© On Good Authority, Inc.

ADDICTIONS A

Interview #1: “UNDERSTANDING PERVERSIONS”

ARNOLD GOLDBERG, M.D.

Interviewed by Barbara Alexander, LCSW, BCD

(Edited slightly for readability)

ARNOLD GOLDBERG, MD 122 S. Michigan #1305B Chicago, IL. 60603-6107 (312) 922-6796

Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are reading or listening to an interview from CD #1 in our program, ―Addictions A.‖

This program is devoted exclusively to the topic of addictions, and here we cover a range of addictions. More importantly, though, we highlight a variety of models of understanding and treating addictions, ranging from the original Twelve Step model, which is in fact, cognitive behavioral, to systemic family therapy, to developmental, to self-psychology, to traditional psychoanalytic.

It is important, I think, which such an intractable foe as addictions, to have an arsenal of approaches available within one‘s own repertoire of thinking, so that you, as counselor or therapist, are better equipped to do battle.

We begin in this first CD with return interviews to two popular On Good Authority speakers: first, Dr. Arnold Goldberg discusses his recent book

1 and work on the topic of perversions. We present his interview first because Dr. Goldberg‘s explanation of splitting is so crucial to the understanding of addictions.

Then we will hear from Mary Rich, who views gambling from a developmental perspective. Getting addicted patients engaged in therapy is a serious problem and major challenge, not for the thin-skinned. Dr. Rich will explain why so many addicts cannot attach and she shares some innovative suggestions with us.

Now to our interviews.

Dr. Arnold Goldberg is a Professor of Psychiatry at Rush Medical College in Chicago, and is a training and supervising analyst at the Institute for Psychoanalysis in Chicago. He is well known as one of the leading exponents on self psychology and is the author of many books and articles on the subject.

Today we will be discussing his book, The Problem of Perversion, The View from Self Psychology.

ALEXANDER: Dr. Goldberg, we are back again talking with you. Our first interview was on self psychology and now we are going to talk about your new book on perversions. Before we really get into the topic of perversions, I want to ask you if you have an opinion as to whether perversions are really addictions, or are they compulsive behaviors? How do you view them?

GOLDBERG: I think that it is very important to recognize that addictions should not be thought of as addictions to substances like heroin, cocaine, alcohol, etc, but that there is a wide variety of behaviors that one becomes addicted to. For instance, one can become addicted to therapy. We have many patients who are endless patients, sometimes from one therapist to another, because they are addicted to the process of therapy. So, we have to get a meaning for addiction that goes beyond the overt behavior and see what underlies the nature of addiction to something or someone.

2 ALEXANDER: Is there a physical component -- I mean obviously there is a physical component in perversions, but is there anything that would be physically addicting in perversions, much as there is in the substances?

GOLDBERG: That‘s a mystery. I think that the biological substrate to, let's say, sexual perversions is unknown. From the studies that I know about sexual perversions, it's not very clear as to whether one is more prone to one kind of behavior or another kind of behavior. What seems much more significant is that sometimes, one who gets involved in sexual perversions just happens upon a particular kind of activity that seems to work for them: shoe fetishes, some cross- dressers and some exhibitionists, etc, etc. It is not clear at this point that we could give anything like a biological basis.

However, it is clear that sexual perversions do give two kinds of physical relief. There is the physical pleasure of these sexual perversions. If one ejaculates or has some kind of orgasm, then that is one component of the perverse activity and there are some investigators who feel that people who have perversions have an exquisite kind of sexual pleasure that is different from the kind of sexual pleasure that homosexuals and heterosexuals normally have— they feel that that there is something special about the sexual pleasure of perversions. I, myself, have never met or seen or treated anyone with that particular emphasis on, ―the pleasure I have is like no other pleasure.‖ I know other investigators like, Otto Kernberg insist that this is true. It may be so, I've never seen that.

The second component, other than the physical pleasure of sexuality, and the one that I am the most familiar with, is that the perversion, for the most part, makes a person feel more relieved and relaxed, and usually follows a period of anxiety or depression. So, in that sense, the perversion, like an addiction -- something that they have to do -- is relieving and it makes them feel more comfortable and better. Therefore, it is an answer to some kind of more severe underlying pathology.

ALEXANDER: Well, then, Dr. Goldberg, can you give our listeners an outline or an overview on how you conceptualize perversions?

3 GOLDBERG: Yes, I think that the ideas about perversions, for many years, have been based on some kind of psychodynamic formulation, that people with perversions had a particular kind of mother or father or relationship in childhood, etc. I have always felt that this is not a sufficient enough answer to understanding perverse activities since many people with similar dynamics do not have perversions and many people with perversions never seem to have the same dynamics. So, I have always felt that psychodynamics was unsatisfactory and just a partial answer to understanding why people acted with this particular kind of behavior disorder.

When we began to study perversions in intensive psychotherapy or in psychoanalysis, we found one other salient characteristic of people who were involved in perverse activity, that is that they had what self- psychologists from Heinz Kohut on have called, ―a vertical split.‖ What this means is that most people who have a perversion, let's say like an exhibitionist perversion, will act on the perversion, and afterwards, often speak about what they did after as if it were another person doing it. They seem to disown or disavow that aspect of themselves that engages in the perverse activity. The split, therefore, is as if another person with different goals, values and ideals is living alongside of this person who otherwise has disdain, contempt and disgust for the perverse activity. The classical upright businessman or executive who periodically goes into a pornographic bookstore or who picks up a young boy to engage in perverse activities and then afterwards, expresses shame and disgust at his behavior represents the classical picture of the vertical split. On the one hand, ―I am a perfectly responsible citizen,‖ on the other hand, ―I do these disgusting horrible things and I feel terrible about them afterwards.‖

ALEXANDER: The question that I have about splitting is this: when the person is engaged in the perverse behavior, what happens to the part of them that feels shame and disgust?

GOLDBERG: Well, we often ask the person that in treatment, and they will give various forms of the same answer, which is that the perverse activity dominates the scene. It overwhelms, and the other part of the personality, which we call, ―the reality ego,‖ or ―the reality self‖ is momentarily obliterated, absent, or quiet. That is, indeed, what is so characteristic of addictions: that they dominate the personality, they

4 take over and they run the show. We have many alcoholics who will, after a binge, say that they feel disgusted, ashamed, and convince and resigned to never repeating the activity. That is what is so beautiful about it -- that they can look upon what they have done with the same kind of negative feeling that you could look upon it. ―How could I have done that? I'll never do that again. I feel so ashamed, embarrassed etc.‖ So, that's why we say it's like two persons.

This is not like multiple personalities. Here the split is between two individuals who are seeking two different things: the one is the upright citizen; and the other is much more involved – ―I must get involved in this activity.‖

So that was the second salient characteristic of these people: that they had a vertical split and that what they did seemed to be disowned or disdained by them as it occurred, sometimes periodically, sometimes very frequently, often times, quite rarely. There are some people with addictions and perversions who only occasionally get involved in this kind of behavior, and then will look on it like, ―Oh I don't know what was going on and what happened to me.‖

The next feature after the vertical split and after the particular psychodynamics of the individuals that we saw in perversions, and this gets back, I think, to the question of the physical and the biology. The nature of what people with perversions, as opposed to people with substance abuse, do to make themselves feel better has to do with sexualizing. They get involved in some kind of sexual activity.

Sexual activity is such a great answer to being upset because these people have learned at an early age that if they do something sexual that will obliterate whatever negative feelings they had. So the sequence goes something like this: something occurs that makes one feel depressed, or anxious, or on the verge of fragmentation (as the self-psychologists talk about: some kind of narcissistic injury leads one to fragment). As one is starting to feel more and more anxious, depressed or fragmented, some kind of emergency measure is called forth, a learned emergency measure which will, in one fell swoop, obliterate the depression and the anxiety and sexualization is a great answer, great answer, I mean, only that it is very effective.

5 You know, people have a variety of ways to handle their depression and anxiety. Some people go jogging, some people drink, some people get into arguments with their husband or wife, but people who have perversions usually resort to their sexual behavior. The sexual behavior obliterates the anxiety and depression and also makes them feel somewhat better.

What we seem to see is that what the sexual behavior does, like what a substance will do, is make them feel whole again, make them feel connected, make them feel alive, and make them feel some component of pleasure. So, it is a wonderful answer to feeling bad. Sometimes, you will see a patient who says that at the slightest hint of depression or anxiety -- and this is what makes it such an addictive behavior -- they will resort to some sexual activity: exhibitionism; a whole variety of sexual activities. Momentarily, they will fell better and then afterwards, they may or may not feel bad about what they did.

ALEXANDER: On the topic of sexualization, how does it come about that an inanimate object like a shoe, or doing something that is hurtful to somebody else, let‘s say a child, can give sexual stimulation? That‘s the key question, isn‘t it?

GOLDBERG: Well, the key question, of course, is why do they pick what to do that they do? But, I think that there is something implicit in your question, which is, ―Why do they do what they do in terms of other people?‖ I think when you think about the activity as being mainly self-healing, you must recognize that they do not have that much consideration or empathy for the other person. The other person is but a part of the process of making themselves feel whole and together again.

So, many times they will engage in sexual activity that has no concern for the other person. The Marquis de Sade used to write about what he did and insist that people did not, at any time, feel for the other person, or think of the other person. He had a philosophy about not feeling for other people. So, during the moment of sexualization, these people are relatively without empathy. They are mainly involved in a self-healing process.

6 We have cases of sexual behavior where that behavior insists on anonymity. There is a location in this particular city where group homosexual activity takes place, usually in the summer time in the park, where no one ever knows the identity of the other person. It is kind of blind, massive, or oral felatio. It is very interesting in that they appreciate and want this much more than having a relationship with the person because, ―It is not my concern about that other person or the other person‘s feelings‖ Rather, it is, ―I must get myself feeling better,‖ and therefore the anonymity helps.

A lot of the sexualizations, whatever the particular dynamics are, are much better seen as desperate attempts to regain some kind of sense of self cohesion, not as efforts to hurt the other person or have any relationship to the other person. The other person doesn't count. Sexualizations, like addictions, are efforts for self-regulation and somehow to get the self to feel better again.

ALEXANDER: Let‘s talk about how we look at perversions socially. I think that attitudes have changed over the years, certainly with regard to homosexuality, which was, say 20 or 30 years ago, viewed as most definitely a perversion and now it seems to be viewed as some variation of normal. So...

GOLDBERG: Well, I think that that is a good lead-in to the fact that we should not think of perversions in a social sense. We need a much more psychological explanation of perversions, so that, any given activity, at any time could be, or could not be a perversion. One could be engaged in heterosexual activity that looks like on the surface as ―normal sexual behavior,‖ but really is perverse in the sense that it is not so much aimed as a sharing or mutuality of a relationship, but is much more involved with a desperate self-healing process. Rather, people who come to be considered as having sexual perversions have to be examined in a psychoanalytic and psychodynamic sense: what is this sexual activity doing for them and how is it experienced by them?

One could never, never say that all homosexuality is a perversion, but there must be some room for some homosexuality being a perversion, just as some heterosexuality is a perversion. So, when we see, is this behavior involved with a split, is this behavior involved with some

7 particular kind of psychodynamic story and is this behavior involved in a desperate sexualization for self-healing, then it can be classified as a perversion.

Now society changes all the time, and certain things that may be considered perverse in certain cultures and certain subcultures are not considered perverse elsewhere. Cross-dressing is an interesting example of people who have carved out a particular subculture of acceptance. There are cross-dressing clubs, magazines, networks, etc. and many people say that they are very comfortable with cross- dressing. They are happy with cross-dressing. They have solved their problems with cross-dressing.

However, occasionally one will see a very unhappy cross-dresser, for whom the cross-dressing clearly serves for this periodic, erratic, solution to self- fragmentation and self-dysregulation. Perhaps all cross-dressers at one time experienced this kind of fragmentation, found a way to heal themselves, and live happily ever after doing that.

That is why many, many cases of sexual perversions will never present themselves for treatment if they can find a subculture that supports them. On the other hand, many, many cases of perversions, no matter what the subculture says, as long as the activity is a desperate attempt to heal themselves -- and many times an attempt that is not very long lasting or very successful -- these are the people that come for treatment.

I think that one can never use society's portrayal of what is correct, right or wrong in terms of asking, ―Is this pathology?‖ As psychologists, we must have a psychological evaluation of the behavior rather than a social one. In fact, if you talk to most people who have one or another kind of sexual perversion, you will quickly be able to pick up how they feel about it. If this becomes the clue to our having a successful diagnosis of perversion, if someone comes in to you and says that they periodically cross-dress or they periodically get involved with pornography and masturbation, or they periodically get involved with exhibitionism, the important thing is how do they feel about what they do? Does what we call, ―the reality ego,‖ look upon the activity with disgust, disdain and contempt, or is the reality ego perfectly comfortable with what they are doing?

8

Now, besides the rationalizations that people make, there are, no doubt, many people who engage in periodic sexual perversions, just like any addiction and they say, ―I'm very happy with what I do; I don't want to change.‖ Of course, those people do not come to your office or consulting room. They are not going to be treated, although many times, it comes up late in the treatment, and with great reluctance, they admit some kind of sexual perversion.

But, if someone comes in and says that, ―I do this periodically and I hate it, and I can't stand it and I feel terrible about it,‖ then the reality ego, obviously, is saying, ―This is a part of me that I dislike.‖ That is the absolutely necessary, essential ingredient for any kind of treatment. You need, somewhere, somehow, for that person to feel, ―What I am doing is a part of me that I dislike.‖ Only with that opening is treatment possible.

ALEXANDER: What about the people who are referred by the courts, let's say the pedophiles? Is there any hope of treatment for them if they don't come themselves as viewing it as a problem?

GOLDBERG: I think that that is one of the most interesting areas for future investigation and research. There is a group of pedophiles that are being treated in the church in a particular setting in the United States. In my conversations with the people who treat them, they say that they are incredibly successful in the treatment because most of them, after a bit, do confess their intense shame and disgust at what they have done.

Now, one of the reasons that we consider perversions addictions, is that in trying to treat addictions you have to get the person to the point of saying, ―I want to stop doing this. I want to give up the drug or the substance or whatever.‖ Otherwise, the groups do not work. They have to have reached a point of desperation. Many times, with many of these perversions, we find that they feel awful about what they do, but they cannot control it, handle it, or they rationalize it in a million different ways.

But, there are a whole bunch of perversions that are quite acceptable, that work quite well in society, that people don't have that much

9 contempt or disdain about and they are the most difficult to treat. Every shoe fetish that I have ever seen, at least in my experience, has not been treatable because, let‘s face it, is such an absolutely safe and agreeable way of handling one‘s upsets. You know, you go to the closet and you put on shoes, or you look at shoes, you masturbate and you feel better. So, it just works very successfully, as opposed to something like stalking, or being involved with animals, etc., which usually has a much higher level of shame and depression following it.

So, this becomes a very important ingredient: how do they feel about what they have done? It runs the gamut of, ―It doesn't bother me at all,‖ to, ―I feel terrible about it,‖ and many, many of these people who say, ―It does not bother me at all,‖ after a while, especially with pedophiles will say, ―I feel terrible about it, but I never thought that I could do anything about it, therefore I have rationalized it all over the place.‖ That is why many, many cross-dressers will say, ―It doesn't bother me at all‖ because they have found a subculture that supports it. But, certainly, the clue to the treatment has to be what we call, ―The ego dystonic‖ attitude of the reality aspect, the reality ego, toward the particular kind of behavior that they are involved in.

With the group treatment programs, the 12-step programs that AA and all the addiction control efforts model themselves after, the same can be said of perversions as one form of addiction. Sometimes in the group setting, one can get a certain acceptance of what they have done to the point that they can start to talk about how much they feel negatively toward it.

Sometimes it takes a great deal of time. We have had a lot of cases of perversion that don't surface in treatment until many, many months into the treatment, where the patient feels comfortable enough to usually come out with some confession that they are an exhibitionist. The most common perversion, I think, that exists by far in our society is pornography and masturbation, where they can quietly either watch a video or read a magazine and masturbate and calm themselves and make themselves felt better after whatever days agitation may exist.

Now, this of course, gets us into the whole area of how and when can you treat these people. We have to recognize that with almost all of the addictions, there is a great emphasis on psychopharmacological

10 intervention from Antabuse for alcohol to Depo-Provera for pedophiles, etc, etc. This emphasis on some kind of psychopharmacological or biological interdiction has dominated the psychotherapeutic scene for many, many, many years because psychotherapists have pretty much thrown up their hands as to what to do. That is why chemical castration for pedophiles, or Antabuse, or sometimes lithium for alcoholics works with the point being that they must somehow be controlled to an end point of complete withdrawal from the negative activity.

I think that we have some evidence now that intensive, somewhat prolonged psychotherapy is quite effective in a variety of sexual perversion, as well as addictions. People who are addicted, of course, with substances often have to have a point of withdrawal before they could become too involved in psychotherapy, but certainly our efforts with people with perversions have been very successful.

One of the reasons that they are successful is that almost everyone who has a periodic episodic perversion with a negative feeling towards a perversion, will, after a while, in the treatment show that they are a person who is longing for, needs, and does not have some kind of psychological regularity. They get out of whack easily. They become hyper-agitated or quickly distressed, periodically and regularly. This is shown very quickly in the treatment.

They start to use the treatment process as some form of regulation. Their lives become regulated around the treatment. Therefore, we often advise much more frequent treatment because we see this treatment becoming kind of a scaffolding for the person‘s life. They need the treatment to regularize them. More often than not, and I know that it may sound magical, but many people who have lifelong perversions get into, let's say very frequent treatment like psychoanalysis three or four times per week, and the perversion seems to disappear. A lot of times, we say that it goes underground for a while, but it seems to vanish.

Sometimes, there is a great deal of relief and pleasure on both the patient‘s and the therapist‘s part when, just by coming regularly, the perversion seems to go away. The relief and pleasure is not to be embraced too quickly when the perversion disappears because the

11 perversion returns. Sometimes it doesn't return for a long time; sometimes more frequently. But, when it does return, you can see that it has kind of taken part in the conversation of the therapy. It returns as a participant in the therapy, usually over breaks, irregularities in the treatment, empathic breaks on the part of the therapist, breaks in terms of holidays, vacations, weekends, etc., on the part of the treatment. The perverse activity seems to reappear with the breaks, disappear with the connections. The disappearance and the reappearance of the perversions is an amazing thing to watch if one is able to treat perversions frequently over periods of time.

Again, I say, sometimes perversions that have been around for a very long time and that seemingly are resistant to any kind of control measures, do seem to just abate themselves entirely with frequent psychotherapy,

ALEXANDER: I suppose that there would be a certain danger here of another sort, which is that the therapist gets too happy about it; I think that we need to talk about neutrality here. You don't want the therapist to celebrate because that takes a meaning of its own.

GOLDBERG: Well, there is no doubt that the biggest problem in the treatment of perversions is the countertransference problems of the therapist. We have struggled mightily with the fact that your use of that wonderful word, ―Neutrality,‖ just cannot exist because, when someone comes in to see you and says that they have been a pedophile and picking up little kids in the school yard, it is very hard to be neutral, because, immediately your own feelings about what is being done or not done comes to the fore, and one cannot help but show or sometimes openly express how one feels. You must realize that the split in the patient -- ―I feel both terrible about what I've done, and I feel that it is necessary that I do what I do,‖ -- that split between the upright citizen and the misbehaving citizen, that split reoccurs in the therapist, so that the therapist starts to feel, ―I think what you have done is terrible,‖ versus, ―I understand that you're in a lot of pain and have to do what you do.‖

It is beautiful to watch the various therapists in their counter- transference struggles with, ―How can I help this person, as much as, I hate what he or she is doing?‖ and that struggle goes on.

12 You're absolutely right. When the perverse behavior disappears, you make a little holiday in your heart, and say, ―Oh goody, we've finally cured this person, we've eradicated that bad part of him,‖ but of course, the patient sees in you, in your face and in your eyes and your mind, and says, ―Oh, if it comes back, he or she won't like me anymore.‖ That is the problem, because you've got to allow it, when it does come back, to participate in the treatment and that is the struggle that all of our therapists have: ―How can I help this person without hating this person?‖

ALEXANDER: You said in your book that almost every patient that comes in wants to know the therapist‘s stance about their perversion.

