the meeting. I’m certain no one would have noticed if I hadn’t. My rationalization was just my rationalization. I felt a little guilty for breaking my intention and I noticed my attention going back to the candy throughout the meeting. It was easy not to eat any more, but that may have been because there were no more Reese’s Peanut Butter Cups visible. I would have had to dig noisily through the container while others were reading or sharing.

But while I did have that experience, I don’t mean to make light of the experience of the people at that meeting, or of actual food addicts. I am not a food addict. I have some usually-mild compulsive behavior around food, but not to the point that I’ve ever done anyone wrong or maintained an unhealthy lifestyle. These folks were dealing with something on a whole other level of suffering and trouble. And they seemed to be doing admirably. One man described how when he started craving alcohol, he knew it was time to “reach out”–go to more meetings, call for support, be with good people. As with the others’ sharing, I was moved by his sincerity, conviction, and wisdom.

After an hour of talking, we stood, held hands, and closed with the Lord’s Prayer. I did not expect to be moved by it, but their delivery of the about temptation and evil had such feeling and meaning after hearing their stories:

Our Father who art in heaven,
hallowed be thy name.
Thy kingdom come.
Thy will be done
on earth as it is in heaven.
Give us this day our daily bread,
and forgive us our trespasses,
as we forgive those who trespass against us,
and lead us not into temptation,
but deliver us from evil.
For thine is the kingdom,
the power and the glory,
for ever and ever.
Amen.

I’m taking a class called Contemporary Issues in Addiction. One of the things we’re learning about is how different clinicians think about addiction. Here are the official diagnostic criteria for substance abuse and dependence, word-for-word from the DSM-IV-TR:

Criteria for Substance Abuse

A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

(1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

(2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

(3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)

(4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)

B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

Criteria for Substance Dependence

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

(1) tolerance, as defined by either of the following:

(a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect

(b) markedly diminished effect with continued use of the same amount of the substance

(2) withdrawal, as manifested by either of the following:

(a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)

(b) the same (or a closely related substance is taken to relieve or avoid withdrawal symptoms

(3) the substance is often taken in larger amounts or over a longer period than was intended

(4) there is a persistent desire or unsuccessful efforts to cut down or control substance use

(5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects

(6) important social, occupational, or recreational activities are given up or reduced because of substance use

(7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

Specify if:

With Physiological Dependence: evidence of tolerance of withdrawal (i.e., either Item 1 or 2 is present)

Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 1 nor 2 is present)

Course specifiers (see text [below] for definitions)

Early Full Remission

Early Partial Remission

Sustained Full Remission

Sustained Partial Remission

On Agonist Therapy

In a Controlled Environment

Here are those definitions, from pp. 196-7:

Early Full Remission. This specifier is used it, for at least 1 month, but for less than 12 months, no criteria for Dependence or Abuse have been met.

Early Partial Remission. This specifier is used it, for at least 1 month, but less than 12 months, one or more criteria for Dependence or Abuse have been met (but the full criteria for Dependence have not been met).

Sustained Full Remission. This specifier is used if none of the criteria for Dependence of Abuse have been met at any time during a period of 12 months or longer.

Sustained Partial Remission. This specifier is used if full criteria for Dependence have not been met for a period of 12 months or longer; however, one or more criteria for Dependence or Abuse have been met.

On Agonist Therapy. This specifier is used if the individual is on a prescribed agonist medication such as methadone and no criteria for Dependence or Abuse have been met for that class of medication for at least the past month (except tolerance to, or withdrawal from, the agonist). This category also applies to those being treated for Dependence using a partial agonist or an agonist/antagonist.

In a Controlled Environment. This specifier is used if the individual is in an environment where access to alcohol and controlled substances is restricted, and no criteria for Dependence or Abuse have been met for at least the past month. Examples of these environments are closely supervised and substance-free jails, therapeutic communities, or locked hospital units.

Most parenting psychology literature talks about four parenting styles, derived from the combinations of two parenting qualities, warmth (also called “responsiveness”) and demandingness, like this:

Parenting Style Warmth Demandingness
Authoritative High High
Authoritarian Low High
Permissive High Low
Neglectful Low Low

Parents who are both warm and demanding (having high standards) are called “authoritative” and considered in psychology to be the best parents. Parents who are both not warm and have low standards are called “neglectful” and considered to be the worst parents. Authoritarian parents and permissive parents (also called “indulgent”) come out in the middle somewhere, the first lacking warmth, the second lacking standards.

The table of parenting styles below is from Rodriguez, Donovick, and Crowley’s 2009 article, “Parenting Styles in a Cultural Context: Observations of ‘Protective Parenting’ in First-Generation Latinos.” In their work with Latino parents, they decided to add a third category, autonomy granting, giving us four new parenting styles: protective, cold, affiliative, and a new kind of neglectful. I’m still thinking about this, but it seems like it could be a breakthrough in parenting theory.

It will be interesting to see if this idea is meaningful in terms of outcomes for the kids of these different kinds of parents. There is evidence, for example, that the kids of authoritarian parents have a lot more trouble with alcohol abuse than those of authoritative, and kids of permissive parents have even more trouble than that. Will there be a significant difference on this outcome between authoritarian and “cold” parents, who differ only in their giving their kids the chance to mess up or not? How about between permissive and “affiliative”?

