Living on the bottom

NMLG-cover300-201x300Debra Jay addresses the belief that families should let an addicted family member hit bottom:

Hitting bottom is an old idea, still imposed upon families as if it were an absolute. Many families sadly believe that they must wait for alcoholics to hit bottom before there is any hope for recovery. They rarely stop to consider that this belief sentences them to years of unhappiness and devastation. No one ever mentions the fact that alcoholics and addicts don’t take the trip to the bottom alone–the family goes with them. Families are never warned that the journey to the bottom takes even the smallest children.

. . .

“Bottoms” can be temporary. Alcoholics resist getting sober even when things are going badly in their lives. They are good at weathering storms. Perhaps they’ll swear off alcohol for a while, but as soon as things cool down, they begin drinking again. The addicted brain can’t make lasting connections between alcohol and the problems it causes. Once the problems go away, alcohol is their best friend again. Addiction is both invisible and sacred to alcoholics: they deny its existence yet sacrifice everything to it.

Addicts don’t want to cause trouble or hurt the people they love. Quite the contrary: they struggle to be the person they think they still are, the person they were before the addiction took hold. They can’t make sense of their own actions. As their addiction progresses and troubles mount, they work harder to manage their lives, but addiction never lets anyone lead a life free of trouble. There are always problems, big and small. Bad behavior, poor decisions and emotional upheaval are all symptoms of this disease that affects both the brain and soul. Families are confused, too. Not understanding what is happening to their loved ones, they mutter: “When will she learn?” But addicts can’t learn because addiction keeps tightening its grip, demanding complete allegiance.

Women, Alcoholism and AA

AA meeting sign
AA meeting sign (Photo credit: Wikipedia)

An interesting new blog has a great post on Women, Alcoholism and AA.

Admitting that I was an alcoholic has had a profound effect on my life. Most of my friends from the old days are not around anymore; they didn’t want to hear about my alcohol problem and some understood it so little that it somehow led to me being characterized as a drama queen. They’ve have been replaced with people who are willing to share all of their experience, strength and hope with me over a coffee.

But perhaps even more interesting than what the WSJ piece had to say about women and drinking is what it had to say about AA. It essentially summarizes AA as a haven for sexual harassment and abuse of women, explaining that the female population of AA is left vulnerable because they’re made to feel further victimized and powerless over their lives. Having spoken to several female members of AA, I have found the exact opposite to be true. The women I spoke to, in fact, found nothing but continued support and understanding through their battles with alcohol from both the male and female members in the program, and took pains to point out how they felt safe and nurtured. As one woman put it, “I find AA no different than any situation in life where males and females socialize. There will always be flirting and attempts at hooking up, but the vast majority of men I have met are very respectful and considerate.”

Seeking Safety + 12 Step Facilitation = good outcomes

The Journal of Substance Abuse Treatmentseeking safety looks at Seeking Safety plus twelve step facilitation. Good news:


The Recovery Management paradigm provides a conceptual framework for the examination of joint impact of a focal treatment and post-treatment service utilization on substance abuse treatment outcomes. We test this framework by examining the interactive effects of a treatment for comorbid PTSD and substance use, Seeking Safety, and post-treatment Twelve-Step Affiliation (TSA) on alcohol and cocaine use.


Data from 353 women in a six-site, randomized controlled effectiveness trial within the NIDA Clinical Trials Network were analyzed under latent class pattern mixture modeling. LCPMM was used to model variation in Seeking Safety by TSA interaction effects on alcohol and cocaine use.


Significant reductions in alcohol use among women in Seeking Safety (compared to health education) were observed; women in the Seeking Safety condition who followed up with TSA had the greatest reductions over time in alcohol use. Reductions in cocaine use over time were also observed but did not differ between treatment conditions nor were there interactions with post-treatment TSA.


Findings advance understanding of the complexities for treatment and continuing recovery processes for women with PTSD and SUDs, and further support the chronic disease model of addiction.