GOLDBERG: Yes, and almost every therapist has to lie, because almost every therapist has to say, ―Well, I don't mind if you pick up little children in the school yard,‖ or, ―I do mind but, I‘ll…‖ they don't know what to do with it because only the recognition of the vertical split allows us what is necessary, that is to be of two minds at the same time: ―I both think it's terrible, and yet I think that it is necessary.‖

It is a very hard thing to do, and especially when you get into group therapy or 12 step programs, it is very clear that they only take one attitude, which is ―It‘s bad; you must get rid of it. You must control it at all counts.‖ That is why 12 step programs, as successful as they are, must inevitably be unsuccessful because they're only interested in suppressing or eradication of the symptom.

Psychotherapy, on the other hand must be interested in understanding the symptom. Understanding the symptom will pretty much lead to its disappearance. We have had a goodly number of successes in long- term treatment of people with perversions recognizing this very important fact that they need to have the perversion, just like you need to have any addiction, sometimes for a long period of time. You have to be able to live with that need of the patients, rather than trying to eradicate it outright.

What happens is you and the patient engage in a conspiracy of suppression. You both agree that it is a terrible thing, you both

13 suppress it, you both think that it is great that it is gone, and that is a danger because it will have to return in order to be understood.

ALEXANDER: Let‘s go to a short clinical example then, Dr. Goldberg.

GOLDBERG: Well, of course, the clinical example will be short, but the treatment was long!

There is someone I know who was treating someone who had had a long period of analysis before the present treatment and had never confessed to his analyst that he had a particular kind of perversion which involved masturbating with pornography periodically whenever he was upset. He never, never mentioned it to the analyst. The analysis was completed; his life went on that way. He felt that he was fairly impotent with women because he could just engage in masturbation with pornography to satisfy his sexual feelings. He would try sexual intercourse periodically and he found himself unable to maintain an erection, etc, etc. Then he began this new treatment and managed to express the problem over the symptom, and the treatment was a fairly successful one, beautifully characterized by his recognizing the particular occasions when he resorted to, let's call this, ―The perverse activity:‖ getting a porno magazine, going to his room, masturbating, etc.

One could find a sequence, he would do something at work, he would feel insulted, he would start to feel depressed that he was not appreciated, he would move to the symptom. He would cure himself and then he would hate himself for what he did, but the depression and the particular cause of that was completely obliterated.

It is such a neat way to look at these perversions -- they really are great problems solvers. They are immediate, they are successful, they give pleasure, and sometimes, you don't feel too bad about them afterwards. When you get into the more serious perversions -- let's say someone that I treated who was involved with animals and would have the animals, lick his penis until he ejaculated. He would feel horribly depressed and ashamed afterwards. Yet, in the treatment, it was very clear that the activity with the animals was preceded by an incident in which he would feel horribly depressed and ashamed. He would then get involved with the animals, would have some sexual

14 behavior, and it would completely obliterate what had happened beforehand, and he would be able to devote his remaining feelings to what he had done and the sexual activity. Again, this was successfully treated with no recurrence whatsoever of the symptom.

One can work very successfully with perversions if you recognize that they are treatable and that one of the greatest problems in the treatment are the countertransference feelings of the therapist, because it is much too easy to take a stand about how you feel about the perversion and the patient therefore realizes, ―Well, this is no place for me to be able to talk about it or hope to get better from it.‖

ALEXANDER: What about the feelings of the therapist when the patient‘s addictive feelings turn to you, the therapist. In other words, they become in love with you in some kind of way or obsessed with you, obsessed with what you're thinking of them, and even masturbate thinking about you. They confess to you that they are doing this. How, as a therapist, do you manage your own feelings about it?

GOLDBERG: Well, when it occurs early in the treatment, when there is an erotic sexual transference that occurs very early in the treatment, I think most of the experiences that I know about would indicate that these patients are not treatable by you. I think that these rapid erotic transferences, sexualization of the transference without a lot of effort that has gone into the treatment in terms of recognizing how you are to be utilized by the patient -- I don‘t know of anyone who successfully treats them. I guess that there are a lot of brave souls out there who are heroic about treatment, but I always advise people to break off those treatments. They're not going to work.

When it occurs later in the treatment, after a good deal of non-erotic issues, then it almost always is related to some particular kind of countertransference reaction that has occurred with you and the patient, where you have somehow unwittingly encouraged the patient in some feelings which are not being handled, but are being sexualized instead of being handled. I think that you have to start to look at sexualization as a way of handling feelings that are otherwise unable to be experienced or expressed. The sexualization handles feelings of depression, anxiety, even hyper-excitement.

15 You know, many people will find that they won a big contract and become excited to the point of having to sexualize. They will often say, ―Well, I‘m celebrating,‖ but what they really are doing is trying is to bind their excitement and agitation by some kind of sexual performance.

Sexualization, I think must be seen as an emergency defense and the answer to sexualization is desexualizing it, seeing what lies behind this sexual activity. What is the anxiety or depression that you are fending off or avoiding by using sexual behavior instead of experiencing it? So, again, I think that erotic transferences early in the treatment are just beyond my ken; later on, I think they are part and parcel of the transference/countertransference reactions in the treatment.

ALEXANDER: You talk in your book about vacations and breaks in the treatment and how that is an underestimated event. So, maybe you could explain that to us.

GOLDBERG: Well, since I feel so strongly that the treatment becomes the structure for the patient to live with -- you know, we often say that these people have structural defects. They can't regularize themselves. They sexualize instead of being regulated. The treatment then becomes the structure for the patient and they rely on it and they live for it and it starts to organize their lives. So the disruption is like completely pulling the rug out from under them and very, very often, over periods of vacations, weekends, etc. they get involved in sexual activity.

The beauty of that, is that it can be shown to be involved in the treatment and I think that that is a point when, as you said earlier, the therapist would feel good when the symptom goes away and will feel bad when the symptom returns. I think that they should feel good when the symptom returns because then they can see that now it is participating in the treatment: ―I went away for Thanksgiving, and the patient started going back to his old haunts of perversion.‖ That‘s a good sign that the treatment has taken hold, the treatment has become regularizing and the acting out becomes an instance of, ―There is something missing in my life.‖

16 So, when we talk about, ―structuring the treatment,‖ we talk about these people having, in psychoanalytic jargon, ―structural defects.‖ The treatment fills in the defect. The therapist becomes the substitute for the missing structure and as the therapist is available, the symptom goes away. As the therapist is absent, the symptom reappears.

ALEXANDER: Also in this brief period of time, an impossible question. can we talk some about healing the split?

GOLDBERG: Healing the split. Yes, I think that that is something that is absolutely central in all treatment. When the patient with the split, that is, ―A part of me is resentful of the symptoms, a part of me lives with the symptom and enjoys the symptom‖ -- that is the split-- meets the therapist, the therapist also starts to experience, in the transference, the split. That is, ―A part of me disdains what you do and a part of me understands what you do.‖

These splits have to be brought together. It is what we call, ―integrated;‖ they have to be joined into one person. We have developed, what we call, ―an integrating interpretation,‖ which I think, is what is necessary in the healing of the split. The integrating interpretation recognizes that the patient feels two ways about themselves and sees you in two ways about you, and the healing bridges that split. You say to the patient, ―On the one hand, you feel this about me and on the other hand you feel that.‖

Let‘s say something happens -- you go away on a weekend. The patient then goes to some bathroom and picks up some man and they engage in anonymous oral felatio. That is then brought into the treatment. You say, ―You feel that I wasn't there for you; you then got someone who was there for you. That person who was there for you, you treated in this particular way, rather than coming and talking to me about how you felt about my not being here,‖ etc. That brings the misbehavior into the consulting room. It integrates the misbehavior into the entire organized self of the individual.

Now let me explain that if you say, ―You went into the washroom and you did what you did because you were mad at me or to get even with me, or to show me something,‖ that‘s not really brought it into the hour. It has to be brought into the hour in terms of ―how you felt with

17 me leaving you, deserting you, not there for you,‖ and integrating that into the total personality.

Now, that is such a shorthand version of it. I realize that I'm not doing justice to it because these integrating interpretations usually develop over long periods of understanding the patient: understanding what is behind the nature of the misbehavior, going to the washroom and getting involved with an anonymous man. What does that mean in terms of the men in his life, his father etc? And also in terms of the treatment: ―Where are we in the treatment, how much can you rely on me, how much do you need me?‖ etc, etc. The goal that we have is integrating that vertical split. Healing that split, making one person out of what was previously a person who was really rent in two.

ALEXANDER: Well, then I would imagine, as you gave in one of your examples in your book, the behavior does not just abruptly stop. You give an example of someone who continued the behavior but it came to be less terrific for them. It came to do the job less well, so to speak.

GOLDBERG: See, I think that you put it very well. What we usually find is that, as I said, the behavior goes away and returns in the treatment, and then, as it is understood more and more, the person starts to recognize when he or she would like to do the behavior, and then decides against it. Usually this is presaged by dreams of doing the behavior. In other words, they dream about it and they don't do it and then they think about it, and they think, ―I‘d rather not,‖ and then they think about it and they think, ―Gee, it‘s not going to be as important as it was to me, or not as necessary,‖ etc.

It is a gradual weaning process over some time, and what we see is that it becomes integrated in the entire personality. However, I think that it is very important to recognize that it never, never, never goes away entirely. In other words, every person who is involved in a sexual perversion periodically will entertain the idea of, ―Maybe I'll do it again.‖ They usually don't because they have so many negative feelings about it. Sometimes they might, but I've never seen a case where, ―It is absolutely never occurs to me anymore.‖ So, every cross-dresser who gives up the cross-dressing, thinks about it occasionally, as is true of every exhibitionist, pedophile, certainly the pornographic masturbators are always looking fondly at magazines or

18 videotapes. We do not, to my knowledge, obliterate these feelings and most cocaine users will tell you that they always think about it; the drug always whispers to them, but they manage to turn away from it.

ALEXANDER: Dr. Goldberg, we have covered a lot of territory and we have not really begun to get into this in anywhere near the depths of your book. Is there anything else that you would like to add about the topic before we close?

GOLDBERG: Well, the one thing that I was like to add is that in this period of managed care and psychopharmacology, a lot of people are looking for quick cures and medication cures, but there is absolutely enormous field open for intensive psychotherapy, especially in the treatment of behavior disorders. There are no new good drugs to treat this. There is no way that one could treat it in short-term care. These people really, really benefit mightily from long-term, intensive psychotherapy and it is a wide-open field that I wish more people would get involved in it. We need a lot more people to study it and gather case material about it and I think in its own way, it is a new frontier, the treatment of these narcissistic behavior disorders and I would urge all of the people who are listening to this interview to start to treat these people, struggle with them because there are many, many more people with behavior disorders than you could ever imagine and they are all looking for help.

ALEXANDER: Thank you, Dr. Goldberg, once again for a very interesting interview.

GOLDBERG: Thank you.

To order Dr. Goldberg's book, The Problem of Perversion, A View of Self Psychology, call the Yale University Press, (203) 432-0940.

This concludes our interview with Dr. Arnold Goldberg. We hope you have learned from this interview and that you enjoyed it.

I must say here that the views expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority. Until next time, this is Barbara Alexander. Thank you for listening.

19 © On Good Authority, Inc.

Interview #2: “ENGAGING GAMBLERS IN TREATMENT”

MARY RICH, Ph.D.

Interviewed by Barbara Alexander, LCSW, BCD

(Edited slightly for readability)

MARY RICH, Ph.D. 1420. N.W. Lovejoy Street, #508 Portland, OR

Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are reading or listening to an interview from CD #1 in our program, ―Addictions A.‖

We return in this interview to a popular On Good Authority speaker, Dr. Mary Rich, who views gambling from a developmental perspective. Getting addicted patients engaged in therapy is a serious problem and major challenge, not for the thin-skinned. Dr. Rich will explain why so many addicts cannot attach, and she shares some innovative suggestions with us.

Mary Rich, Ph.D. and Board Certified Diplomate in Clinical Social Work was a nationally certified gambling counselor and, until her relocation to Portland, Oregon, was a certified supervisor of alcohol and other addictions counselors in Illinois. She has taught in the continuing education curriculum at Smith College School for Social Work in Northampton, MA. She is a widely sought after consultant, having consulted with such organizations as the Illinois Department of Public Aid, and Napier, a program for drug- addicted mothers and their infants. Prior to going into full-time private practice, she worked for 13 years in in-patient addictions programs. She received her Ph.D. from the Institute for Clinical Social Work in Chicago, with her dissertation on women gamblers.

20

ALEXANDER: Dr. Rich, let‘s begin by talking about gambling in America.

RICH: You‘ve asked me to talk about problem gambling and pathological gambling today, and you asked me to talk about how difficult it is to engage clients. Most of the approaches for this problem, like for most addictions, have tried to be cookbook or behavioral conceptualization and solutions.

I feel that we should say something about the fact that 49 states have legalized gambling now, all but Utah, and maybe that $500 billion dollars per year is wagered. As legalization has increased so has pathology. The estimates are from about 4% to 7% and climbing all the time of real pathological gamblers as opposed to just problem gamblers or social gamblers.

The social consequences are phenomenal, ranging from 50% of the people in Gamblers‘ Anonymous (GA) being at some times suicidal, with huge credit card problems down with bankruptcy exploding all over the culture, lots of child neglect, lots of elderly going broke from their pensions.

In the beginning when gambling was legalized, people were worried about crime increasing, and indeed it has, with embezzlements in industry. The consequences of this gambling are either you get into the GA, or you kill yourself, or you end up in jail. And, a lot of people end up in jail these days.

ALEXANDER: In our first interview that we did a few years ago, you cited a statistic about the number of teenagers gambling in America. I have had a lot of people challenge that and hear that with disbelief. Can you say something about teenage gambling in America?

RICH: That research, like a lot of research in America was based on numbers. That was in New Jersey, where Atlantic City has had legalized gambling for a very long time. Actually Henry Leger, my friend in Illinois, the editor of the Journal of Gambling Studies did that research. When he got 37% of teenagers gambling weekly in New Jersey, he redid the research because he did not believe his own

21 statistics. There is a huge prevalence of teenage gambling in America and I am finding that women who gamble have had families who gamble so, in some ways, it is a learned behavior. It is what you watch the grownups do and you become a grown up, or it is a rite of passage into adulthood now. Or you read Sports Illustrated about sports gambling in college. It is an epidemic in the culture. So, I think that teenagers have a big problem.

ALEXANDER: Regarding adolescent gambling, do you have some additional citations on that?

RICH: That research by Leger was by Leger and Klein and it was a 1987 article called, ―Pathological Gambling among High School Students.‖ That can be found in Addictive Behaviors, volume 12. I also have a 1996 study from the Journal of Gambling Studies which was a sample of 900 students at the University of Windsor finding that 91% of the adolescents had gambled in their lifetime and 5.7 percent were considered to show signs of pathological gambling. They go on and on that problems of gambling were related to tobacco, alcohol, drug abuse, truancy and academic difficulties, as well as parental problem gambling. So, they had parents who were having a problem.

In a Canadian foundation on compulsive gambling, a 1994 telephone survey of 400 adolescents between the ages of 12 and 19 in the province of Ontario utilized the South Oaks Gambling Screen and found that 65% of the sample had participated in gambling activities in the previous year, and 4% of the sample were probable pathological gamblers, with 33% having some problem.

That is a nice tool for assessment when somebody comes in. Now they have a South Oaks Gambling Screen for teenagers that they have revised. So, I'm sure that both surveys are available.

One of the things that you asked me to talk about is how to engage these people. Barbara, I get a huge number of referrals because of my research on women who gamble, plus I am a nationally certified gambling counselor in the state of Illinois. I would say I have had 20 referrals in the last six months and maybe I have engaged one or two of those people. Now, this is a very, very difficult engagement. How

22 do we get patients to first attach and then idealize us, as in the self- psychology theory, when they can't show up for the first session?

ALEXANDER: Would you say this would apply across the board in addictions, or do you think that it is different or worse for gamblers?

RICH: I worked for many years in a cocaine inpatient treatment program, and we had a terrible time keeping cocaine addicts attached to outpatient therapy, what they call aftercare. Heroin addicts, and by the way, heroin addiction is on the rise in the culture, also have tremendous difficulty. When you are competing against a needle experience and a high that is like nothing else, you are talking about a difficult engagement.

I have a basic theory that ultimately, these people are not able to attach. I had identified myself for a long time as a self psychologist – this refers to the works of Heinz Kohut and his followers. This is an interesting theory that broke from Freud. Freud thought that babies were hardwired for things to go wrong. Self psychologists thought that babies were hardwired for things to go right. Daniel Stern has a wonderful book called The Interpersonal World of the Infant, which is really the developmental theory that self psychology uses and is probably the most important book on child development in the last, I don't know, long time, 50 years maybe. That is a 1985 book, and I would encourage counselors to struggle through reading that. It is dense but it is wonderful. Daniel Stern is a profound thinker and includes a lot of research on child development.

ALEXANDER: Why do you think it is important to know about developmental theory in treating patients with addictions?

RICH: Well, I think that that is a good question because child development theory tells us what is normal and what causes problems. Where is the deficit? What can we expect in a response to our attempts at intervening? My position is that addictions come from a deficit in the early mother/infant bond. I understand that we inherit temperaments and other traits to some degree, but, you know, it is like if you want to grow flowers, you have to first tend the soil, fertilize, water, prepare the ground, make sure you have enough light. Later you get flowers. Well, the same is true with babies. Often a

23 mirasmus or an anaclytic depression sets in and then we see addicts who have trouble showing up.

ALEXANDER: What about current popular theories and therapies? Do they take these ideas into account?

RICH: I think that current, popular, cognitive behavioral treatment theories do not match what I believe to be the preverbal deficit, caused probably before babies even had cognitive development that would have been ready to flourish, like the plant that isn‘t fertilized. Managed care has canned these programs in a way, and they are not geared to help those at the earliest levels of these deficits. So the treatment recommended often doesn‘t match the place where I believe the deficit to be. The people feel empty, alone, despairing, and that no one is going to understand. Relationships for these people don't work give a feeling of aliveness.

ALEXANDER: So, is that what you think happened that leads to people turning to outside substances to shore themselves up?

RICH: I think that their brains atrophy from a lack of an early holding environment and then further abuse of chemicals and such destructive behaviors such as gambling certainly don't help on top of that. I think that these patients attempt solutions with inanimate objects like slot machines and they fail and they come up empty. So, they come to us to attempt again to be held. This ―holding‖ is like a metaphor for space, the time, the dialogue, interpretations, and the overall attunement that we provide.

ALEXANDER: So, you think that really there is a connection really between that early deficit and what we need to be doing as therapists and what is needed in the therapy?

RICH: Yes, yes. Just as babies need to be talked with, you know, gazed at, cooed at, adult addicts need to be held in this way. We learn that when 100,000 Romanian infants are left in orphanages, their brains do not develop. They atrophy. I mean you can actually see pictures of this lack of brain development. I see this and I postulate from these extreme Romanian cases to learn that babies need loving and holding to thrive. They need to traverse that development of a

24 ―me/not me‖ world, to use us, to have a relationship, to attach, to feel alive. This is from abandonment and too little mother.

ALEXANDER: Is there such a thing as too much mother?

RICH: I think that that is the other extreme, yes. The deficit can also be from like a merger or too much mother in that she is so needy of the child for her own nourishment that she cannot help the child separate psychologically. These are the folks who have symbiotic mergers and can't use us to recover. Drugs or gambling are the adaptation they find for survival in a sterile, nonverbal environment. In some addicts, the deficit is not so early. They can and do show up and use us and use self-help groups. Then we know that the prognosis is better. We know that they had a somewhat good enough holding environment in the first year or so of life.

You know, Barbara, diagnosis depends. We need to know child development theory to know what level we are dealing with psychologically and then we can be less frustrated. We‘re less just taking potluck and we know what we are doing. I mean, I have had patients show up for the first visit, go to AA for the next day, and never drink again. On the other hand, I have had addicts for years who could not give up the addiction until they felt safe enough to trust me. They had to first notice that I was a person in the room and then an attachment began. So every person is unique. I mean, we cannot diagnose and treat well without theories of what normal is and what causes pathology.