Parenting Style Warmth Demandingness Autonomy Granting
Authoritative High High High
Authoritarian Low High Low
Permissive High Low High
Neglectful Low Low Low
Protective High High Low
Cold Low High High
Affiliative High Low Low
Neglectful II Low Low High

I just read in Brock & Barnard’s Procedures in Marriage and Family Therapy about Wolin and colleagues’ research into rituals in alcoholic families. Apparently, the negative effects of an alcoholic parent were predicted better by the amount that family rituals were disrupted by the alcoholism than by the presence of alcoholism itself. For example, if the family continued to eat dinner together every night, continued with their bedtime rituals, etc, children remained about as well off as those in non-alcoholic households. But if the family rituals were destroyed, the children were much worse off, including much more likely to become alcoholic or marry an alcoholic themselves.

I haven’t read any of the original research, so I don’t know for sure if it is that these rituals actually provide resiliency or if the presence or lack of rituals served as a proxy measure for how bad the alcoholism was. It could also be a combination of the two. It does look like the family therapy literature considers that rituals promote resiliency in general, providing structure and comforting predictability for kids, and resulting in better outcomes. (I doubt they are bad for the adults, either.)  Something to think about, parents!

I listened to a story on NPR a couple days ago about a how high divorce rates and teen-pregnancy rates are correlated to the state’s political ideology. Republican states have significantly more divorce and teen pregnancy. In fact, as a whole, the US divorce rate has been holding steady since the mid-90s, while the “red state” divorce rates (and teen-pregnancy rates) continue to rise. That means the blue states make up the difference and their rates are falling. NPR speculated that it’s because in family-values states, people get married earlier because of social pressure or so they can have sex, but choose badly because they don’t know themselves as well as they would several years later, when Democrats tend to get married. They also note that states that are swinging Democratic, like New Hampshire, are starting to have less divorce and teen pregnancy too.

It makes some sense, though I wouldn’t have guessed it. There are a couple of things not made explicit in the story that I wonder about. First, I wonder if the Republican fixation on “family values” issues is being driven by this phenomenon; to someone living in a Republican state, divorce and teen pregnancy are really pressing issues, because their ideology and behavior are not matching up. It could even be a vicious cycle: Values driving divorce driving values…. Second, I wonder how much of this has to do with money. Social class, really. Red states tend to be poorer, and poverty puts serious stress on a marriage. And poverty is correlated with a lot of other stressors, like substance abuse, domestic violence, and child abuse. Also, they mention that the demographic whose divorce rates are dropping the most are women who have graduated from college. I’ve been attending a state university for a few years now, and I can tell you that it’s not full of poor people. These kids (‘ parents) have money.

I’m learning about child abuse and neglect in my Child and Family Assessment class. Today I read about the ACE study, by the US Center for Disease Control. It is a huge study, with over 17,000 participants, where they gathered information about childhood abuse, neglect, and household dysfunction, and then proceeded to see what health outcomes and behaviors they could predict with that information. It turns out they can predict a lot. They’ve published 50 articles on the study and the research is ongoing–they are continuing to collect health information as the participants in the study age. I’ll present a few of their findings below. For more, see the ACE Study.

Here are some of their findings. I’ll paste in the definitions of the categories of adverse childhood experiences below. Strong correlations were found with the following:

  • alcoholism and alcohol abuse (4 or more categories of ACE meant 4-12 times increase)
  • chronic obstructive pulmonary disease (that is, lung disease)
  • depression (4 or more categories of ACE meant 4-12 times increase)
  • fetal death
  • health-related quality of life (way more inactivity, severe obesity, bone fractures)
  • illicit drug use
  • ischemic heart disease (IHD)
  • liver disease
  • risk for intimate partner violence
  • multiple sexual partners (4 or more categories of ACE correlated with 50 or more sexual partners)
  • sexually transmitted diseases (STDs) (4 or more categories of ACE meant 4-12 times increase)
  • smoking
  • suicide attempts (4 or more categories of ACE meant 4-12 times increase)
  • unintended pregnancies

Here are the kinds of abuse, neglect, and dysfunction they asked about, quoted from the site:

Abuse

Emotional Abuse:
Often or very often a parent or other adult in the household swore at you, insulted you, or put you down and/or sometimes, often or very often acted in a way that made you think that you might be physically hurt.

Physical Abuse:
Sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at you and/or ever hit so hard that you had marks or were injured.

Sexual Abuse:
An adult or person at least 5 years older ever touched or fondled you in a sexual way, and/or had you touch their body in a sexual way, and/or attempted oral, anal, or vaginal intercourse with you and/or actually had oral, anal, or vaginal intercourse with you.

Neglect

Emotional Neglect1

Respondents were asked whether their family made them feel special, loved, and if their family was a source of strength, support, and protection. Emotional neglect was defined using scale scores that represent moderate to extreme exposure on the Emotional Neglect subscale of the Childhood Trauma Questionnaire (CTQ) short form.

Physical Neglect1

Respondents were asked whether there was enough to eat, if their parents drinking interfered with their care, if they ever wore dirty clothes, and if there was someone to take them to the doctor. Physical neglect was defined using scale scores that represent moderate to extreme exposure on the Physical Neglect subscale of the Childhood Trauma Questionnaire (CTQ) short form constituted physical neglect.

Household Dysfunction

Mother Treated Violently:
Your mother or stepmother was sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at her and/or sometimes often, or very often kicked, bitten, hit with a fist, or hit with something hard, and/or ever repeatedly hit over at least a few minutes and/or ever threatened or hurt by a knife or gun.

Household Substance Abuse:
Lived with anyone who was a problem drinker or alcoholic and/or lived with anyone who used street drugs.

Household Mental Illness:
A household member was depressed or mentally ill and/or a household member attempted suicide.

Parental Separation or Divorce:
Parents were ever separated or divorced.

Incarcerated Household Member:
A household member went to prison.

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