Alcohol’s place in our culture

A Kranz (wreath) of Kölsch beer.
A Kranz (wreath) of Kölsch beer. (Photo credit: Wikipedia)

Following up on yesterday’s post, a few articles jumped out at me.

First, the Michigan legislature is considering lowering the blood alcohol level for boats and other recreational vehicles to 0.08, so that it matches the BAL for driving a car. Sorta makes sense, right? Look at the comments in the Detroit Free Press and the Detroit News. Yikes. Being allowed to drink to the point of impairment and still legally drive a boat is really important to us.

The other thing that caught my attention was another exchange from the interview I linked to yesterday with Kleiman:

Matthews: Roughly how much of the crime problem would you attribute to alcohol, percentage-wise?

Kleiman: Half the people in prison were drinking when they did whatever they did…Of the class of people who go to prison, a lot of them are drunk a lot of the time. So that doesn’t mean that they wouldn’t have done it if they had not been drunk. It’s just that being drunk and committing burglary are both parts of their lifestyle. Still, alcohol shortens time horizons, and people with shorter time horizons are more criminally active because they’re less scared of the punishment. Most people who drive drunk are sensible enough to know when they’re sober that they shouldn’t be driving drunk. It’s only when they’re drunk that they forget they’re not supposed to drive drunk.

We need to keep them from drinking, which is what the 24/7 program does. We could also require everyone to be carded. Maybe you still get carded, but I don’t. But imagine everyone got carded, and if I had a DUI, I had a driving license showing I wasn’t allowed to buy a drink. You’d make the alcohol industry regulate its own customers. And I think you’d cut down on crimes substantially. But if I say that, I’m a nanny state fanatic, and if I say adults should be allowed to smoke a little bit of pot, I’m a crazy drug reformer.

This guarding of alcohol’s place in our culture puts us in some pretty crazy knots, huh?

“look at alcohol!”

Edited copy of Image:The Brewer designed and e...
Edited copy of Image:The Brewer designed and engraved in the Sixteenth. Century by J Amman.png (Photo credit: Wikipedia)

I frequently find myself in discussions about drug policy. I feel strongly that incarcerating people for possession is stupid and wrong, but I’m reluctant to legalize drugs. (I think there are a lot of options in between.) In these discussions, I inevitably hear someone say, “Look at alcohol. It’s way worse and it’s legal!” My response is always, “Exactly. Look at alcohol. It’s a public health and public safety disaster.”

Mark Kleiman points out that higher alcohol taxes would reduce battery, burglary and murder. The problem? The power of the alcohol industry’s lobby. Michigan has been incredibly revenue starved and we haven’t raised the beer tax since 1966. And, the beer tax is a flat tax per barrel, so there haven’t even been any increases in revenues because of inflation.

From a recent Kleiman interview [emphasis min]:

Matthews: No, of course not, single-malt all the way. But how much power do the spirits companies have? It seems like they’d fight any price increase.

Kleiman: Much power. The spirits guys are not really important because they’re not the real market. The real problem is beer. The beer guys are powerful. It’s two thirds of the market. Not only do they have heavy campaign contributions to politicians, because they’re state regulated and thus have a stake in state politics, but customers don’t dislike their beer company, so if they get a political message from the beer company, they’ll respond.

Contrast that with tobacco, with a smaller number of lower status users who hate their providers. The cigarette companies have absolutely no luck mobilizing smokers. Smokers hate tobacco companies. It’s easy to say it’s just a tax on responsible drinking until you do the math. It would cost a typical beer drinker $36 a year. The man who’d get hit is the 10 beer a day drinker, and he’s the guy we want to hit.

Taxation is just about the perfect way to control alcohol use. It’s not complete, because you need controls for the real problem drinkers. But if we tripled the alcohol tax it would reduce homicide by 6 percent. And you’re not putting anybody in jail. But instead we spend our time talking about doing marijuana testing for welfare recipients.