Now, the way that I think about optimally responding or being creative in the transference or the use of myself has been to experiment and to take risks in terms of both fees and time. This may sound provocative and it is because when you get 20 calls and two people show up once and one woman shows up 45 minutes late, you know that there is something else going on because obviously, there isn‘t the ability to idealize when you can't show up. So, I will spend maybe 20 minutes on the telephone with somebody on an initial call and I think ideally, if I wanted to engage everyone, I would probably start free group therapy and run 10 sessions of free group. One of the reasons that I have never done that, which Dr. Leger actually encouraged me to do a few years ago, is that I don't think that they

25 would show up then either. So, Gamblers Anonymous, which is free, is having the same kinds of engagement issues that I have and I don't think that it is different from cocaine or heroin addictions.

On the other hand, I want to say that I have never met two addicts alike. I think that you have to engage and understand every person's story and try different things with different people. I‘d like to talk little bit about a case from a gambling referral. Let‘s call him Ken. Here are the diagnoses that I was thinking about. The diagnoses range from borderline personality disorder to antisocial personality to narcissistic personality to where I think the man may have a 150 IQ and cannot sequence information or consequences at all so I think that there may be a learning disability involved, to my now sending him on a medication evaluation and really I am asking for a consultation on whether the man is manic-depressive and should be on lithium and/or has a learning disability.

Anyway, Ken is a man whose mother died when he was two years old. She died very suddenly and he was then raised by his father‘s family. At the age of nine, his father married again. So then, he was yanked away from the caretakers, lost them, was forbidden to talk to his maternal grandmother, and behavior problems started.

Now, here is a man who called me only because his girlfriend forced him or urged him to call. Here is the precipitant. First of all, he is really committing felonies all of the country. He is gambling with the money that he is earning illegally. Maybe the precipitant is that his father died one year ago and that he just had his first child, a son.

So, he comes to see me three times in one week and I'm pretty intrigued with him and he is pretty intrigued with me. There is some kind of connection that went on. Then he tells me that he has seen three or four therapists over the years, and I right away know that this man is not going to continue to come and he is not going to attach. But I thought, ―Well, I'm going to go for it.‖ By the third session, I interpreted that I thought that his mother had died, that he was in a pathological mourning response for 30 years, never having mourned that loss, and that he needed to do some work internally to understand how he was really looking for the lost object all over the country, and

26 was acting out an attempt at a solution that really needed some talking and understanding and it was ―an inside job,‖ not ―an outside job.‖

I only saw him four times in three months, and it was all within the course of 10 days. At the fourth session, I knew that he was going to be traveling again, going off and doing his scams, having women all over the country, and that no matter where this man was, he wanted to be somewhere else. He could not settle down, in a very manic kind of way. So I wrote him a post-it paper that said, ―When I want to run, it is to master the helplessness of being left, so I never have to attach.‖ I said that life seemed like a joke for him, that death was the great unknown and maybe he hoped to die and join his mother. I said that he sounded like Bonnie and Clyde, where you live like you don't care and have nothing to lose.

At that point, he said to me, ―You know, if the FBI knocks at my door someday, I'm going to say, ‗Excuse me just a moment,‘ and run and throw myself out the 40th story window.‖

I went through a lot of explaining to him about psychotherapy, what it was, that it was a dialog. It was a bringing together thoughts and feelings with another person over time in the process where feelings and thoughts hopefully come together in a narrative of one's life and one's self and who one is. And I said even in psychotherapy, they believe that the brain changes and develops anew, and one hopefully gains a sense of self with ideals and ambition.

Well, this man said to me, ―You know, I always date older women and I'm in love with you already,‖ and he had this kind of instant transference.

In the meantime, the last five or six months, we speak to one another over the phone periodically. And now, he calls me, ―Mary, my friend.‖ He says, ―I hope you haven‘t abandoned me; I know you haven‘t abandoned me.‖ These are phone messages that he leaves. He is now trying to get a job and sit still, and says to me, since the first session, he has gambled much, much less and he is trying to understand and sit on his urges to rush and run away. And his girlfriend, he reports, thinks that he has changed tremendously.

27 Now, I feel like we have not begun. But here is a case of my being very patient for like nine months, seven months from the initial visits, and now I have maybe seen him 10 times, but I am very flexible with him around the time. I am pretty insistent, though, around the fee.

ALEXANDER: With this population and with this man in particular, do you have him pay you each session?

RICH: Yes. Absolutely. I walk a philosophical tightrope between my own needs of surviving and I'm a professional. I also don't want to collude with a gambler and having him get something for nothing.

So, on the one hand, you know, there is a cognitive deficit involved in this, Barbara. It is so interesting that on the telephone, I will get them, before I have ever met them to tell me how much debt they are in, and I will get them to talk about what game preferences they have and what the problems are now in their family situation and why they are calling. They will always tell me, ―Oh, I'm spending $400 every Saturday night at the gambling boat.‖ ―I‘m in $8,000 of debt or $30,000 of debt,‖ but there is a cognitive gap between that and thinking of paying me for recovery: I should love them into wellness free of charge.

So, I find that most intriguing because there was an interesting Winnicottian thought about that, where fees are a demand that appears beyond their tolerance or comprehension. It is a quirk.

So, how do you optimally respond when they have an intolerance of you charging them? It‘s a paradox and we go right to the very basics of what we do for a living, in terms of what we've learned in school. Time and space and fees are creating a holding environment but they can't show up in the beginning, so obviously the instant transference to me says something about the inability to attach or to use a holding environment at all. Do we just think about this in our work as saying, ―Well, I guess the 19 out of the 20 people who called and didn't show up or don't come back to Gamblers Anonymous or don't come back to Alcoholics Anonymous, or continue to use cocaine after four or five inpatient treatments, -- I guess we just let go of them. I guess that we give up on them in the culture?‖

28 I don't know the answer to that. I know that it is important to have a developmental theory about how people get sick and how people get well. Again, this is provocative and it certainly provocative in the field of addiction to say that early on, the mother/infant holding environment is where we all begin. I keep wondering: is it going to take the neuroscientists to inform the psychologists that we need to go back and hold our babies and nurture our infants and even nurse our infants? I am totally mindful, as a feminist, that it is politically incorrect to say that mothers need to stay home and nurture their babies, at least for the first two years.

I believe that you said on one of your ―Today‘s Psychoanalysis‖ interviews that 75% of the brain is developed after birth, and it has everything in the world do with how one is held, how one is fed, how one is touched, how one is talked to, how one is looked at. That seems so commonsensical or essential. But, roughly half of all mothers of children one -year-old in the United States in 1996 have jobs out of the home and certainly, that is a causation for setting the stage for later addiction problems and crime problems and language problems and educational problems and behavioral problems of all sorts.

That seems pretty simplistic to me. You can't solve a problem unless you have a causation, a belief in the causation. To just, ―Say no,‖ to drugs or gambling when cognitively this isn't going to work, serves another function of illusion, of fantasy, of dissociative states. We‘re talking here early, early cognitive deficit in my opinion. An emotional deficit!

Dr. Henry Leger has two theories in gambling addiction: one is that male gamblers seek action, and that female gamblers seek escape. That is written and accepted in all of the theories on gambling. Now, I'm more in the business or process mentally for myself of saying, ―Okay, escape what? For what purpose, for how long, and for what functions does it serve, and when do the addictions set in?‖

If you and I go to gamble together, to the casino, we might be having fun and it is social, and I think that for 90% of the Americans who gamble, it‘s true. Most people have enough good sense and have had enough good early mothering and parenting that they are able to say,

29 ―Okay, I just won at the slot machines and I'm going home now.‖ Those are the real winners, the people who leave after they have won. They do it three times per year and it is a recreation.

There is something else, though, in this 10% of the population with the problem or pathological gambling response. Most of the women that I have interviewed on gambling have some kind of really severe deficit, or series of deficits, like the case that I just presented of Ken, What if your mother does die when you are two? What are the consequences of that? Well, if you have caretakers after the first two years who are consistent in a holding environment, you may do very well.

But, here‘s a man who, by the age of 9, was yanked again from caretakers, really replaying the original trauma of loss and of course, when the behavior problems start, they don't look for therapists. They look for punitive solutions to tempering this wild child‘s behavior, which causes him to merely accelerate the acting out.

I think that you do have to individually assess each person for the trauma and their perceptions, subjectively, of what has happened in their life, because, the gambling is a soothing experience. It is a soothing experience until, of course, they cross over that invisible line where they can't pay their bills and they're losing their house and their husbands or wives are ready to leave them, and they are embezzling from work. This all starts very innocently but ends up where my friend, Mike, in GA told me the other night that we only see people once or twice and they end up in jail. By the time that they begin to recover, it is too late.

ALEXANDER: Let‘s talk about a phrase that you have used a few times. The phrase is ―the holding environment.‖ I would like you to explain to our listeners what you mean by that and where that phrase comes from and why that is so important in understanding people with addictions.

RICH: Well, I‘ve recently been relearning the work of a man named D.W. Winnicott, from England, who died in the 1970s. He started out in England as an Object Relations theorist in the Independent School of Object Relationship there in England. He was

30 originally a pediatrician, so, he had early mother infant experience. He would watch mothers and their infants very early and could tell when there was an anomaly in the partnership of mother and infant. He used to say, ―There is no such thing as a baby, only a nursing couple.‖ He believed in an initial stage of primary undifferentiation between ―Me and not me,‖ and that every human being has to separate the ―Me from the not me‖ and come out as a separate person where they can then use the environment.

Now, the process that Winnicott talks about over and over in hundreds of articles that he writes is this: first, the baby has to come out of the womb relating to the object and then …

ALEXANDER: By the object, you mean the mother.

RICH: Yes, I mean the maternal environment. Yes, because that is the original dyad. Then, he uses the word, ―Destroy.‖ The baby has to ―destroy‖ the mother, and he is speaking here psychologically. The key here is that the mother has to survive without retaliation and then the baby can use the object, meaning the mother. That then sets the stage for human beings being able to use human beings and attach to them and idealize them throughout their life.

ALEXANDER: Why is ―destroying the mother‖ so important and can you give some examples of how a baby would ―destroy‖ the mother?

RICH: Hopefully he doesn't destroy her literally, but psychologically, he needs to traverse a self and a ―me.‖ Now, whether that is a testing of the mother, maybe that is in gazing and seeing if she inhibits his play. I think that that process goes on in a million different tiny, tiny bits or pieces of behavior between the mother and the infant over several years.

Now, a man named Robert Kagan, in 1982, talked about this happening with adolescents, that it continues through the life cycle. He says that it takes a special wisdom for the family of an adolescent to understand that by remaining in place, so that the adolescent can have family there to ignore and reject, the family is providing something very important and is still, in a new way, intimately and importantly involved in the child's development.

31 I‘m of the mind now that other people serve both internal functions for us psychically and we need them in our lives, they are essential, they are the central motivating factor in human beings‘ existence, attaching to others, and that we need that, but that we also need people. So, while we need an internal experience with people in a ―psychic function‖ way, we also need people in reality! The mother has to survive without retaliation.

Some of the problems that I have with treating gamblers concern using self-help groups, and I'm kind of an expert in using self-help groups because I have worked so many, 20, years in addiction. Gamblers Anonymous has reworked the steps and the program and unfortunately, it seems to me, they retaliate and judge and provoke new members who come in. There is a lot of grandiosity in Gamblers Anonymous members, and they cross talk, which they never do in AA or Narcotics Anonymous. They have reworked the program in a way that I think makes it difficult for people very depleted and in much debt and very depressed and probably suicidal coming in to their first meeting, and having judgments and retaliation, and so that they destroy the object and the object doesn't survive, in Winnicott‘s theoretical framework.

I can spend many months with a gambler who will come in and clearly avoid talking about the gambling but will tell me everything about their lives and I stay where the client is. I believe in that. I stay with the process. I'm not going to come in and bully them or confront them initially; it isn't going to work.

ALEXANDER: So, if you've seen somebody for two or three months and over the phone you‘ve had the sort of intake interview in which they‘ve said, you know, they owe $20,000 or whatever, and then they come in and they never mention it again for months. So you don‘t think then that saying, ―Look, you know you haven't said anything to me about your gambling in a long time‖ --- How do you weave back to it, or do you?

RICH: It will inevitably come up in the process. I mean, it isn't even having to weave back to it. It's always on the table; it's always on the table. I just wouldn't be like a bull in a china shop about

32 confronting that because I know, well it depends upon each individual case, but I'm assuming that there is a very fragile capacity to attach.

Kohut believed that patients were very narcissistic and that you couldn't confront behavior that is destructive because that is a narcissistic injury to a patient. It taps into their grandiose self and it causes more defensiveness and more grandiosity. They don't feel understood and they become even more rageful.

So, a repetition of this has to occur in the therapy, where this is felt to the patient just like a judgmental parent. So if you confront, Kohut thought, the patient is not going to get well. Kohut mirrored the grandiosity.

In addiction treatment, we have a big dilemma because gamblers are out of control. Their lives are threatened on every level, home, job, medically, legally, financially, psychologically. They are suicidal 50% of the time. This is a fragile situation. How do we treat this in outpatient therapy with managed care and short-term treatment? Do we confront addicts with reality testing like saying, ―Hey, you're ruining your life.‖ Well, I think that their friends and family say that already. It doesn't help. If that helped, they wouldn't need us.

Winnicott‘s theory tells us to create time and space for patients to redo a development where there is an arrest or a fixation and to get unstuck from a very primitive level of attachment. In my mind, Winnicott is helpful because this primitive level of absolute dependence in the ―me/not me‖ has not been done, has not been worked through. We need to provide a ―good-enough mother‖ environment and help them to get unstuck.

Kohut had always talked about using optimal frustration on patients, which he thought built this psychic structure. I believe in optimal responsiveness, and I think Winnicott believed in optimal responsiveness. Winnicott experimented with two and three hour sessions with difficult patients and had wonderful success. He saw people at random. The patient decided when they were coming. The patient decided how the treatment was going to go. It wasn't the objective, superior therapist ramming their theory onto the patient

33 who needed to comply because Winnicott said that you'll just get a false self if that happens.

I think that this has happened in the case with Ken where growth has resumed. I don't confront his felonies. I don't confront his running away. I don't address his gambling. Now, that doesn't mean that I never talk about it, because sometimes he will come in and I will laugh and I‘ll say, ―Okay, did you bet the game Sunday?‖ I mean it's not like I don't talk about it, but it's a question of how you go about that. I go more for the understanding. I‘m always framing things around the loss of his mother when he was two years old. I go for an interpretation of his behaviors around the whole self, which is very self-psychological, and I say this to explain; not to judge but to understand. I show him and encourage him not to judge himself, but to stay curious with me in understanding, ―Who are you?‖ and discovering that.

Now, nine months into treatment, he is on Luvox, and he tells me that curiously, he has not thought about death or suicide since we first met. That's when I talked about is looking to master the death of his mother. If she's in heaven, a two-year-old would say, ―Well, if she's in heaven let's go to heaven.‖ So, he has subsided with his suicidal ideation.

Now, why is he seemingly getting better? I think it‘s because I engaged him without going for the antisocial behavior, because one needs to understand the development of normal behavior and then one understands what the patient needs. As Kohut teaches and as Winnicott had great results with, then the antisocial stuff begins to subside.

Ken asked me, ―If I come here for a year and I go to GA, what good is it if the FBI walks into my house and busts me? I'll never be a father to my child and I‘ll go to jail, right?‖

And, I say, ―No, I don‘t think so. You know, I think if you go to GA and you come here‖ -- and he is thinking of stopping this felony behavior – ―I could testify for you and show your efforts and your progress, and while you might be found guilty, you would probably get probation.‖

34 He gets very excited by this, like there is hope for a future, like it engenders his ambitions and his ideals to get moving. He started, just this month going back to school to a postgraduate program for a career and he is looking for a job. So, we will see what happens.

He still destroys me and that's what you're interested in. What did Winnicott mean by this metaphor of destroying the mother? I have to survive this. He calls me all the time. He cancels. He is so omnipotent that it does not occur to him how this disrupts my life and he doesn't care. There is no ―me/not me‖ yet, in my mind. And so, in a way I don't exist. I am there to serve a function. The task is for me to exist, I think, at some point. He cancels day after day. I try to reschedule, he cancels again. He‘s sick, his son is sick, it's too cold, he doesn't have the car today, but he always makes it clear that he wants to come in. So together we traverse this paradox of his urge to run, to separate, to even die and I deal with my frustration of his cancellations and my anger. I usually wait a day or so to call him back to reschedule because the theory keeps me level, that I am, in Winnicott‘s theory giving him the space that he needs to traverse this development that got stopped, really, when his mother died.

ALEXANDER: Just as an aside here, I do want to highlight that as a real plug for having a theoretical base, a theoretical orientation that gets you out of yourself and into the realm of ideas and ways of looking at this that are bigger than just the therapist's own emotional response to the behavior of the patient.

RICH: Yes. I think that there is so much trouble out there in the world with young people who are truanting and violent and drug and alcohol addicted that we want quick solutions but, unfortunately, I don't think that there are. I think that some people get helped. I think that there is a developmental process, actually that goes on in AA over a 10-year period where there is a dialogue, there is empathy that develops, the meetings start on time, the meetings end on time and there is a real safe space, and you could put a lot of AA into a developmental theory that occurs there. I think that, again, it is language out loud in a dialogue with others creating a narrative of one‘s life over time.

35 So, I think that it only enhances our work to have a developmental theory. Again, I would encourage people to read Daniel Stern and the Interpersonal World of the Infant and the Frank Summers book on object relationship theories and psychotherapy, both fairly recent works.

I wanted to make a few other comments about exploring the use of Luvox, which I think is important in the treatment. We have to use everything: I think a combination of things with G.A., self help groups, sponsorship, therapy and medication. It makes the patient feel taken care of when I send them for a medication consultation for this population of gamblers. And, again, playing with the times of the sessions. It helps to spend maybe an hour and a half or two hours for the first session especially, so that the patient -- they usually come late and they are anxious and they are very highly ambivalent about, ―You‘re going to be just like everybody else; you're not going to understand me either; you're going to judge me.‖ Patients really expect not to be understood, I think.

Just keep an open mind about these theories and play with them and see what works. Reading self psychology is a wonderful way to begin to learn about empathy and explaining and understanding and getting inside another person's shoes to imagine what their life has been like. I'm talking here about attachments. How do we help people attach, and when they can come and show up on time, you've made a huge beginning. I mean, I always think, getting the patient to AA or GA is the most important goal of anything that you do. But, again if these people can't show up for therapy or GA, either one, do we just relegate them to the wastebasket and say, ―Well, oops, lost population, forget that?‖

So, I want to highlight those theories around traversing the paradox of separating: the patient needs to learn to separate and individuate and then learn to attach and use others in their lifetime. Winnicott said that it was a sophisticated game of hide and seek in which it is a joy to be hidden, but it is disaster not to be found.

The other thing I really feel I want to end with is to say, as politically incorrect as it might be, people in the helping professions have to began to encourage mothers to stay home the first and second years

36 with their infants and to nurse their infants and provide that holding environment that Winnicott talks about because the lack of that is the beginning causation of lots of trouble later.

ALEXANDER: Well, thank you for your very sound and sage and experienced advice.

Dr. Mary Rich has relocated to Portland, Oregon. You may contact her at 1420 North West Love Joy Street, Apt 508, Portland, Oregon 97209 or by e- mail [email protected]

This is the end of this interview. We hope you have learned from it and that you enjoyed it. I need to say here is that the views expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority.

Until next time, this is Barbara Alexander. Thank you for listening.

37 © On Good Authority, Inc.

Interview #3: “SUBSTANCE ABUSE IN ADOLESCENTS”

PETER PALANCA, M.A.