Sentences to ponder

alone by Lst1984
alone by Lst1984

Marc Schuckit discussing findings from a 30-year study of nearly 400 men:

“If you’re an alcoholic, you’re going to have a lot of mood problems,” Schuckit said. “And you may be tempted to say, ‘Well, I drink a lot because I’m depressed.’ You may be right, but it’s even more likely that you’re depressed because you drink heavily.”

2012’s most popular posts #10 – Almost Alcoholic

This article demonstrates a big problem in understanding addiction and the a big problem in the current diagnostic categories.

…when we think about alcohol abuse or alcoholism, our thoughts often go to situations like this where someone is at a stage where they are doing immediate damage to themselves or others, but what about the stage many people go through before getting to full-blown alcoholism? What about the pain and suffering, not to mention health damage, that occurs in this almost alcoholic stage? If we had more awareness of this area on the drinking spectrum, could we prevent situations like this from occurring?

It is estimated that 22 million Americans suffer from an addiction to alcohol or drugs. Helping professionals have long viewed the problem of alcoholism and addiction in absolute terms: either you are addicted, or you are not. The official psychiatric diagnostic category — alcohol dependence — is what is commonly called alcoholism. The alcoholic must drink more or less continuously to maintain a level of alcohol in his or her body. If all the alcohol is metabolized the alcoholic goes into withdrawal and experiences severe, even life-threatening physical symptoms.

What’s the issue?

Let’s start by stating that addiction/alcoholism is the chronic and relapsing form of the problem characterized by loss of control over their use of the substance.

Problems with the current DSM categories include:

  • DSM dependence has often been thought of as interchangeable with addiction/alcoholism, but this is not the case.
    • The current DSM dependence criteria capture people who are not do not have the chronic relapsing form of the problem—many of them will experience spontaneous remission.
    • The current DSM dependence criteria capture people who are not experiencing loss of control of their use of the substance.
  • The word dependence leads to overemphasis on physical dependence which, in the case of a pain patient, may not indicate a problem at all.
  • The word abuse is morally laden.
  • For me, there are serious questions about whether abuse should be considered a disorder at all.

Same kind?

My problem with the spectrum approach is that it frames all AOD problems as one kind of problem that occurs in varying degrees. The problem here is that addiction and non-chronic dependence are different kinds of problems with vast differences in appropriate treatment approaches.

Your cousin Bob who drank way too much in college and got into some trouble but then cut back when he started a family has a problem that is a different kind or type from Aunt Suzie who has multiple treatments, has had the problem for decades and it’s severely impaired her work, family relationships, friends, housing, etc.

The article illustrates my concern with this sentence [emphasis mine]:

Alcohol abuse is the diagnosis used when an individual is not yet physically dependent on alcohol but has nevertheless experienced one or more severe consequences directly attributable to drinking.

What’s the solution?

One option would be to add addiction as a third category to separate the those with the chronic and relapsing form and those with loss of control from the others.

Another option might be to create two spectrums, one for forms of misuse (abuse to non-chronic dependence) and another for addiction (the chronic relapsing form with loss of control).

Keep only 2 categories, but eliminate abuse and add addiction.

I’m sure there are a lot more options. I’m concerned about the spectrum approach, but I fear the train may have already left the station. We’ll see.

Related articles

Motivational Interviewing works, but no better than other treatments

Cochrane conducts a meta-analysis of motivational interviewing (MI) and concludes that it’s no more effective than other treatments.

More than 76 million people worldwide have alcohol problems, and another 15 million have drug problems. Motivational interviewing (MI) is a psychological treatment that aims to help people cut down or stop using drugs and alcohol. The drug abuser and counsellor typically meet between one and four times for about one hour each time. The counsellor expresses that he or she understands how the clients feel about their problem and supports the clients in making their own decisions. He or she does not try to convince the client to change anything, but discusses with the client possible consequences of changing or staying the same. Finally, they discuss the clients’ goals and where they are today relative to these goals. We searched for studies that had included people with alcohol or drug problems and that had divided them by chance into MI or a control group that either received nothing or some other treatment. We included only studies that had checked video or sound recordings of the therapies in order to be certain that what was given really was MI. The results in this review are based on 59 studies. The results show that people who have received MI have reduced their use of substances more than people who have not received any treatment. However, it seems that other active treatments, treatment as usual and being assessed and receiving feedback can be as effective as motivational interviewing. There was not enough data to conclude about the effects of MI on retention in treatment, readiness to change, or repeat convictions.The quality of the research forces us to be careful about our conclusions, and new research may change them.