Interviewed by BARBARA ALEXANDER, LCSW, BCD

(Edited slightly for readability)

PETER PALANCA, M.A. The Hazelden Foundation 867 N. Dearborn Chicago, IL. 60611

Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are reading or listening to an interview from CD #2 in our program, ―Addictions A.‖

Adolescents have always posed a unique challenge to therapists. And substance abusing adolescents push us to an even higher frequency. Here to give us hands-on help in understanding teen-age addictions and what to do about them is Peter Palanca, a leader in the field of adolescent substance abuse, whose methods of getting resistant adolescents to talk to him will bring satisfaction to all therapists who have ever faced the Big Stony Silence.

Peter Palanca, Executive Director of Hazelden, Chicago, has spent the majority of his career working with adolescents and adults in the Substance Abuse field. Over the last 25 years, he has founded and directed in-patient and out-patient programs for chemically dependent adolescents, including Engels Hospital and the Parkside Program in the Chicago area. He has taught at Governor‘s State University since 1982 and was President of the National Adolescent Treatment Consortium through the mid-80's and early 90's. He was also Deputy Director of the Illinois Department of Alcoholism and Substance Abuse, and responsible for overseeing the state‘s publicly

38 funded programs. He has 4 children of his own, ranging in age from 14-24, which, he states, most qualifies him to do this work. Now to our interview.

ALEXANDER: Peter, you have worked for all these years in substance abuse and with adolescents, in particular, has substance abuse in adolescents changed in the last week 25 years, let‘s say?

PALANCA: Barb, substance abuse treatment has changed dramatically in the last 25 years. In the middle 1970s, for example, I was the director of an outpatient program and actually, treating kids was sort of an afterthought. Kids in AA and kids in NA were afterthoughts back then and we were really sort of blazing trails. Kids were treated in quasi outpatient programs, and I‘m talking middle to late 70s, and were not thought of as actively engaged in or should have been actively engaged in AA or NA because of the fact that they were not accepted readily in AA programs. The kids would attend AA meeting and a 16-year-old might hear something like, you know ―I‘ve spilled more booze on my tie than you‘ve ever drank. What are you doing here?‖ So, kids were never made to feel like they belonged in AA or NA.

But, actually subsequent to that and through the years, there have been inpatient programs that have been developed and through, I believe the early 1980s and through the middle to late 80s, there was a proliferation of adolescent substance abuse and mental health programs that developed that treated kids for addiction related problems. There were broad lengths of stay in those programs, sort of the private side of treatment that was reimbursed through insurance and third-party which provided some financial support for kids to go through really whatever they needed during the 1980s when the programs began. Publicly, there were therapeutic communities that kids lived in for long, long periods of time that were different than the private programs. That was the more public model.

At this point in time, we have been reduced to many fewer treatment opportunities for adolescents because the reimbursement issues have had dramatically affected the amount of services that are available for kids.

39 ALEXANDER: What about the addictions themselves in adolescents?

PALANCA: What kids were using actually in the late 1970s, was a myriad of drugs, but always the primary drug of abuse was alcohol. There was a period of time when the primary drug of abuse, and this was the middle 1980s, was marijuana. But, it really has always been, kind of back and forth between alcohol and pot and we‘re back to a place where alcohol is, without a doubt, the most abused drug for adolescents. However, kids are using marijuana to a large, large extent today.

One of the things that has changed fairly dramatically, when you asked earlier about the history is that what we would see kids doing in the late 1970s or early 1980s, middle 1980s, at 15 and 16 years old, in terms of their onset of addiction, or their onset of serious chemical use has dramatically changed and compared to today, what kids are doing at 11 and 12 is what kids years ago were doing at 15 and 16. Therefore, the impact of drug use is much more dramatic because of the impact that it has on psychosocial development, emotional development, and all of the developmental areas.

ALEXANDER: Now, we have another wrinkle in the adolescent substance abuse problem and that has to do with the limbo that I think parents find themselves in. Parents of 15 year olds were, themselves teenagers or young adults in the 1970s and both used and, in fact, ―inhaled,‖ so now their children ask them, ―Did you do that then?‖ It‘s hard to find a boundary, I think, for a lot of parents.

PALANCA: Well, you‘re exactly right. It is hard to find a boundary and I think that the question becomes, and I have had this question asked to me many, many times by parents -- I do a lot of work with parent groups -- the question is, ―Well, should I say to my kid, ‗Yes I have used,‘ or ‗Yes I have smoked pot and in fact, inhaled, maybe even tried some of the more illicit drugs like LSD.‘‖ We know that many of our current baby boomers have done that and many that grew up in the drug culture in those middle and late 1960s really did experience significant experience and exposure to drug use.

The question is, should a parent admit to having used drugs or should they not? I really frankly believe that it‘s contingent upon the

40 relationship that the parent has with the son or daughter. The question becomes, is the son or daughter ready and able to handle that information? Is the son or daughter going to know if the parent is lying? You know, our kids can pick up pretty quickly on the fact that we‘re concealing information or concealing truth. So, I think there is not a simple answer to that one. But I would say as a baseline and for the most part, parents should opt to be direct and truthful and honest with their kids, knowing that that can have some negative ramifications.

ALEXANDER: When a child, a young person is brought to you, what are usually the presenting symptoms?

PALANCA: Almost always that they are out of control. I can‘t get him to school, and let me tell you about what I think is a fairly typical conversation that I had just this past Saturday. Mom had called and I returned the call and we spent considerable time on the phone. The kid was there. He went away at 18 years old. He had flunked out of the university. Prior to going away to school, mom and dad had suspected marijuana use, but had never done anything because they didn‘t know how to intervene. They didn‘t know what to do. They didn‘t know what kind of steps to take as parents. But, the son did, in fact, flunk out of the university that he was attending. When he got home, there was clearly now a need for some intervention to happen and parents attempted to lay down some limits and say, ―You can‘t come home at 3 o‘clock in the morning. You‘ve got to keep us posted on where it is that you are going. You‘ve got to let us know when you‘re not going to be home. We‘ve got to have some... ―and the attempt to establish clear-cut limits was where the parents went. Unfortunately, this kid said, ―I‘m not going to respond to your limits. I‘m not going to respond to any guidelines that you‘re establishing. I‘m out of here.‖ The kid has been out of the house for the past 2-1/2 months. He is really struggling; they are really struggling with, what‘s next? What‘s the next step?

So as to presenting symptoms, I would say, out of control, and frequently, kids are struggling with anger issues. Kids are struggling with personality issues and I have to believe that self esteem, my not feeling good about myself, is often a precipitator and kind of a foundation to frequent drug use.

41 ALEXANDER: Okay, so assuming, and I think we have to assume that by the time a child is a senior in high school, probably the majority of them have had a drink, at least, have smoked marijuana, perhaps. What distinguishes the child who is the experimental -- couldn‘t even say that they‘re a user -- the experimenter from the abuser? PALANCA: I think that there are a number of things. First of all, let‘s talk a little bit about the stages of addiction. You know, there is, there is the stage of ―nonuse‖ that a teenager goes through or a pre-teenager goes through. Then there is the stage of ―thinking about using‖ that engages a lot of an adolescent‘s time and then there is the stage of ―experimental use,‖ and then there is the stage of ―regular use,‖ and then there is the stage of ―abusive use,‖ and then there is the stage of ―addiction.‖

I operate from a perspective of zero tolerance and that means that when a parent says, ―What use is acceptable use?‖ The answer to that question is, ―No use.‖ It is illegal, it is inappropriate, it does not favorably impact any area of development. Therefore, the approach that I take is one of ―No use is appropriate.‖ Is that realistic? Yes, it is realistic. Is it something that any school, any community, any family has been able to accomplish completely just because the parents take that perspective? No.

However, what do you look for when you are doing an intervention? The first thing that you look for are the areas where the teenager is out of control. That ―out of control‖ issue is an extremely significant area: out of control in terms of unresponsive to parental limits; out of control in terms of academic performance; out of control in terms of the physical impact that drug use is having.

Then the next thing that you look for is often the need to very definitely take a look at, ―Is the adolescent‘s use having a negative impact on their development and other areas of their life, and creating negative consequences, and are they continuing to use in spite of those negative consequences? If there is continued use in spite of negative consequences, that indicates addiction.

ALEXANDER: What determines when a child would go inpatient for treatment, or outpatient?

42 PALANCA: The primary differentiating factor is, and I should say first that it should always be a treatment center‘s attempt to hospitalize or to put a young person into the residential program when other approaches to intervention have failed, or the least restrictive environment should always be applied when appropriate.

Now, what differentiates an adolescent who needs an inpatient program from an adolescent who needs an outpatient program? One of the major questions that make that differentiation this: when you look back at the young person‘s history to when they began using, you ask a question like, ―Have there been significant periods of your use since you began using where you were completely abstinent over a period of time?‖ If the answer to that is, ―Yes,‖ then you can pick out a period of four, six, seven weeks where there actually was a period of complete abstinence. Then realistically, there is an opportunity that that kid can do well in an outpatient program. If there isn‘t, then I think the likelihood of that kid needing an inpatient program is much more clearly apparent.

What are the support systems that the young person has? Are all of his friends chemical users? What kind of supportive environment does he come from at home? We have to evaluate the level of support systems that exists for an adolescent to determine potential success or lack of success when it comes to potential for positive treatment outcome.

The focus needs to be on what is going to lead to positive clinical outcome at the end of the treatment experience. Positive treatment outcome is defined as the willingness to remain abstinent, willingness to maintain a continuing care program, willingness to maintain contact with some form of ongoing, long-term, continuing care like a 12-step program, Alcoholics Anonymous, Narcotics Anonymous, and restoration of some sort of supportive environment for adolescent to stay sober in.

ALEXANDER: Now, let‘s talk about treatment. Freud said --and I‘m paraphrasing extremely -- that once a person has experienced a certain pleasure, they never want to give it up. They might substitute something else, but they never want to give it up. Do you think that that is true or not, and how does this apply for adolescents? Once

43 they have experienced whatever it is that is meaningful to them in substance abuse, why would they want to give that up?

PALANCA: I think that most adolescents that I have dealt with through the years have significant voids in their lives. They have significant areas of pain in their life that substances do a good job of masking. One of the things that treatment can teach a kid is that there are effective ways of dealing with those areas of emotional pain, physical pain, pain related to loss of a loved one, pain related to a lack of performance, pain related to a lousy sense of self esteem. There can be, and I think that one of the role that treatment plays, is that it teaches an adolescent and the family of that adolescent that there are ways to meet needs other than chemical use.

One of the things that we should all be aware of is that most adolescents who talk about using get hooked into using and some become physiologically dependent, although that is a very, very, very small minority of kids. What kids get contingent upon and really addicted to is the emotionally positive void or the emotional sensation that fills that emptiness, which fills that void. So, if you can teach kids that there are other ways to fill that void, absolutely they can let go of their chemical use.

ALEXANDER: So, you don‘t necessarily see addictions in adolescence as biological or genetic?

PALANCA: No, I did not mean to say that. I do think that there is a genetic, in many cases, in fact maybe most cases, there is a genetic predisposition to adolescent chemical dependency.

Let me give you a specific example. The mom that I was talking to this past Saturday, as she was talking about her son, one of the questions that I asked her, as we spent time on the telephone, was if there is evidence of alcoholism in her family? And, as I would have expected, she said, yes. She had a family of five siblings, she was one of five. Two of her siblings, both females were chemically dependent, one actively chemically dependent and one in recovery. Her son‘s father, the boy‘s father, is also chemically dependent, in recovery. I would say, and this is grounded in some research, that approximately 7 out of every 10 have a blood line relative who is chemically

44 dependent. I am absolutely convinced that there is a genetic predisposition to chemical dependency.

ALEXANDER: So from what they experience from their family and from the world, chemical dependency would be the treatment of choice. In other words they would be medicating themselves; this is how they would be most likely to solve the inner voids, as opposed to substituting some other method.

PALANCA: Absolutely. They have observed parents or family members, so they become chemically dependent sort of by observation. Then there is the physiological predisposition that the disease that exists, and there is clearly a disease component to chemical dependency. You can see that whether you‘re talking about a 15-year-old, or a 50-year-old. Anybody who uses chemicals in spite of negative consequences -- it is not unlike somebody who eats obsessively in spite of the fact that they are grotesquely overweight -- the reality is that there is an addiction there. There is a disorder there. We believe that that disorder, that disease, is grounded in genetic components.

ALEXANDER: Are there medications that have been helpful?

PALANCA: We have not typically medicated adolescents for chemical dependency. Now, in some cases, there has been application of psychotropic medications for specific accompanying or concomitant psychiatric disorders, whether depressive disorders or other personality disorders, but for the most part, and one of the things that is very important is that medication does not get prescribed until after a period of abstinence. And, I think that that period of abstinence has to be at least eight weeks so that you can get a clear picture of what the behavior is without any kind of mood alterations.

ALEXANDER: Let‘s talk about what you actually do. First of all, of course, you have to establish a relationship with the person.

PALANCA: That‘s exactly right, and I that that is a good question. We do the assessment. We do an assessment that looks at

45 physiological domain, family domain, academic domain -- all of the domains affect the adolescent. Then we assess the degree to which those areas have affected the adolescent.

The second thing that we do then is to determine support systems. What support systems are available to that adolescent?

Then, the third thing that we do kind of as part of the assessment is to determine, based on what‘s going on, based on what support exists, based on what resources are available, what level of care is best for the adolescent, whether it is an outpatient program, and some level of care within outpatient, or whether it is a residential program.

So, clearly there has got to be a comprehensive assessment that exists and that comprehensive assessment has got to be very much grounded in data and information with regard to the adolescent‘s chemical use.

ALEXANDER: How do you get the adolescent in and talking to you?

PALANCA: The most common way that an adolescent comes to treatment is through either the school system or parents. And I want to underscore that forcing the adolescent in one way or another, in some way or another, rarely, rarely, rarely works. I would say less than 1% of the time is an adolescent going to volunteer to be assessed, is going to volunteer to be treated. In almost all cases, there is a pretty significant push that comes from the school system, the parents, maybe a pastor. There are a variety of different people who can be positively impactful in the intervention with an adolescent. But, clearly there has to be some motivating factor or the adolescent will not come to his parents or the school counselor or the school social worker and say, ―I really would like to be treated.‖

ALEXANDER: So, how do you even get them to talk to you?

PALANCA: One of the things that is very, very important, and one of my favorite techniques is, if you, Barb, were a 16-year-old, one of the techniques that I use frequently is: ―You know, Barb, it appears that you‘re here and you don‘t have a lot that you want to talk to me about. In fact, you‘d probably rather not be here, right?‖ And, in almost all

46 cases, Barb will give me an answer like, ―You bet I don‘t want to be here,‖ and she might have some other expletives in there.

The approach I take is, ―You know, I understand that you really don‘t want to be here, but you‘re here, and I‘m here, and I have some questions to ask you. If you can give me at least some support in getting through these questions, this can be much less painful for you and I‘m going to get paid whether you answer my questions or not, so we can sit here for as long as you‘d like to.‖ Because of the fact that most adolescents want to get the heck out of the room that you have them in, they will be at least relatively responsive to those questions.

Relationship development is the first step. Absolutely the most efficient and effective adolescent programs have people working in them that can establish a relationship with kids. Now, very important, those people should be establishing a relationship with those kids should be also establishing a relationship with the referral source, should be establishing a relationship with the family members. Absolutely, there should be a family component whether the program is an outpatient program, intensive outpatient day treatment, continuing care or a residential program, there absolutely should be a very intense family program attached to that providing the family with support and didactic information around the disease of chemical dependency.

ALEXANDER: Okay, so back to the child now. Let‘s say that you have engaged them, they are willing to look at their use, a little bit anyway, what then?

PALANCA: One of the things that is very important this: I have a principle that I have operated with for a long, long time and that is, ―As long as the pain of using is less than the pain of quitting, then you get continued use.‖ So, one of the things that you have to do is try to identify that, ―There is some pain that has been attached to use, Suzie, (or Joey, or Sammy or Freddie),‖ and once you get the kid to begin to take an honest look at the fact that, ―Yeah, you know there really are some consequences that I have experienced in my life that are actually tied to my drug use.‖ Once they make that connection, it is amazing the extent to which they are willing to take a look at other behaviors

47 related to their chemical use, and other behaviors just in general, as it relates to their recovery.

So, is there an opportunity for an adolescent to make life changes? Absolutely, but they have to be exposed to the consequences, and tie those negative consequences of their chemical use to what is actually going on in their life. That is a huge part of what happens in treatment, and once they then begin to see that, they can begin to look forward and on to long term sobriety and recovery. One of the things that is essential is that kids don‘t come to a place like Hazelton for treatment; they come to a place like Hazelton for recovery.

ALEXANDER: How do you define the difference?

PALANCA: Treatment can be viewed as sort of episodic: the adolescent is here for this treatment program. Most things in an adolescent‘s life are viewed as very short term. They are viewed as very brief, are viewed as, ―Well, I‘m going to do this and I‘m going to get it done and it‘s over with.‖

One of the things that is very crucial is that he or she has to understand that recovery is an ongoing lifestyle change and a lot of that change is in small incremental changes, that if those small incremental changes occur and occur a day at a time, in some cases an hour at a time and in some cases, a minute at a time, that adolescent can move from a place of pain to a place of much less pain, if, in fact, they can understand that there truly is a better way to live.

ALEXANDER: How do you deal with the real little guys? You know, the 12 and 13 year olds who maybe don‘t have the capacity to look at themselves yet?

PALANCA: You ask a very, very crucial question. Generally speaking, it is very difficult to treat those kids. They may not have experienced a lot of life‘s negative consequences, and if a 12 or 13 - year-old is using abusively or abusively to a point where they need intervention, it is highly likely that they don‘t have the internal and external support system present that should be monitoring their behavior. Now, the 16 or 17 year old who is out of the house and on his own a lot of the time can pull off and hide, and they get very good

48 at hiding behavior. The 12 or 13 -year-old who should be more actively monitored, just because of that stage of adolescent development -- that would reflect a significant lack of parental support or guardian support that really should be there. So, it is very difficult to intervene in the lives of those kids.

What is the essential though, is to do -- you know, you would have to go back to the basics. You have to do a comprehensive assessment. You have to evaluate where the adolescent is in terms of the impact that their chemical use has had on their behavior, and you have to, generally speaking, motivate ongoing abstinence from chemical use.

ALEXANDER: Let‘s talk about some of those tiny little steps, even the minute by minute successes that a child can have. Can you give us some examples of those? PALANCA: Absolutely. But, I do want to say one other thing about the 12 and 13 -year-old: it is absolutely crucial to involve parents in this process. I know that I have said that, but, especially with the 12 and 13 -year-old, it is absolutely crucial.

You know, basic parenting is frequently something that parents need: how do I deal with my son? How do I deal with my daughter? How do I deal with issues around recovery? These are very important issues as it relates to an intervention in the life of the family of an adolescent who is chemically dependent. That family can be defined as a blended family, a nuclear family, mom only, dad only, aunt only, whatever, in spite of their family configuration.

Now you asked about some of those minute by minute successes: a kid just getting up in time to get to a morning lecture; a kid getting up and showering before he comes down for breakfast; a kid experiencing laughter as a result of something that is actually funny, that everyone else laughs about, and then can talk about what it is that precipitated that laughter. Some of those kinds of things that some of us who are living a relatively normal and healthy life take for granted, those can be very definite minute by minute successes that you have to reinforce positively with the adolescent. Many of these adolescents have not had positive reinforcement for doing even the little things well. So, you have to, in as many cases as possible, reinforce the little things.

49 ALEXANDER: Do you worry about suicide in some of these children?

PALANCA: One of the things that our data does tell us is that there is an increase in suicide with adolescent females and with adolescent males over the last 7 to 10 years. So, yes, there is a concern, particularly when you take the drugs away from a kid. Those drugs have been filling a certain amount of a void and taking away a certain amount of pain, so that has happened. But, kids are far more likely to have suicidal ideation and actually commit suicide when they are under the influence than when they are sober. So, yes, it is a concern as a result of beginning and early abstinence phases, but a kid is far more likely to be suicidal and/or have suicidal ideation when they are using.

ALEXANDER: Again, let‘s go back about 12-steps for kids. Do you have them attend AA meetings and NA meetings? Are they especially set up for teenagers?

PALANCA: Yes, there are young people's AA meetings. There are young people's NA meetings. There is extreme value in Alcoholics Anonymous and Narcotics Anonymous. I believe that and we at Hazelden believe that the Alcoholics Anonymous and Narcotics Anonymous, the 12-step programs -- they are free, they are accessible, they are available wherever a young person goes or wherever an adult goes. There are consistent programs for family members as well, Families Anonymous, Ala-Non, Ala-Teen for brothers and sisters of, or kids who have parents who are chemically dependent -- those programs are absolutely crucial for the adolescent who is chemically dependent. Absolutely crucial for long-term sobriety and recovery.

ALEXANDER: Do they work the steps in the same way that adults do?

PALANCA: Absolutely. We sort of summarize the first three steps as, ―I can‘t do it, I just can't continue this lifestyle that I'm in anymore.‖ The second step is, ―I can get some help from a higher power and the group,‖ that is Alcoholics Anonymous and Narcotics Anonymous, and the third step we summarize as, ―I think I‘ll let the group help; I'll think I‘ll let my higher power help.‖ That is an extraordinary indication of surrender that an adolescent has to make as one of the very important precursors to ongoing recovery.

50 ALEXANDER: Then what does the adolescent do in terms of his or her own peer group, because unless you take the child and put them out of the desert or something, they are going to be home, back with their friends. That is going to take a great deal of strength for the child.

PALANCA: You‘re absolutely right, and it is why it is absolutely crucial, and even more so, reinforces the need for Alcoholics Anonymous, Narcotics Anonymous and sober groups. Many schools now have sober groups and support groups inside the school systems. Many, many, many of the suburban schools in Illinois and the suburban schools in other parts of the country have support groups inside schools for kids who are trying to stay sober. You asked a very good question, but there are those groups that are available for kids.

ALEXANDER: Let‘s go back to the parent groups because we have said that they are educational, but what are we really educating them on?

PALANCA: One of the things that parents have to have a clear understanding of is specifically, ―What is addiction?‖ What is their role in the addiction process? They have to understand that. They have to understand drug use and the role that drugs have played in their family's life. They have to have a clear picture and an understanding of the stages of addiction. What is their role in the addictive process? What is their role in the recovery process? Are there issues between mom and dad? Are there issues that are sort of parenting in nature? We do a lot of basic, ―This is how you parent an angry adolescent.‖

I should say a couple things about angry adolescents. You know, we have thought for years about anger being an emotion. Well, we believe that anger is not so much an emotion, but it is kind of a reaction to emotions like ―hurt‖ and ―being displaced‖ and ―being resentful‖ and ―feeling left out.‖ Many, many adolescents are walking around as angry time bombs. Parents are often walking around as angry time bombs because of the fact that they have had a lot of their hopes and dreams for their son or daughter dashed by this thing called, ―chemical dependency.‖ So, we allow them a place to talk about their feelings relative to their son or their daughter who may be chemically dependent, who maybe didn't get into the school that they wanted them to get into, maybe didn't make the team that they wanted

51 them to get into, maybe actually has failed in many courses, or has actually chosen not even to go to school. Or maybe a teenage daughter has gotten pregnant.

Now, one of the things that parents need to understand is that they are not alone in the process. They need to understand that there are other parents who are dealing with exactly the same thing that they are dealing with and that there is support there for them.

ALEXANDER: You‘ve covered a broad sweep in this topic and maybe there are some things that you would like to add before we close.

PALANCA: Actually, I have a list 21 things that I will give to you to take with, but I think that it is important list of things that what adolescents need as it relates to both kind of facilitation to help them stay on the straight and narrow, but also as it relates to their development. One of the things that I think is key and crucial is this list of 21 things.

ALEXANDER: The listener or reader will find that list at the end of this transcript.

Now, here is a question that therapists get asked a lot by parents. The parents will ask, ―Do I go into my child's room and search through my child's stuff?‖

PALANCA: Barbara, you might not like my answer to this but my answer is ―Absolutely.‖ There is no question that if a parent suspects that there is something going on in their son or daughter's room, in their son or daughter's whatever, that is subject to being responsible for creating problems or issues in their life, should they pursue it? Absolutely. Now, should they do this out of the gate? No. They should make attempts at communication. They should make attempts at confronting the issue, but if they feel as if there is something going on, they have to pay attention to their gut and pursue the information. Kids really do become chemically dependent; families really do become co-dependent. It is extremely important to recognize that kids and family can, will, and do recover.

ALEXANDER: Thank you very much for doing this interview with us.

52 PALANCA: Thank you Barbara, it has been a pleasure.

(ALEXANDER: Following this interview with Peter Palanca, I had a few more questions to ask him. So, we will now have a postscript.)

ALEXANDER: Peter, in the interview that we did, you described a line of drug use ranging from occasional to addiction, and what I want to further ask you about is this: what in the child propels the child along the line from experimentation to the more pathological addiction, and if you had any thoughts about that.

PALANCA: Yes, I think that there are several things, Barbara, that I would point out. The first is the notion of parental use. You know, there are varying statistics on what percentage of parents, parent/children who become chemically dependent or who become, at least, abusers and the percentage is significantly high. Probably in the neighborhood of 7 to 7-1/2 out of 10, there is an indication that there is at least one parent, in some cases both, who will have substance abuse related problems. I think, as a result of that, the offspring learns that the way to deal with stress, the way to deal with challenges in life is through substances. Sort of like ―Weekends were made for Miller,‖ or if you need to take the edge off, there are a whole variety of chemicals, both pharmaceutical, illegal, as well as alcohol that can take the edge off when necessary, and that is a lesson that gets learned early on, as well as the genetic predisposition that comes from parents who are substance abusers.

The second area that I would talk about, that I think is an extremely important one to note is the whole self-esteem area: the typical adolescent who does not have a positive sense of self, hasn't been affirmed by parents, hasn't been affirmed through school systems, hasn't been affirmed in ways that would create a foundation and a basis for the adolescent to feel good about himself or herself. There is often a strong indication that poor self-esteem is clearly one of the foundations to adolescents who have substance abuse related problems.

The third area is an area where when those adolescents make friend choices, make associate choices, make peer choices that are negative and negatively influence what they do. They become part of a drug-

53 using culture as a result of the friends that they pick, and they begin to feel good about that drug culture and those friends that they've chosen, primarily because they have this bond, this camaraderie. That camaraderie and that bond is often based on their ability to use drugs and alcohol together. Those are three areas that are extremely, extremely important.

The other is one I believe is often very characteristic of the whole range of kids that develop problems relative to substance abuse and problems in other areas of their life is that those adolescents have a lots of free time on their hands, kids that are simply not busy. They don't find that school is an interest; they don't find that extracurricular activities are interesting; they don't find that work as an interest; they don't find an interest even in personal relationships. They end up having a lot of free time, a lot of time on their hands to do their own thing, time when they are unsupervised, time when they are in a position to make the negative choices that often lead to drug use.

The other, final area that I would talk about is the classic adolescent who has a life‘s view that is relatively negative. The classic, and if I can depart from my professional reference here, the attitude that says, ―You know, life just kind of sucks.‖ It‘s that kid that almost erases how badly he or she feels about life and that life has dealt them a poor hand, and they escape from that through their chemical use. It is that chemical use that becomes problematic, and then they develop such an intense relationship with chemicals that that relationship becomes the single most important relationship in their life. So, it is that openness to the relationship with chemicals that they have that is often motivated by this lack of life‘s goals and areas in their life that they might reach out to in a more positive way, things like school, things like extracurricular activities, but it is that lots of free time on their hands to sort of make negative choices, and then the view that ―life has just not dealt me a very positive hand.‖ Those five areas are areas that I would be very, very, very concerned about if at least two or more were present with an adolescent.

ALEXANDER: If a child knows that something is going to be hurtful to them, self-destructive, damaging, they could die, maybe, what would make them choose to do it?

54 PALANCA: Most adolescents, in fact, I can tell you probably 95% of adolescents that I have worked with in my career have always had the attitude that says, ―It‘s not going to happen to me. It just will not happen to me. It might happen to those kids on TV, it might happen to those other kids that are just kind of stupid, but it's not going to happen to me.‖

ALEXANDER: Yes, the adolescent omnipotence is...

PALANCA: Adolescent omnipotence and the denial that is often characterized by the adult alcoholic, or the adult chemically dependent person, is often the same denial that characterizes the adolescent‘s view that says, ―There is nothing bad that is ever going to happen to me. I'm beyond it, I'm above it, and I‘m going be okay in spite of what I choose to do. I'm gonna be okay in spite of what I choose to do. That means that I can take two hits of LSD before school, I can drink eight beers and get behind the wheel of a car, I can engage in promiscuous sex while I'm under the influence and (if I'm a male) pregnancy is not going to develop, I'm not going to get a sexually transmitted disease.‖

Adolescents thrive on new experiences and often high risk experiences and so it is that adolescent who has this attitude that says, ―You know, I can try anything.‖

There is a certain amount of tacit acceptance, or tacit approval that occurs, I think, with over-the-counter medications, over-the-counter drugs that reflects, ―If they‘re over-the-counter, if my parents do them, if I see other adults doing them, if people do them on TV, they are not going to negatively affect me.‖ So, it‘s that kid that has the attitude that ―I can do whatever I want to do and it is not really going to have an impact.‖

The other area that I would certainly want to have people be aware of is, the whole area of secretiveness. Kids with substance abuse problems are often extraordinarily secretive, whether it is an adolescent female or an adolescent male. That whole secretive behavior, that whole orientation toward, ―I'm not going to let anybody know what is going on in my life, particularly my parents or an adult,‖ is something that we need to be particularly concerned about.

55

To contact Peter Palanca, call (312) 943-3534.

This concludes our interview with Peter Palanca. We hope you have learned from it and that you enjoyed it.

As always, I must say here that the views expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority.

Until next time, this is Barbara Alexander. Thank you for listening.

56 WHAT DO ADOLESCENTS NEED? Peter Palanca

Adolescence: A kid said to me at an Illinois Teenage Institute on Substance Abuse, ―A lot of people have talked about alcoholism being a disease. I think adolescence is a disease.‖ Recovering adolescents need more than abstinence. They need a new way of life.

ADOLESCENTS NEED…

1. CLEAR LIMITS SET: What is safe and acceptable and what is not? What are the consequences? No second chances. Eliminate as much gray area as possible.

2. DISCIPLINE: Which carries over into every area of their lives. Discipline should be consistent and fair.

3. POSITIVE ROLE MODELS: Do you know teachers who discuss ―partying‖ with kids? Teachers and other ―caring adults‖ are selling dope.

4. OPPORTUNITIES TO HONESTLY EXPRESS THEIR FEELINGS AND THOUGHTS.

5. PERMISSION TO FALL AND RETURN: Not necessarily to accept the behavior, but to accept the kid. Tolerance for mistakes.

6. OPPORTUNITIES TO LAUGH AND BE HAPPY.

7. OPPORTUNITIES TO BE SUCCESSFUL IN SCHOOL, AT HOME, IN THE COMMUNITY, WITH PEERS, ETC.

8. STRUCTURED FAMILY ACTIVITIES: Church, Holiday, Meals, Movies, etc.

9. CONSISTENCY: It‘s lacking everywhere – with friends, school, policy, parents and rules and regulations in general.

57 10. ENCOURAGEMENT TO TAKE RISKS.

11. ACCURATE INFORMATION: About drugs and alcohol; also about crime, sexuality and other areas which might promote fear and uncertainty.

12. COMMUNICATION WITH ADULTS/PARENTS: Nichole: Can Stacy sleep over? Mom: No, I just don‘t like Stacy. Nichole: I don‘t either; I just want somebody to sleep over.

13. SUPPORT FROM IMPORTANT ADULTS IN THEIR LIVES.

14. TO BE TRUSTED BY IMPORTANT ADULTS.

15. GENUINE COMMITMENT: From teachers, counselors, ministers, priests, etc.

16. POSITIVE PEER INFLUENCE: A helpful friend.

17. TO BE ENCOURAGED TO BE RESPONSIBLE.

18. TO BE RESPECTED.

19. TO BE TOUCHED: I think it is incredible that we need a bumper sticker to remind us to hug our kids.

20. TO BE LOVED: Genuine and real.

21. A HIGHER POWER: As AA refers to it. Being greater than themselves to whom they can pray and ask for help and guidance.

Peter Palanca Executive Director Hazelden Chicago 867 N. Dearborn Chicago, IL 60601

58 © On Good Authority, Inc.

Interview #4: “EATING DISORDERS”

JOAN EBBITT, LCSW

Interviewed by BARBARA ALEXANDER, LCSW, BCD

(Edited slightly for readability)

JOAN EBBITT, LCSW 128 N Main St Adrian, Michigan 49221 (517) 266-6666

Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are reading or listening to an interview from CD #2 in our program, ―Addictions A.‖

In this interview, Joan Ebbitt presents the clearest understanding I have ever heard of how eating disorders develop. To sum it up, like the old joke about ―How do you get to Carnegie Hall?‖ full blown eating disorders don‘t just happen; it takes a lot of practice to get there.

Joan Ebbitt is a Licensed Clinical Social Worker, licensed to practice in Illinois and certified to practice in Michigan. In private practice, Joan specializes in the treatment of eating disorders. She has developed eating disorder programs in Illinois, Texas, Connecticut, Colorado, Alabama, and Michigan. Currently, Joan is the Eating Disorder Consultant for Guest House for Women Religious, located in Michigan. She is also the Eating Disorder Consultant for the Archdiocese of Chicago, and conducts an Eating Disorder Group for Priests of the Archdiocese. Joan is the author of several books, video and audio tapes, and articles about eating disorders

59 ALEXANDER: Joan, we are here to talk about eating disorders and let's begin by giving our listeners an idea about what your general orientation is to the problem.

EBBITT: My orientation with eating disorders is that I come out of an addictions background. I treated alcoholism and other addictions before I knew about eating disorders and had any idea how to treat them. So, my bias, in a sense, is that I generally view eating disorders as addictive illnesses.

However, I don‘t see them as exactly the same as alcoholism or other drug addictions. I think that there are components to them that include physical but we don't know yet about physical craving. I think that there is so much in terms of learning about how the body is affected that there will be a piece that will show up as an addictive component to the illness.

I also think that there is a great deal of compulsion and mental obsession related to the eating disorder and in turn, I think that affects one's what I would call, ―spirit.‖ That is my addictions background showing up in the sense that I think that people's spirits are affected when they feel depressed, when they feel not themselves, when they feel not able to relate to other people. I think when you spend most of your day being obsessed about food or obsessed about your body, it is pretty difficult to be aware of yourself or in a healthy relationship with others.

ALEXANDER: Have they found already something about eating disorders stimulates the production of endorphins and that that part is addictive? Or is that kind of making this thing pleasure where it isn't pleasure?

EBBITT: Well, speaking as a nonscientist, I would definitely say that what we're learning about the brain chemistry is that certainly, what people put in their mouths affects what happens in the brain, not just in other parts of the body. We know a lot about how serotonin levels are affected when how people are eating carbohydrates. Women, frequently before their menstrual cycle will say that they have more craving for sugar or other high carbohydrate foods and, in fact, there is some proof that the

60 serotonin levels are really affected when they eat these foods. So, I think that maybe hopefully, in the next five to ten years, we will really begin to learn more about the chemical component. So, this isn‘t strictly ―the Joan Ebbitt bias‖ but I do think that there is something about the nature of the chemical component that does affect people with eating disorders in an addictive manner.

ALEXANDER: Let's get down to defining our terms. Tell us something about how you identify eating disorders and how the categories work for you.

EBBITT: When I talk about eating disorders, the definition I use would say, ―Eating disorders exist when a person‘s use of food, or rituals and practices around the use of food, grow to the extent that it causes increasingly severe problems in the major areas of one's life.‖ In other words, it's not the food that causes the eating disorder; it has to do with the rituals, the practices, and all of the rest. We began to look at how the eating behavior is affecting one‘s major life areas before we really say that there is an eating disorder here. It's not enough to look at body size; it's not enough to look at eating pattern. What we have to do is take all of those things together and see how this person‘s eating behavior is harming their life. When I talk about major life areas, I‘m talking about such things as home and family life, physical and mental health, emotional health, finances, social life, spiritual life, all of those kinds of things.

ALEXANDER: I think that most people would probably agree that anorexia and bulimia are eating disorders, but let me step out of that for a minute. Would you say a 12-year old premenstrual girl who declares herself to be a vegetarian and drives everybody nuts with what she will and won't eat -- and I think that we are seeing a lot of little girls being vegetarians and being very restrictive and controlling and what they will and will not eat and making a lot of demands on their families. Would that fall into something like an eating disorder or would you say that that is more like a child and parent issue?

EBBITT: Well, how about some of all of the above. I think when we are talking about our culture, sometimes I say, ―What is the

61 difference between an eating disorder and the rest of normally neurotic America?‖ and we kind of laugh at that but it is really true. Our culture is obsessed with its body these days. Research tells us that most girls have been on a diet at about age 8. It used to be age 10; it's moving backwards. So, when we find a 12-year-old girl who is already experiencing symptoms of anorexia in that they may be declaring that they are vegetarian or they may be skipping meals and doing those sorts of things, the really difficult part, unless they are very far advanced in the anorexia, is to know if this is a teenage phase, if this an adolescent phase, or if this really an eating disorder.

What you have to begin to look for is not so much body weight but behaviors around the eating. Do they eat with members of the family? Are they skipping meals? Are they coming to the table and just sort of pushing food around on their plate? Are they saying constantly, ―Oh, I already ate with a friend?‖ Is their mood changing? Do they seem more tired? Are they more lethargic, more depressed? All of those sorts of actions and behaviors need to be considered when we are looking to see, ―Is this really an eating disorder?‖

ALEXANDER: You can‘t make the diagnosis or assessment by one piece of behavior.

EBBITT: No, it‘s really impossible to do that. I mean, I think that we can say, when we look at anorexia, most of us when we hear the word think of the stereotype: the 13-year-old girl who is emaciated, whose eyes are bugging out, whose hair is falling out. What we are really talking about there is someone who is probably in the late stage of the illness in terms of -- think about an alcoholic. When we think about the stereotype of an alcoholic, we see the 45-year-old man shuffling down skid row with a bottle in a bag. Well, we have come light years from that. I think, in terms of anorexia in particular, the meaning of ―anorexia‖ is fear of being fat. And, if we could begin to hear their preoccupation, if we could begin to see the other behaviors before they've lost all of their body weight, we could probably began to deal with the illness sooner. But, we are so conscious of somebody's body weight as the eating disorder, that we wait until it's often too late to begin to deal with it. We need to be listening better and knowing the symptoms better.

62 ALEXANDER: So, what should we be listening for?

EBBITT: Well, I‘d like to talk about any eating disorder. Of course, the popular ones so to speak are anorexia and bulimia, with bulimia meaning ―having the appetite of an ox.‖ This is kind of funny because I think sometimes, the medical community uses their own secret words like every community has their own secret words and social workers do and the policeman do and the doctors do, and we all have our own little secret language. I think if a doctor wrote on a patient's chart, ―This patient has the appetite of an ox,‖ I'm not too sure that someone would see that as a serious problem. But, in fact, bulimia does involve gargantuan hunger, binge eating, sometimes purging by vomiting, purging by laxative use, purging by using water pills, by over-exercising.

One of the things that I think that we need to begin to do is begin looking at the commonalities across these eating behaviors. We tend to view anorexic behavior as being very different from the behavior of someone who is binge eating and especially someone who is binge eating and also who is overweight. We focus on what‘s different.

I would like us to begin focusing on what is same. So, one of the first things that I think is important to do is to look at what I call, ―the eating line.‖ We all have to eat to stay alive. We know that.

I think that we all eat at various spots on what I call the eating line. At one end of the line is ―too much food‖ and at the other end of the line is ―not enough food.‖ Somebody who develops an eating disorder does not start out at one end or the other end of the line. Frequently they start out someplace around the middle. No one eats on one little dot, but people who don't have eating disorders swing back and forth in a much smaller arc than someone who develops an eating disorder. So if I don‘t have an eating disorder and I've been to a party and I‘ve eaten too much food, the next day I might naturally monitor myself and say, ―Geez, I ate so much food last night I‘m not very hungry today.‖ So, I monitor it myself. It is kind of a natural, built in behavior.