This is a great example of a major flaw in research. There are so many assumptions in every study. One wrong assumption can lead to bad findings. For example, that motivational interviewing is an especially effective and sufficient intervention to treat alcoholism.

MI is being integrated into treatment for all sorts of medical problems, chronic health problems in particular, where part of treatment is recruiting the patient into participating in a treatment that is known to be effective but often suffers from low rates of patient compliance.

The difference here is that researchers seem to be interested in replacing existing treatments for addiction with MI.

One big problem here is that this inserts the assumption that alcoholism is resolved be increasing motivation to quit or reduce drinking.

I believe that these assumptions may be correct for low severity alcohol problems and that MI may be an effective intervention for these problems.

I also believe that MI is probably a valuable tool for more severe alcohol problems, but, in these cases, its proper use is to get patients to accept and participate in treatments that are known to be effective when patients comply. Twelve step facilitation, for example.

Why is there this push for MI as a replacement treatment rather than a treatment inducement tool? Does this constitute a bias on the part of researchers? I don’t know, but note that I’m not the one tossing out the baby with the bath water. I’m suggesting MI might be very important but that they are just asking the wrong questions. It’s also a little ironic that the push to use MI to replace other treatments actually weakens the case for MI having an important role in treating alcoholism.

Following alcoholics for decades

McLeans has an interesting interview with George Vaillant about, “the surprising things you find out about people if you follow them for long enough.”

What’s so different and interesting about this study is that it followed the subjects for decades from a pretty young age. Their subjects were college sophomores when the study began and their selection was not based on any problems or characteristics. So, they studied them before, during and after their active alcoholism.

Here are a few of the better bits.

On alcoholism and recovery:

Q: What, then, are the great lessons to be drawn from the study?

A: Some of the most important ones involved alcoholism. About 50 per cent of alcoholics recover, but a remarkable percentage of those do so with AA. The fact that this study followed up with these men on 60 different occasions with regard to their alcoholism over a period of 50 years did allow us to identify what made a difference.

You’ll have to read the Natural History of Alcoholism, because he didn’t expound on that in the interview.

On childhood unhappiness and alcoholism:

Q: A lot of long-held theories flew out the window over the decades thanks to your work.

A: One of the simplest examples was the notion that unhappy childhoods cause alcoholism. What a study like this shows is that, first, lots of alcoholics invent an unhappy childhood to justify their drinking. Second: if an alcoholic’s childhood is miserable, it’s because a blood relative has alcoholism. If the unhappy childhood is the result of an alcoholic step-parent, the person doesn’t drink to relieve the misery. So it’s the genetic component of alcoholism that matters.

On alcoholism’s toll (Too bad these lessons need to be re-learned!):

Q: You argue that alcohol abuse is the most ignored causal factor in modern social science. Why?

A: Because it’s much more fun to pay mind to nice people than to angry, passive-aggressive people, and the disease of alcoholism makes people angry and dishonest. If you look at the major books on marriage, alcoholism is mentioned nowhere in the index as a cause of unhappiness. Yet 57 per cent of all the divorces in the Harvard sample occurred when one or other spouse were drinking alcoholically. The alcohol abuse almost always preceded the trouble in the men’s life. Another dramatic example: depression does not lead to alcoholism, whereas alcoholism leads to depression. If you take 100 cases, you can find two or three exceptions, but that’s all. People didn’t really know that before the Grant study.

[hat tip: Jeff Jay]