63 The person who develops the eating disorder, however, becomes unable to monitor that behavior. There is a mechanism in our brain that I call, ―the appestat,‖ which basically tells us when to stop eating, when we‘re full. In many who develop eating disorders, that mechanism doesn't work properly. So, it takes much longer in those individuals for the brain to signal the rest of the body that the person should stop eating and is full.

Let's talk about someone who might develop anorexia. Supposing they start out at around 10 pounds overweight. The first thing that they say is, ―I‘m going on a ‗diet,‘‖ our favorite word. I kind of kid about that because when we think about ―diet,‖ we think of words like ―being deprived,‖ eating carrots and lettuce and cottage cheese, although they don't even consider that a very good one anymore. But, anyway you don't exactly think of ―fun food.‖ You think of just being deprived. So, our notion of going on a diet is that we rush over on the end of the eating line to ―not enough food.‖

The person who develops anorexia has to practice getting good at it. So, when they get over to that ―not enough side,‖ the body starts to cry out and says, ―Give me some food! I'm hungry. You're punishing me.‖ And, because he or she has been starving, instead of swinging back to the middle, which is what I call, ―moderation,‖ they swing all the way over to the other side, the ―too much side.‖ They become horrified. ―Why have I done this? I've eaten too much. I‘ll never do it again,‖ and on and on.

Well, as they develop the anorexia, the pattern begins to look like this: ―not enough food/ too much food; not enough, not enough/ too much, and the line keeps swinging towards the ―not enough‖ side. It takes them quite a while to get all the way there. By the time they are all of the way there, when we see the emaciated body, that is when we see the real sickness, the late stage, as I call it. But, the important thing is this: this anorexic person is obsessed with food and obsessed with his or her body size.

Now, on the same token, a person who is a binge eater or a compulsive eater and develops obesity may start out in exactly the same place as the anorexic. Maybe they're 10 pounds overweight. You know, obese people do not start out at 400 pounds. It takes

64 practice to get there too. They do the same thing, they go on a diet, and they swing over to the ―not enough‖ side, but as their illness develops, their pattern begins to look like, ―not enough/ too much;‖ ―not enough/ too much, too much,‖ until they finally end up all of the way on the ―too much‖ side. They are also obsessed with food and obsessed with their body size.

Then we have the bulimic, the bulimic who may or may not be at normal weight, the bulimic who is binging and purging in some way. The bulimic simply swings back and forth, ―not enough/ too much,‖ ―not enough/ too much,‖ and so on.

In all three of these cases, what were seeing is obsession with food, and obsessing with changing one's body size. Even though, in general, our culture says, ―But these folk's are really different,‖ I think that the more that we learn about eating disorders, the more we‘re seeing that they're not so different after all. The journey that the eating disorder itself takes is a little bit different, but, the obsession and the preoccupation with food and body size remains the same. We really have to deal with that in order to deal with the eating disorder.

I would like to throw those words way. We hear the words, ―compulsive overeater,‖ and we immediately think of someone who is obese. Well, in fact, anorexics sometimes compulsively overeat, just like the obese person sometimes compulsively under-eats. I think, if we could throw those words away, especially ―anorexia‖ and ―bulimia,‖ I would call it an ―eating illness.‖ Then I think that we could begin to focus on the real issue: the eating behavior, and not on the weight. That is a tough lesson to learn, that we have to stop focusing on the weight, because if we began to focus on the eating behavior itself, we will in fact, help the weight do what it needs to do.

Now, unfortunately, with weight, if a person has been very advanced in her anorexia, let‘s say, when she begins to get well, if her arms and legs have begun to atrophy, what sometimes happens is that as she gains some weight, she gains it more in her trunk than in her limbs and so that is a very unfortunate consequence that they have to deal with as part of their recovery.

65 The obese person on the other hand, has more and larger fat cells, and especially if they have a history of childhood onset obesity and/or genetics that play a part in that picture, they have to settle for the fact that they may not get to the magic number. They may be able to begin eating reasonably well, and they might have to settle at a weight number that is higher than their magic number, and that is a consequence of their eating disorder as well.

ALEXANDER: Let me ask you about one more thing, and that is the concept of splitting. Is that something that you think about? In other words, one part of the person will say, ―I really can't make myself eat so much. I really can't let myself eat so much.‖ And, they are saying this on one side of their head, and a plate of cookies is on the table and while they are eating cookies, they are actually saying this, ―I can‘t do this, I can‘t do this.‖ There is a split. Is this something that you find occurring?

EBBITT: I think that that is pretty common with most illnesses that have addictions involved in them. I think that the alcoholic that is at the bar and continues to order drinks and says to himself, ―I really need to stop. Everyone is going to be upset with me. I'm going to get in trouble with the job,‖ and they can't figure out why they keep doing it.

I think in the case of eating behavior, it happens culturally, in many ways, because food is a reward in our country. If you're a good boy or a good girl, you get treats. Food is ―love‖ in our country. Look at all the commercials on TV that say, ―Nothing says ‗lovin‘ like something from the oven,‖ etc, etc, and so we get these strong messages that food is love. And, on the other hand, we have the obsession in our country with, ―be thin, be thin, be thin.‖

So, if our culture is split, I think it would follow that the individual hardly has a chance because they are getting it at home, they're getting it at school, they're getting it on TV. Look at the television shows that make jokes about, ―I've had a bad day,‖ open the refrigerator, get out all of the food. That is a really big thing on some of the TV shows these days. So, I think that as a culture were split, and I think as individuals were split. It‘s very hard to deal with.

66 ALEXANDER: Now, most therapists and counselors don‘t see the end stage, particularly, I don‘t think, do you? What would we usually see in our practice? The reason I ask this is because it is so easy to identify when it is the late stage in the problem, but it is when it is in the beginning or the middle, we may get the person in for some other problem: when it‘s a teenager, it might be some kind of school or a behavior problem; and with an adult, they might come in for depression or something else. How do we know, if it's not late stage, how do we do the identifying of this problem?

EBBITT: I think that we have become rather sophisticated at knowing that when someone comes in for an assessment, we automatically ask them about their drinking behaviors. I think that we have to learn to do the same thing with eating disorders. In fact, I think using a screening tool is pretty important. The interesting thing is, when you ask these questions, especially about the eating, they'll be honest with it because in some ways they kind of joke about it. They say, ―Oh, yeah, I eat too much‖ blah, blah, blah,‖ but I think that it is really important to actually do a screening, and I am going to review some of the questions here that I would ask. I think that if we don't do the screening, sometimes therapy goes on and on and on, and there is never any movement in the person. Well, many of us have had the experience of dealing with an active alcoholic and not figuring out right away that they are alcoholics. And then finding out that the person has been drinking. So, that is one of the reasons that they cannot move in their therapy.

When someone has an active eating disorder, it affects them in the same way because it affects memory, it affects emotions and it affects all of those kinds of things. If I come to therapy for an hour and leave therapy and go out and binge my brains out, I‘m not very likely to be able to deal with the issues that happened in the last hour. I've sedated myself. That happens as a matter of course. If I‘m starving and not getting enough food to the brain, I also may not be able to focus very well. I may not be able to concentrate very well and I may not be able to remember.

Alcoholics have blackouts in which they continue to function, but they don't have memory of parts of their day, sometimes a whole day, because of what has happened to them with the drinking. I

67 think that eating disordered individuals have what I call, ―vague outs.‖ They are frequently scattered; they remember bits and pieces of things. They have trouble focusing, concentrating, and the thing is because we don't know that that can be a symptom, we just say, ―Oh, that's just the way Mary Lou is. She's always been scattered. She's like that. She has to write everything down.‖ Well, maybe Mary Lou has to write everything down because she is in an active eating disorder.

So, it's really important when we‘re beginning to deal with someone in therapy that we screen for chemical dependency as well as eating disorders. Some of the questions that I would ask, just in using a simple screening tool, and these questions do relate to the DSM criteria for eating disorders, are these: Does your body weight often change more than 10 or 15 pounds? In other words, how many times have you been up and down the scale? Are you pre-occupied or extremely concerned about your weight or body size, about food, about dieting? Once you start eating, do you feel like you might not be able to stop? I think that that is a very telling question because that might relate to what's really going on with the brain chemistry. Normal people, people who do not have eating disorders, would usually so, ―No, I can stop. I stop when I'm full.‖ People with eating disorders routinely say, ―Yeah, once I start, it is really hard to stop. I have to use sometimes some kind of external stimuli to get me stopped. Either, I can either have this much food that is on my plate, or I need to take away the extra food at the beginning of the meal. I need something outside of myself to be my locus of control.‖

Another question: have you ever vomited or purged yourself in any way? That is kind of an obvious question. You know, have you ever taken water pills? Have you ever taken laxatives to lose weight? If you ask them, ―Have you ever vomited to lose weight?‖ I think that the difficult part with that is, many people say, ―Oh, no.‖ Then, I might rephrase the question to say, ―Have you ever eaten so much that it made you sick and you had to throw up?‖ Then some individuals will say, ―Well, yeah, that's happened to me.‖ They've gone in the bathroom, they've induced vomiting, and they say, ―But I'm not bulimic.‖ Well, that is bulimic behavior. But, two reasons that make them think that they're not bulimic: first of all, if they

68 have obesity, they automatically say, ―I don‘t have bulimia.‖ They just don't think that they have it. Secondly, they think that the vomiting has to do totally with the body weight or wanting to lose weight, and in some cases it is simply a matter of, ―I've eaten so much that I have to make myself sick to get rid of the food.‖ So, I think that rephrasing the question sometimes is important.

Sometimes I also ask them -- it is very important to ask them, ―Have you used diet pills, over-the-counter diet pills?‖ One of the big things is Dexatrim, and there are lots of over-the-counter diet medications, and I think that it is very important to look at that and individuals because a lot of them will say, ―No I've never used speed; I've never used amphetamines. But, oh yes, I've used all kinds of over-the-counter stuff.‖ So, I think that it is pretty important to ask them in the screening some of these questions and then if they're saying, ―Well, yes I do that,‖ then that is a sign that we have to ask them even more questions.

One thing that I would like talk about also is that we‘re used to, especially if we‘re dealing with individuals in our practices who have chemical dependence, we‘re used to looking at workplace issues. We‘re used to looking at symptoms that the family might experience because of the eating disorder. It is amazing how many of those symptoms can relate to the same type of behavior as chemical dependence.

For example, when someone has an active eating disorder, they may experience things like on-the-job absenteeism: they may be away from their desks; they may be down at the candy machine buying candy; they may be in the bathroom weighing themselves. I had a client who went into the bathroom about 10 times during the day at her workplace -- it was a private bathroom. She took off all of her clothes and she weighed herself and put all of her clothes back on and went back to her desk. Well, think about the time. If she was going 10 times a day, I would guess that that is it about a 10 minute minimum, where we are talking about 100 minutes lost. That's a lot of time on the job. So, on-the-job absenteeism is one.

Sometimes taking longer lunch hours, going in the bathroom right after lunch, sometimes to purge themselves. Keeping candy, junk

69 food, all of that kind of stuff in the desk drawer, eating it all day, feeling groggy, those kinds of things affect the job. We might notice that someone's production is not up to par and, in fact if we are the employer, that‘s what we need to focus on: are they doing the job?

But, as a therapist or a counselor in practice who is talking to a patient, it is very important to talk about what is happening to you on the job. How is your concentration? How is your focus? Are you falling asleep? Are you absent? Are you coming late? Are you leaving early? Do you have excessive sick leave? I think that it is very important to talk about that.

One of the many physical symptoms, but one of the common physical symptoms and illnesses that eating disorders individuals develop is irritable bowel syndrome. If someone comes in and tells me that they have a history of stomach and bowel problems, boy, that is an alarm going up to talk about the eating behavior. Now, there are individuals who have irritable bowel who don't have eating disorders, but there are a high number of individuals with eating disorders who have irritable bowel. It does relate to stress, but it also relates to what they're putting in their mouth. When they are constantly binging or starving, or eating all of the wrong kinds of food and then trying to go on these crazy crash diets, that really does affect the digestive system.

Personality and relationships on the job -- I think that a lot of times, individuals with eating disorders experience things like overreaction, being moody, being forgetful, being edgy, being irritable, and those can relate to, ―If I'm starving all day, that might make me pretty crabby. If I am advancing in my starvation, I might respond very slowly to other individuals who are speaking to me because my brain has to work twice as hard because I don't have enough food to nurture the brain, to think.

Looking directly at the work performance then, the employer can look at things like: missed deadlines; mistakes because of poor judgment or inattention; complaints from coworkers about this person's behavior or what's going on with them; difficulty handling

70 details or reading instructions; alternating periods of high and low productivity. That's not unusual.

There is one more thing that I want to say, though, about the job performance. People with eating disorders sometimes don't do any of the behaviors that I just said. Sometimes, in fact, they are your star worker. They work 10 times as hard and twice as fast and that frequently relates to how they feel about themselves: people pleasing; trying to be the good guy; trying harder because they don't want anyone to catch them in what is going on. So, you can see either/or: sometimes the super perfection person; and sometimes the person who is having really serious job problems.

I want to address a term that actually I coined when I was working in an inpatient treatment setting many years ago and the term is ―spinning.‖ In the Chicago area, we hear that word often amongst the treatment community and sometimes amongst patients who are recovering from eating disorders. When I talk about spinning, I'm talking about the thought pattern that frequently accompanies eating disorders. When I first dealt with eating disorders, I wondered if many of the patients had actually mania. They frequently presented as being in an almost perpetual manic state: they had rapid paced thought patterns; moving from topic to topic very quickly; fragmented thoughts -- all of those kinds of things that we sometimes see in kind of mania or agitated kinds of depression or so on.

What was amazing, was that after they had been following a food plan of healthy food, you know three meals a day, snacks, whatever they needed, but eating balanced and in a healthful manner, it took about anywhere from 7 to 10 days and they would report, after 7 to 10 days, and it was also observable, feelings of calmness, better concentration, less irritability, better ability to focus on things, not so tired, not falling asleep all of the time and there was a real observable change in how fast they talked.

We began to see that while it was not a pattern that is always unique to a person with an eating disorder, but we began to see that this pattern was sort of common. The person with the eating disorder never lived in the present moment. They were always spinning, so

71 to speak, from the past to the future to the past to the future. So often they were focused on their weight and their body size and their belief that if they could just change their weight, they would live happily ever after: they would get the brass ring; they would get the good-looking husband or wife; they would get that great job; they would get everything, because their focus was always on, ―When I change my weight.‖ It didn't matter if they weighed 60 pounds or 400 pounds.

Sometimes they would brood over the past. ―Why do I do this?‖ they would ask themselves over and over again. ―Maybe I do it because of how I grew up. Maybe I can't change my eating and my weight because of my family life, my school life, because of abuse issues that happened to me in the past,‖ and they would brood a lot about the past.

Then, they would jump from there to the future, saying, ―I know what I'll do, I'll just go on this diet. I'll move to California and eat green leafy vegetables and get a lot of sunshine and walk and it will be great,‖ especially when we‘re sitting in a snowy day. But, they would just constantly move back and forth.

With that kind of constant movement, coupled with the eating or lack of eating that they were doing, they were almost never in the present moment. So, we would talk with them about the need to change this spinning thought pattern. When we would talk about that thought pattern with patients or clients, sometimes it was amazing, because they would say, ―How did you know? I always thought like that; I thought everybody did that.‖

Then, when they were able to follow a healthy eating plan long enough that that started to change, they were amazed at how calm they became, at how present they became, at how able they were to pay attention, because paying attention is very difficult for someone in an active eating disorder. So, I think that it is important to pay attention to that.

ALEXANDER: In establishing a relationship with a person with an eating disorder, what are the pitfalls and what are the most important things to do to engage this person in looking at their eating disorder?

72 EBBITT: I think that looking at an eating disorder takes many, many, many years. The layers of denial that we attribute to alcoholism are great, but at least the world is out there trying to educate us. We open a magazine: ―Are you addicted to drugs?‖ Take this test.‖ We‘ll see information on TV about alcoholism, treatment centers, we are aware of those today. With eating disorders, what we see is, ―Come to this weight-loss program and we will give you the magic answer.‖ That's what we see on television.

So, we first need education. From the time that someone begins to even look at the fact that maybe there is something wrong with the eating, until they really began to address the issue, it can take years. In engaging someone to address the eating disorder, if someone comes and says, ―I know that I have an eating problem (they usually don't even say that -- they say ―I have a weight problem‖). Help me. I‘m not sure if they're ready to be helped yet. They know that they cannot deal with their eating and their weight. So, I think that one of the very important things to do is to begin educating them.

They need to learn that they have an illness and it's not their fault that they have it. If they can learn that, they have a chance of getting well because most people in this culture who have an eating disorder blame themselves over and over and over again. When you talked earlier about the split, asking themselves, ―Why do I do this, and then I eat the cookies?‖

One of the things that is important to begin teaching them is to stop asking, ―Why do I do it?‖ You may not know why for years and years or you may have many reasons why. Maybe you were abused; maybe you weren't. Maybe you learned to cope by eating or by starving and so when we look at that symptom of the illness, using food for relief, starving for relief, vomiting for relief, individuals with eating disorders learned to use that mechanism to cope with all of their problems. So, if we stick with the question of ―Why are you doing this?‖ almost the answer to that is, ―Why not? It's a good day, it's a bad day, it's raining, it's not raining, you know, I've just learned to use this to cope?‖

I'd rather have them change the question to, ―How do I get it stopped?‖ because when we change from why to how, we can begin

73 taking action. We can help the client to feel effective. We can help the client to begin to believe, ―There is a chance that I can change.‖ That‘s not to say that we don't deal with the other emotional issues along the way. But, if we only focus on those, and don't get the eating behavior stopped, we don‘t really have the person with us because they are continuing to spin and spin and spin. And, it is important to try to get the spinning stopped. So, I would say that education is one of the key issues with the eating disorder, teaching them that this is not your fault that you have this. It is, however, once you know you have it, your responsibility to begin making some changes or trying to get some help. And getting some help is not going on a diet. Getting some help is dealing with the eating behavior so that what needs to be changed can be changed. I think that that is very important.

I think that one of the mistakes that we make in therapy sometimes is that we expect the client to know how to talk about their eating disorder. If they think that their problem is a weight problem, they don't have a clue that they have an eating disorder. We have to help them, to educate them about what the symptoms are before they can say, ―Oh yeah, I have those.‖ They just don't know what to say.

So, if were not very active in a treatment session with a client in relationship to an eating disorder, we may think, ―Oh, they're being resistant.‖ They‘re probably not being resistant; they probably just don't know what to tell you, because they don't know what the symptoms are either.

When we hear the word denial, we automatically think of chemical dependence. Most of the world has some education about chemical dependence today, but we are just not educated yet about eating disorders. So, when I do a therapy group for eating disorders, part of every group is a brief lecture, because it is important that they get this information. This can happen to you.

Sometimes it is amazing to see the light go on in their eyes: ―Well, yeah, that's been happening to me a lot of time. You mean that's part of the eating disorder?‖ and sometimes they are amazed. So, I think that we have to educate.

74 I think, also, that we have to look at addressing their medical issues. It is very important if someone comes in and they‘re having other medical complications that relate to the eating disorder, that we began to help them to deal with those things. If you see a client, especially someone who has anorexia and their body weight is low, it is very important that they are dealing with an internist who knows how to deal with this type of patient. It is very important, in some cases, that the patient be assessed for depression. The incidence of depression in eating disordered individuals is high. The number of suicide attempts amongst eating disordered individuals is high. I think that it is very important to address all three of those issues.

There is some research, some of it is new, some of its not so new that talks about the use of antidepressants to reduce the craving to binge and vomit, and there is some evidence that says that that may be helpful. I think that, in fact, if it is helpful that a person should have an opportunity to have a trial of medication.

One thing that I would like to say is that in addition to therapy and medical attention and attention to the diet, I think that there is another way for a person to get support: I think it is important for someone to get involved in a self-help group. There are a couple of groups that many people are familiar with, one is Overeaters Anonymous. Another one is Anorexia Nervosa and Associated Disorders and that is commonly referred to as ANAD or ANAD.

An eating disorder is a very painful, complicated illness for people to deal with. What I think is most important is that we learn to respect an eating disorder as an illness in itself. In other words, we don't treat it as being caused by abusive behavior, etc. I want to honor it enough that we give it enough attention to be paying attention to it as a disease by itself because when we do that, we can give it enough time and enough treatment so that a person can get well enough to deal with the other life problems that we have, and we all have life problems. So, I just want us to learn to really give eating disorders the respect that they‘re due.

ALEXANDER: Joan, thank you very much and I think that that last point is extremely important in trying to address this serious problem. So, thank you for sharing your thoughts with our listeners.

75 EBBITT: You‘re welcome. I was most pleased to do it.

To contact Joan Ebbitt, you may write to her at 128 N Main St Adrian, Michigan 49221. Her books on eating disorders may be ordered through amazon.com.

This concludes our interview with Joan Ebbitt. We hope that you have learned from it and that you enjoyed it.

As always, I must say here that the views expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority.

Until next time, this is Barbara Alexander. Thank you for listening.

76 © On Good Authority, Inc.

Interview #5: “COUPLES WITH an ALCOHOLICSPOUSE”

MICHAEL ROHRBAUGH, Ph.D.

Interviewed by Barbara Alexander, LCSW, BCD

(Edited slightly for readability)

MICHAEL ROHRBAUGH, Ph.D. University of Arizona Department of Psychology Tucson, AZ. 85721

Welcome to On Good Authority, Inc. I‘m Barbara Alexander. You are listening to or reading interview #5 from ―Addictions A.‖ It also appears in On Good Authority‘s program ―Marital Therapy.‖

From a Systems Perspective, alcohol problems are inextricably interwoven with the family and social context in which they occur. It has always seemed to me, though, that one of the problems with AL-ANON is that while it aims to help disentangle the family from its substance abusing member, the alcoholic is left alone, dangling, which may not always either the marriage or the alcoholic.

Research has shown working with the drinkers‘ marriage and family relationships yields more durable treatment outcomes. Dr. Michael Rohrbaugh and his colleagues have developed a treatment protocol in which alcohol is viewed as ―the invader‖ and the couple is helped to ban together to fight the invader. He‘ll tell us about this protocol in this interview.

Dr. Michael Rohrbaugh is professor of psychology and family studies at the University of Arizona. His professional experience with substance abuse

77 dates to the mid nineteen-seventies, when he co-directed a drug and alcohol treatment program for Vietnam era servicemen. His current research focuses on family assessment and intervention. With his wife and collaborator, Varda Shoham, he has studied the role of couple and family interaction in maintaining alcohol abuse and has developed a couple-based treatment approach that incorporates systemic principles and practices. This integrative systemic treatment approach was used in an N.I.A.A.A. funded study comparing family systems and cognitive behavioral treatments for alcohol problems. A summary of the approach Dr. Rohrbaugh will discuss today appears in a chapter in the Comprehensive Text Book of Psychotherapy, edited by Bruce Bongar and Larry Beutler.

ALEXANDER: Dr. Rohrbaugh, let‘s begin this interview by giving us some background about your work.

ROHRBAUGH: Okay. The work I‘m going to talk about mainly was part of a research project for which we developed this systemic treatment model for working with alcohol problems in a couple‘s format. I guess if there‘s anything special or unique about what we‘ve done it‘s that we did it in this research context. So we had a chance -- we actually had a rather humbling opportunity -- to see how it really worked and to study it closely, not just in terms of the outcomes, whether it worked, but also how it worked and how it didn‘t work.

Now, we call this a systemic approach and since systemic can mean just about anything, as people who know about family therapy are aware, let me say what we mean by systemic. We consider this treatment ―systemic‖ because the focus is not just on the drinking and the person who‘s drinking but also, and perhaps even more importantly, on the context of the relationships in which the drinking occurs. So this contextual theme is very important in what we‘re doing.

Second, we consider this approach ―systemic‖ because it assumes that drinking problems are maintained by how people interact around them by on-going cycles of social interaction and in this sense, we are much more interested in what‘s happening currently, what keeps drinking problems going rather then in how they originated.

78 A third factor is that this treatment, like many systemic treatments, tries to adapt itself to the client‘s and the family‘s world view, rather then teaching or educating them or imposing some other way of viewing the problem.

And finally -- and this turned out to be very important, at least in our research, and in comparing this systemic approach to the more straightforward cognitive behavior approach: our therapy went to great lengths to respect what some people call ―resistance‖ or at least, ―reluctance to change.‖ Our idea was to try to work with this and to not challenge or confront resistance or denial directly, in the case of drinking problems.

ALEXANDER: In your article, you made appoint about neutrality and that the therapist should remain neutral. Can you talk about that with us, please?

ROHRBAUGH: Yes, well that comes up. That‘s probably one of the main principles in the first phase of our treatment model. Maybe I should first say that the treatment itself is ideally organized in three phases: the first phase, usually the first six sessions of twenty, because in our context we‘re limited to twenty sessions, we call the ―Consultation Phase.‖

One of the main guidelines in that phase is for the therapist to remain neutral, not just in terms of relating or taking sides with the partners, with members of the couples, but also, and perhaps even more importantly, about whether the drinker or the couple or anybody should change. What we try to do there is to shift to the clients the responsibility for choosing to change and then once they do, we align with them rather directly towards that goal.

Then, the therapy, if they do accept treatment, moves into what we call the ―Treatment stage.‖ Ideally, the therapy proceeds in these three phases. The first phase is the consultation phase, one to six. The second phase is the treatment phase, where we work directly towards changing drinking and the interaction patterns around it.

The last phase, which often blurs with the second, we call the ―Re- stabilization phase.‖

79 During this first phase, the consultation phase, the main goal is to do a systemic assessment, to understand not just the patterns of drinking but also, even more importantly, the way the couple and other important people interact around the drinking. In that phase, we also begin to intervene at least indirectly with solution- focused questions and sometimes, circular questions that are intended to introduce the possibility of change.

ALEXANDER: Before we go further into the details of the model, I‘d like to get back to the principles of your orientation and the ideas that you‘re presenting because it‘s very different, very exciting in contrast to the traditional Twelve Step model. Your model is so different. If you could describe the difference to us, I think that would be terrific.

ROHRBAUGH: Well, there are probably three or four major differences, at least as we think about it, both in how we understand how drinking is a problem and also what we do about it. We, as I mentioned earlier, focus mainly on what‘s happening now, around the drinking, how other important people, in our case, mainly the spouse, are responding to it, and how that may help to keep the drinking going.

Twelve step models, AA and Al-ANON, in many ways do that also: the whole idea of the enabling spouse and coaching the spouse to detach and step back and not inadvertently help to keep the problem going. But, unlike some of the Twelve-step approaches, we focus almost exclusively on the present. We don‘t get into influences from the past so much, like personality deficits and co-pathologies that result from past experiences growing up in a dysfunctional family, for instance.

Another big difference, and this is a big one, is that we try not to confront denial directly. The people who come to see us aren‘t always quick to admit that they have a problem, whereas in the Twelve-step approach, the direct confrontation of denial is very central. We try to avoid that. Rather, we use some of the neutrality stance to try to build a more collaborative relationship with the clients and shift responsibility to them and especially to the drinker in terms of choosing to change.

80 The third differences, and I mentioned this briefly, is that we don‘t have a set doctrine or set of principles or beliefs that we try to pass on. We‘re not educating people about the nature of alcoholism, for instance, or talking about the twelve steps towards recovery. What we try to do instead is to work within the client‘s own language or belief system, and to talk in terms of that. It often turns out that people believe in the Twelve steps, the AA model, in which case we talk about that with them and we try to suggest approaches to change that fit that framework. But we don‘t go in a priori, you know, aiming to educate people or teach them that framework.

The last main difference in terms how we actually do the treatment -- although the Twelve-step models are, in many ways, very family oriented, after all, you know alcoholism is a family disease and usually you try to include other family members in AL ANON or AL ATEEN -- is that we generally do family work in a conjoint way. We work with the spouse and sometimes other family members in the same session with the drinker, rather then in separate groups, as is more often the case in the Twelve-step format. So I would see those as the main difference between our systemic approach and at least the more traditional Twelve-step framework.

In the treatment phase, once the couple explicitly chooses to work towards changing their relationship with alcohol and getting alcohol out of the system, so to speak, we try to develop the idea, the metaphor really, that alcohol has ―invaded‖ the lives of these people and in particular, that it has invaded the couple‘s relationship and the best way to deal with this, and perhaps the only way to deal with this is for the couple to pull together against this external invader.

ALEXANDER: Now, how does your work include the solution-focused work?

ROHRBAUGH: Well, that‘s often pretty important. In the consultation phase, in the first six sessions, which are, by the way, pretty structured -- each session has a clear agenda that the therapist follows until the crucial session six -- there are a number of places where we deliberately inquire about exceptions to the problem, exceptions to the drinking. At the end of the first session, we routinely give the couple a homework assignment: we ask that they consider what it is about

81 their relationship that they would like to preserve, that they would like not to change. Because most of the first session, we focus, we talk about problems: what sorts of things have been going wrong and what have they been doing about it?

Then, near the end of the session, there‘s a deliberate shift to what‘s going right and then this often carries over into the second session where the main focus is on the clients as a couple. When we can, we continue the solution focus style of interviewing then too.

One of goals in this therapy to support the client, or the couple. We spend a lot of time talking to them as ―You as a couple.‖ ―What makes sense to you as a couple?‖ ―What‘s important to you as a couple?‖ We try to build this theme. Later on in the treatment phase, which actually has two or three main strands to it, we often use solution-focused techniques there as well, along with the family detoxification stuff. What we found was that for some couples the solution-focused tactics have really become almost the centerpiece of the therapy, that is, talking with them about how they‘re able to do what they want to do basically and to control the kinds of situations that they would formally get into that lead to the problems of drinking.

ALEXANDER: Could you describe for us, in a little more detail, then, what goes on in each of these three phases? You‘ve talked about the first and the second session a bit. In this first consultation phase, you‘re doing a couple of things, right? The therapist is establishing a relationship with the client as a couple. What are you exploring in terms of the addictive behavior? The person, one of the members of the couple, is still using, is that right?

ROHRBAUGH: Well, often. Almost all have been using until at least shortly before treatment started. Some have recently stopped or tried to stop on their own and there are others who are still using at that point. Then when we get to session six and offer treatment, one of our first goals, if the clients accept, is to get a quit date, if that has not already happened. That‘s when we start to work towards family detoxification.

82 In the consultation phase we‘re trying to assess a number of things. We start with the problem or the problems, and we assume the drinking is always a problem, but it‘s not always the one the clients, either individually or as a couple, are most concerned about. So we ask them, what are your complaints now? What are the problems? Then we try to get as clear picture of what people actually do as we can.

One of the favorite metaphors that is borrowed from solution-focused therapy work is ―video talk.‖ If we were there with a video camera, what would we see when John drinks, or when you two get into the arguments that you‘re describing, what does that look like? In terms of the drinking, we‘re especially interested in that and there we‘re also interested in the history of it as well. We‘re interested in severity: how much do they drink, you know, where and in what circumstances? Most important, what consequences has this had? We‘re especially interested in bad consequences, you know, how this has been a problem. The spouses‘ participation and perceptions here are, of course, very important.

So we‘re interested in understanding the very concrete interaction cycles. We call them ―Problem solution loops‖ that happen around the drinking. In some ways, it‘s especially important what the spouse is doing. You know, is the spouse struggling and on his case? Is she nagging and trying to convince him not to drink? Or on the other hand, is she just ignoring it completely, you know, drifting off, pulling away. We‘ve seen both of those patterns quite a bit. They vary a lot in the details but in general, the usual solution efforts of the spouse seem to either involve doing a lot, often too much, or not doing much at all in relation to the drinking.

For instance, we had one client where the spouse, when the guy would start to drink beers during the football games, whatever, she would go off and meditate, kind of just drift away and leave him alone. Understanding that pattern turned out to be important later on when we intervened as were able to persuade her to deal with him more directly, gently, but more directly, to simply go in and put a hand on his shoulder and say, ―Dear, you know, when you‘re drinking like this, it scares me.‖ This was a reversal of her usual way of dealing with it.

83 So we want to understand those interaction sequences, the ―Problem/solution loops,‖ as we call them, because later on, one of our main objectives will be to try to interrupt them.

We also want to understand how the couple sees things, what their views are. So we‘re interested not just in what they‘re doing but also how they‘re viewing things. This turns out to be important, again, in terms of later how we frame suggestions and intervention.

In the second session, which is mainly about the client as a couple, we take a brief history of how they got together as a couple, how they see themselves as a couple. We have a little exercise that we do called a ―Couple Identity Exercise,‖ where we ask them, we invite them to come up with some metaphors, some images that define them as a couple. Again, so we can work with this later on.

In the third session, we see the partners separately. We do that for some important reasons. We want, first of all, to assess their commitment to the relationship, to each other. As you might imagine, it often turns out that that‘s not equal. We see people come in for treatment and it‘s the last ditch effort or the partner is part way out of the door, and it‘s important for us to understand that at that point so we can deal with it later if we have to.

Second, we want to assess at that point whether there‘s any potential for abuse or danger, whether one spouse, usually the non-drinking spouse, is intimidated by the other person, or whether there‘s actual physical abuse going on. What we prefer to do and what we did in several cases was to include negotiations about abusive kinds of behavior in the active treatment phase where the couple begins to negotiate with us and with each other about how they‘re going to handle things.

So, we have the individual meetings with the spouses in session three, and session four generally focuses on the broader system. Here we actually do at least a three-generation family genogram. Although the therapy itself tends not to get into a lot of the broader systems issues, we think it‘s important to know what‘s going on, to know what the history of drinking is in the family, in the generations that proceeded

84 and especially. to evaluate any kinds of family traditions or loyalties that might play a role in keeping the current problem going now.

So, it wasn‘t at all unusual, in fact I can think of several cases, where drinking with, in one case, a father, who himself who had drinking problems, and in another case, with a brother, were very important social events in the life of our identified drinker. In both of those cases, it was important to address those and actually to worry about the consequences of changing that. If the drinker were to stop drinking, with his dad, in one case, or with his brother in the other -- would that pose some real difficulties in terms of how he would be seen in the family and what to do on Sunday afternoon and so on?

In fact, one of the things that we routinely try to do in the active treatment phase is to plan with the couple how they would notify important other people in their lives about their decision to change their relationship with alcohol, to give it up. That often turned out to be quite a sensitive and sometimes difficult part of the intervention plan.

We also spend some time along the way, apart from focusing on the problem and how people are trying to solve it, just understanding the daily routines and the rituals, literally, how the couple spends a day from the time they get up in the morning until the time they go to bed at night, and how alcohol fits into that. It turns out the extent to which alcohol interrupts family rituals is a pretty good predictor of whether a child, a next generation will have drinking problems himself or herself. So, we want to understand alcohol in relation to family routines and rituals.

Another reason for doing that, actually, is to see if we can identify differences in what happens when family interaction is ―wet,‖ that is, when somebody is drinking, when the drinker‘s drinking. What happens when family interaction is ―dry?‖ It often turns out that ―wet‖ or lubricated family interaction is different and not always in bad ways. In fact, many times, alcohol, at least in the short run, seems to have a kind of stabilizing consequence or effect in the family system. It helps people laugh and be looser, or have sex, whatever and it‘s important to understand that because if we‘re going to then proposing removing alcohol from the system, we want to know what

85 some of the tough spots are going to be and anticipate them and help the couple then plan for how they‘re going to deal with the hole left when alcohol goes on the shelf.

ALEXANDER: Now, the sixth session is really the deciding moment.

ROHRBAUGH: Yes. We do quite a bit of planning for the sixth session. Although one therapist works with the couple, there‘s a supporting team usually. The therapist talks between sessions and we have the videotapes of the therapist, and so on. We usually take a least a meeting to get ready for the sixth session. The therapist often goes in with some notes and things in preparation for giving the couple an opinion about their situation and about the drinking.

Ideally it has a kind of balance to it. What we most want to convey is that we see a number of specific ways in which alcohol is invading this couple‘s relationship and we try to document that as much as we can. For instance, here I have a note from a transcript where the therapist says, ―I say that alcohol is a major player in your life, as for example, when you said you wanted to spend a certain kind of vacation together and it turned out very differently because of the drinking, and the two of you never seem to be able to have sex together unless Joe has been drinking, and that you‘re in hot water at work because you don‘t seem to be able to concentrate after you‘ve been drinking.‖

ALEXANDER: You wouldn‘t call this a confrontation exactly.

ROHBAUGH: No, no, no. We‘re just saying what we see: on the basis that we‘ve spent now five sessions together, our impression at this point, after thinking about what you‘ve told us, is that alcohol, in some pretty important and serious ways, seems to be invading your relationship as a couple, causing you problems as individuals but more important, invading your relationship as a couple.

But on the other hand, now this is a part of the balance, the other part of the message is that we also understand and we can see how changing this would be difficult. Very difficult. If nothing else, your life is predictable with the drinking. There may also be ways, although it‘s may be difficult to anticipate how, that without drinking, at least

86 in the short run, you‘d have even more problems to deal with in terms of adjusting to not having alcohol there.

But we want to especially highlight the invasion, the problems that alcohol is causing as we see them, but we want to say that we understand how difficult it will be to change that -- while you might be reluctant to change that, there are always unforeseen problems that might arise.

But having said that, we offer them the opportunity to choose treatment. We tell them that we have a treatment method that‘s usually effective in helping couples take charge of the problems related to drinking. But from our experience, it makes sense only for people who genuinely want to quit and that it‘s important that not just one person but the others in the family want to do that too.

If the couple has presented other problems or complaints in terms of their relationship, we‘ll talk about those as well, and say that we‘re prepared to help them work on those, but in our experience, dealing with the alcohol situation is most important and needs to be done first.

So we don‘t push them here. We present the treatment as something that is likely to be helpful to them if they are genuinely ready to work on changing but that‘s a choice only they can make and they may want to take awhile to think about it. And sometimes they do.

Other couples -- I guess the ideal result is when the couple has already thought about it and they say, ―Okay, we‘re ready to go, we‘re ready to this.‖ Then, if the couple does choose change -- and we make them be quite explicit about it -- then we shift and begin working towards family detoxification right in that sixth session, with the goal of them leaving with a least some beginning agreement about how they‘re going to start to get alcohol out of their bodies, first of all, and out of their home. Then, eventually, over the next few sessions, we‘ll work on getting alcohol out of the whole family social system.

ALEXANDER: How do you deal with relapse? I‘ve talked to a number of people about your model and the first question that usually pops up is, ―Well, that‘s fine but what happens when one person goes ‗off the program?‘‖

87 ROHBAUGH: Well, we have to deal with that quite a bit. The first principle is to define slips not as ―relapse,‖ but as a ―lapse,‖ as an understandable slip back and then we, at least in the first line of approach, try to emphasize what they were able to do before the slip. Sometimes we may also focus on how they then managed to recover from the slip: the more solution-focused approach. Trying to keep the program on tract. Two steps ahead, one step back. We try to keep the family detoxification plan, which they‘ve agreed to do; they‘ve accepted treatment. We try to get it back on track. We, of course, take a look at what happened and how to plan to prevent that from happening again. If it was in a social situation, for instance, or if they had an argument or something, we‘ll try to anticipate things that will get in the way again.

But sometimes it develops that they just fall all the way of the track. There are also some couples, by the way, who never really accept the idea of doing ―treatment,‖ our definition, in the first place. That is, in session six when we offer them treatment, some couples won‘t buy it or more often, they‘ll be one partner who says they should but the other isn‘t so sure. The guy really thinks he can control the drinking and whatever.

Some couples never really enter this treatment phase and others -- the more usual cases, they‘ll accept and start but then there‘ll be some resistance, some reluctance, some slippage. As I say, we work with that as best we can, but the first line of approach is to keep it on track.

But some times it becomes clear that it‘s not working. That‘s when we shift from what we call ―treatment‖ to what we call an alternative phase called, ―Continued consultation.‖ To mark that transition, we often do what we call a ―U turn,‖ where the therapist, after consulting with the team, will come in and basically apologize for either pushing too hard or misreading the situation and suggest that what‘s probably indicated at this point is to back off ―change‖ -- the family detoxification stuff, and to take some time to consider whether change is really a good idea for them given what‘s happened, given the resistance, given the reluctance.

Then what we have is a series of more strategic kinds of intervention that we might try depending upon the circumstances of the particular

88 case. But all of these we frame, we define as ―Continued consultation,‖ rather then treatment. In other words, ―What we‘re doing now is not plowing ahead assuming that you all want to change; you‘re all ready to change. Let‘s take a look at whether change is necessary, whether change is a good idea.

So one of those continued consultation modules we‘ve wound doing at least a half a dozen times, we call the ―Controlled drinking experiment.‖ This is something that would be indicated if we have reason to believe or if the drinker were basically to tell us that he thinks he can control this. We say, ―Well, that‘s a possibility. Let‘s assess that, let‘s see.‖

Then we begin a process of negotiating: well, how would we know and how would he know and how would they know if the drinking gets out of hand? What‘s the maximum number of drinks he can have in a given day? Two or three? If he were to have more than that, would he agree, would they agree, that that was a sign that he couldn‘t control the drinking? So we try to challenge, at least the drinker, to show us he can control it and try to get real specific about the conditions or the signs that would indicate that it was out of control.

Along the way, we also then try to use that controlled drinking experiment to shift what the partner or the spouse usually does, to break up the interaction patterns around it. For instance, if the spouse is on his case a lot, is nagging and so on, we would probably suggest that, at least for the period of this experiment, that she refrain from helping him in that way and maybe just observe and maybe keep some notes. So in that way we might be able to interrupt the interaction patterns around the drinking too.

This can go several ways. The ideal thing is that the controlled drinking would force the hand and he would then come around and they would then agree that getting back on the treatment track would make sense. There was one case, though, where the challenge we maintained over a number of session and the guy was able to show that he could control it. That case, I think, never really did get back to treatment. By termination, there was some improvement in the drinking. He was still drinking. He wasn‘t abstinent, but the drinking was less of a problem and there was some improvement in the

89 couple‘s relationship. But as I recall, that was a case that didn‘t survive too well into follow up. In follow up, things had slipped again.

Sometimes I see the spouse alone. I do a kind of unilateral intervention where we can coach. This is especially indicated when the drinker himself isn‘t a client. What we often do there is to work on helping her detach and avoid what is called, ―The responsibility trap.‖ Basically we try to help her back off and shift the responsibility to the drinker. Again, the focus is on interrupting the interaction patterns that may help to keep the drinking going.

We‘ve had only moderate success with that. In a few cases, we were able to get the spouse back in and things worked out, but then in at least as many, although we were able to help the spouse somewhat, we didn‘t have much impact on the main drinking problem.

The last thing, one of our principles, again following David Treadway, is, ―When stuck, add people‖. If we‘re not able to move things at the level of the couple, and especially if it‘s obvious that there are important people, usually family members, involved in the problem, we will make contact with them and invite them in. We did that in maybe three or four cases of the thirty-nine that we saw. Usually this was the parents, sometimes siblings. Although we don‘t necessarily try to get them to gang up on the drinker, in the style of the Johnson Institute Intervention, we sometimes do try to build alliances and coalitions that will shift things a bit to, maybe in other ways, put some more pressure on the drinker to either come back to treatment or make some changes.

ALEXANDER: You know, Dr. Rohrbaugh, in these interviews, the time always goes faster then I anticipate.

Is there anything you‘d like the listener who is a therapist or an addictions counselor to know about your work or any ideas they should really make sure to take with them?

ROHRBAUGH: Well, listen; they probably want to know whether it works! (laughs)

ALEXANDER: Good point.

90 ROHRBAUGH: And I wish I could say that this is a sure-fire solution to all drinking problems. I can‘t. Although I won‘t have time to go into it, I think we learned some things about the kinds of drinkers and especially, the kinds of couples for whom this approach might be especially helpful.

In terms of general outcomes, of the thirty-nine couples that we saw, about twenty-three, about sixty percent completed the full twenty- session treatment. We lost some along the way. Of those who completed, most had at least a moderately positive drinking outcome as well as relationship outcome at termination.

It was pretty clear that we helped at least a third of the couples in significant ways with drinking problems. With less stringent criteria, we probably helped at least half.

But the point is we‘re not helping everyone. Some of the research comparing who responded better to the family systems approach compared to the more structured cognitive behavior approach, where there was much more emphasis placed on abstinence and expectations about what the clients would do -- there were a lot more rules and so on -- we found a very dramatic kind of matching effect, which is interesting because the results of Project Match didn‘t find many indications for matching patients to treatment.

But in our study we did find some. In particular, the drinkers who were very resistant and impulsive and couples who were very negative with each other, and in particular, who exhibited a pattern that clinicians often call, ―Demand/ withdrawal,‖ or ―Pursue/distance,‖ where one partner, usually the non-drinker, is really pushing on the other one to change and then the drinker withdraws and it goes on and on -- well, those couples, the high demand/withdraw couples and the high negativity couples and the couples in which the drinker was this kind of resistant, impulsive coping style, did appreciably better in the family systems approach then in the cognitive behavioral approach where basically, many of them just dropped out. They couldn‘t handle the structure of that at all.

91 So, this approach, which avoids the denial and the confrontation and works with neutrality and attempts to use what the clients bring may be especially helpful for difficult cases, the kind that I just described.

ALEXANDER: That sounds like a very exciting finding I think and I would urge our listeners to read that chapter of the book.

I want to thank you, Dr. Rohrbaugh, for your time and for sharing this very interesting project with us.

ROHRBAUGH: Thank you, Barbara.

Listeners may write to Dr. Rohrbaugh at the University of Arizona, Department of Psychology, and Tucson, Arizona, 85721. His email address is [email protected].

This concludes our interview with Dr. Michael Rohrbaugh. I hope you learned from this interview and that you enjoyed it.

I must say here that the opinions expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority.

Until next time, this is Barbara Alexander. Thank you for listening.

92 © On Good Authority, Inc.

Interview #6: “RELAPSE PREVENTION”

SUSAN FLYNN, LCSW

Interviewed by Barbara Alexander, LCSW, BCD

(Edited slightly for readability)

SUSAN FLYNN, LCSW c/o Haymarket House 120 N. Sangamon Street Chicago, IL. 60607 (312) 226-7984

Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are reading or listening to an interview from CD #3 in our program, ―Addictions A.‖

Here we look at the subject of relapse, and hear two very different treatment approaches. First we will hear from Susan Flynn of Haymarket House in Chicago. Haymarket House has a twenty year history in providing substance abuse services to the chemically dependent person, regardless of ability to pay. They see over 14,000 people a year in combined inpatient and out- patient programs.

Following that we will speak with Dr. Joseph Cattano, a social work psychoanalyst and certified substance counselor in New York, who urges us to reaffirm the connection between addiction and underlying, unconscious fantasy process.

Susan Flynn, LCSW, is the manager of special programs at Haymarket House and oversees and directs 3 programs there, two of which are funded by grants awarded by Chicago‘s Department of Human Services and the

93 National Center for Substance Abuse Treatment. These programs include the Mentally Ill Substance Abuse program, which serves homeless, mentally ill men and women suffering from addictions, Sangamon House which is a 16 bed recovery home where women can reside with their children in a supportive, drug free environment, and Athey Hall, a 12 month treatment program where 25 women and their children receive treatment for substance abuse in addition to education in child development and parenting techniques.

ALEXANDER: Susan, would you say there are any typical pitfalls that come during this recovery process?

FLYNN: Oh, there are lots and lots of pitfalls. Overconfidence- testing control was a big one. People tend to get a few months of recovery and all of a sudden they are feeling much better about themselves, they are feeling hopeful and the desire to walk the old neighborhood or walk past the old ―get high buddies‖ to show them that ―I‘m clean now and I‘m sober and I did this,‖ is something that a lot of people new in recovery fall into. I tell them, ―Life is going to test you; don‘t set yourself up.‖ But there is still this desire to go back and show them what I did and show them, ―I‘m clean now.‖

A lot of times money is a huge pitfall for people. I‘ve heard people describe that their hearts start pounding, their palms start sweating when they get more than enough money for the bus in their hands, and it just becomes an automated, almost behavior-modification kind of response: getting money and trying to curb the urge to go out and get high with it. So, money is a big, big pitfall for people new in recovery.

It is very difficult, I think, for people to really understand that they need to give up people, places and things. They need to find new places to go and new people to go with and new things to have a good time with. You‘re really asking people to do a lot. I don‘t think people buy into it all at once. It takes some time and sometimes they have to go out and try to prove you wrong. There is still that unwillingness to truly surrender and acknowledge that there is a loss of control over your life.

94 Other pitfalls might be celebrations, which are very difficult. I think people associate drug and alcohol use with feeling depressed and drowning your sorrows and those types of clichés. Celebrations are very difficult for people to manage, feeling really good and not knowing what to do with those feelings, so it‘s necessary to be careful around those days. Prescription drugs that don‘t get you high can be a big pitfall for people, or that do get you high. You know, they are very difficult. You really have to watch a lot of things.

ALEXANDER: I want to go back into these pitfalls because they are very important. When a person does get some money and it is enough money to buy something to use to get high with, so what do they have then? How do they not do that? What have they been given or what do they need internally to be able to combat that?

FLYNN: Well, a lot of the group therapies are focused on increasing insight and helping identify what are their ―triggers,‖ which is what they call them, to relapse. Identifying early on that money may be a trigger is a very important one so that you can plan for what you‘re going to do with your money once you get it. We have a case manager that works with the clients on budgeting and putting money into a savings account so that they don‘t get it in their hands right away. I mean, there are lots of different things that you can do. I‘ve had people turn over checks to a payee and have a trusted family member or friend handle their money for them in the beginning of recovery. I‘ve had people do direct deposit so that at least they have to get in their car or get on a bus to get to the bank before they can impulsively act on a craving or an urge. I‘ve had people mail themselves their checks. There are all sorts of creative things you can do if you‘ve identified this as something that is problematic for you.

Again, the whole focus of relapse prevention is gaining insight and self awareness into what your personal triggers are. Some are going to be universal for everybody, but some are going to be very specific to you and if you can learn what they are and talk about them and learn to manage them, that‘s a big part of it. They fade in time, but for some it‘s always there.

95 ALEXANDER: Well, it‘s about the ―it‘s always there,‖ part that I want to try to talk about. The behavioral management that people are taught is extremely important isn‘t it, in terms of the money? That is a terrific example, finding alternative ways to deal with the money, but ultimately, of course, their going to get the money in their hands, so then what?

FLYNN: At that point, I think you just hope that you have given people enough resources to draw from to make good decisions. Hopefully they have enough phone numbers in their pockets so they can pick up the phone and call somebody and say, ―Look, I‘m having a real hard time with the fact that I just got a $400 check in the mail,‖ or, ―Somebody just gave me $20.00.‖ There are 12-step meetings all over the city and all over the country and you hope that somebody can get themselves to a meeting before they act on an impulse, or pick up some 12-step literature if they can‘t get to the phone or get to a meeting.

I mean, it‘s being able to teach somebody enough recovery tools so that over time that becomes the reaction as opposed to picking up the drink or the drug, that there is something that they can do to combat what they feel, to learn that they don‘t have to act on a feeling or a thought, that there are things that they can do to keep it from getting that far.

You know, the nature of the beast is the obsession and the compulsion to not be able to stop when you‘re using and when you‘re not using, to not be able to stop thinking about it. If you can help them see that it isn‘t automatic, that they don‘t need to act on impulses, I think you‘ve done a lot and you‘ve given them the resources to draw from to be able to make good choices and use what they‘ve learned.

ALEXANDER: Let‘s talk about relapse, which is one of the biggest problems anybody dealing with any kind of addiction has to face. I‘d like to get some thoughts about how Haymarket House handles relapse.

FLYNN: Okay, well to begin, I think it is important to note that there are a lot of erroneous beliefs about relapse. A lot of people who relapse are told that they are constitutionally incapable of recovery or

96 that they haven‘t hit their bottom yet or had enough pain to motivate them to recover, or that relapse comes on suddenly and with no warning. In truth, relapse prevention is really about finding your individual prevention plan, which is what we focus on at Haymarket House. For some it‘s about going too quickly, for some going too slowly, for some not doing enough, and for others not doing too much.

But, what‘s really important, what we want to help clients work with is that there are warning signs to relapse for everybody. There are thoughts, feelings, and behaviors that trigger your addiction and the prevention piece really comes in by helping people become aware of what their individual warning signs are.

The most important thing to remember about relapse is that it can be a vast, albeit a painful learning experience, but if you don‘t learn from it, it‘s a waste of experience and, more times than not, history will repeat itself.

At Haymarket, what we do specifically is we work with people on picking apart the experience. They need to look at their thoughts, their feelings, their behaviors and figure out what brought them closer and closer to picking up the drink or the drug. First, the client does this individually with a counselor because, for many clients, there‘s a lot shame attached to relapse. They think they‘ve failed and they treat it as a failure experience. What we do on an individual basis would be to help the client see that, again, they can learn from this experience and that they can change the way they respond to situations that in the past triggered them to want to drink or drug.

ALEXANDER: To back up just a second, how would you know on an inpatient program that a patient had relapsed or had been using again?

FLYNN: Well, in an inpatient program, we certainly use toxicology screens, which is a urine screen that is submitted to a lab and traces whatever the specified drug is that we ask them to screen for. I think that any program that is dealing with addictions needs to be able to have some measure to be able to see whether or not people are relapsing. I think that addicts know, you know, how cunning their disease is and really wouldn‘t give the program much credit or

97 wouldn‘t find it very credible if drug screens weren‘t used. It‘s a very important tool. And, we use them for therapeutic purposes, meaning if somebody were to approach us and say, ―Look, I was on a pass yesterday and I flipped,‖ or ―I relapsed and got high,‖ there would be no reason to do the drug screen, because we would already know what the results are. So, again, we don‘t use it for any other reason than as a therapeutic tool. If somebody cannot get to that level of honesty, we do do random screens throughout treatment so that we can see if people are being honest in recovery.

ALEXANDER: Do you find that generally people have the capacity to really examine their behaviors and their feelings about what made them relapse?

FLYNN: I think it‘s a process. I think initially no. When people come into treatment, a lot of times, they‘ll talk about relapse happening very suddenly without warning and it kind of just hits them blindsided and they don‘t know what happened. But, I think as they progress in treatment, yes, they do gain insight and become aware of how to respond differently to whatever feelings, behaviors, or thoughts trigger a craving.

ALEXANDER: Can you give us some examples or an example of what you would be talking about with a person who had relapsed?

FLYNN: If I had somebody who came in to me and told me that they had relapsed -- again, I would have them talk to me individually about what happened. I would ask them where they were, who they were with, what they were doing, what they were thinking at the time. I‘d get as much data as I possibly could to get as clear a picture as possible, and literally walk through that with the client.

ALEXANDER: And, that very act of questioning in that way starts to teach them too, what to look for, is that right?

FLYNN: Exactly. Exactly. By helping them pick apart the relapse and really single out all of the factors that contributed to it, you‘re helping them gain insight into what went wrong and then looking at what they can do differently in the future, which is the second piece of processing a relapse. It‘s not for the purpose of reliving the high or

98 going over the gory details, but again, to examine everything that the client was experiencing in order to assist them in figuring out what happened, and then the second piece being to help them to figure out what to do next time.

ALEXANDER: Can you generalize at all about what are some of the most common reasons for relapse?

FLYNN: Well, for a lot of people, being in the presence of drugs, drug users, or places where you used to get high. Just being in certain situations and around certain people can bring on very powerful cravings. Another would be negative feelings, particularly anger, but also sadness, loneliness, guilt, fear, anxiety, all of those. If somebody doesn‘t have the skills to be able to manage those feelings in a healthy way, they tend to fall back on previous coping skills, which may have been getting high. Boredom is a huge relapse factor. A lot of people don‘t know what to do with all of the free time they have once they get clean and sober, because so much of their time was spent around drug related activities. The fourth one might be getting high on any drug, including alcohol. For a lot of people they come into treatment saying that cocaine, for example, is their drug of choice and they‘ve never considered themselves to be an alcoholic. But, a lot of times you find that if you take one of the drugs away, one may substitute with another. Or, they may have used alcohol to come down from cocaine or a variety of different reasons, but they find out that they are multiply addicted to different things.

ALEXANDER: After the person has worked with their counselor individually, then what?

FLYNN: Well, then I think that it is very important that they go into the group and they talk about it in a group setting. Again, they need to get honest about what happened. There is a slogan in AA that says, ―Secrets keep us sick,‖ and a lot of people want to keep it hidden that they have relapsed. And, again, they can process it with a counselor, but they also need to go into the group and talk honestly about what happened and get the feedback from their peers as to what contributed to the relapse. So, they want that information from the counselor but they also want their peers to help them pick apart the

99 experience and identify the thoughts, feelings, and behaviors that led to relapsing and also what they can do differently in the future.

This is very important, because it can be preventive for other members of the group that may not have experienced a relapse and there could also be members in the group that have relapsed over similar issues and have done something differently and it has proven effective, and that person can then share that with the addict that recently relapsed. The other piece is that it gives them support and the ability to get honest about what happened and receive support and realize that they‘re not a bad person for relapsing, that, again, there was something missing in their recovery plan and they need to do something differently.

ALEXANDER: What are some things that you teach people to do and some ideas that they come up with help themselves to learn new skills of managing their emotions and tensions and upsets so that they don‘t relapse?

FLYNN: That‘s the huge focus of group therapy: people need to, again, develop sober living skills and positive coping skills and what works for one might not necessarily for the other and what works in one situation may not work in another situation. So, the idea is to get this repertoire of as many skills as possible and to be able to know when to use them, when to implement them in your daily life.

The overall message that I‘d like people to hear is that there are a lot of situations that you can avoid, that you don‘t need to test yourself, that life is going to test you enough and you need to be able to know when to remove yourself from situations and when you need to get some help in dealing with a situation that you can‘t leave.

ALEXANDER: Now, what about advice for therapists, since it is therapists who are going to be listening to this interview?

FLYNN: For therapists, I would probably have them encourage clients to be as concrete as possible and to predict what their relapse will look like. I think that is something that a lot of therapists and a lot of clients are afraid to look at and that would be entertaining the thought that I might relapse. It‘s not a pleasant thing for people to

100 think about. But, I think that if you don‘t have the pieces in place as to what you‘ll do should a relapse happen, people tend to respond impulsively and use poor judgment.

Relapse and cravings tend to bring on a lot of uncomfortable feelings. People tend to get anxious and if they have a plan already mapped out of what they will do, they don‘t have to think. All they have to do is look down on the paper and look at what is written and they can respond to the situation in a well thought-out way. So, I think that is a real important piece: relapse needs to be talked about, needs to be processed ahead of time, because each client‘s relapse will look different.

ALEXANDER: This is very good for the therapist to have the thought of helping the patient/client rehearse in fantasy ahead of time what could happen.

Susan, thank you very much for your time again and sharing your thoughts with us and the wonderful things that you are doing and that Haymarket House is doing for people who are addicted and trying very hard to recover. We appreciate your time.

FLYNN: My pleasure.

To contact Susan Flynn, call the Haymarket House at (312) 226-984.

This concludes our interview with Susan Flynn. We hope you learned from this interview and that you enjoyed it.

As always, I must say that the views expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority.

Until next time, this is Barbara Alexander. Thank you for listening.

101 © On Good Authority, Inc.

Interview with JOSEPH CATTANO, Ph.D.

“FANTASY AND RELAPSE”

Interviewed by BARBARA ALEXANDER, LCSW, BCD

(Edited slightly for readability)

JOSEPH CATTANO, Ph.D. 36 East Woodbine Drive Freeport, N.Y. 11520

Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are reading or listening to an interview from CD #3 in our program, ―Addictions A.‖

In this interview, we will hear from Dr. Joseph Cattano, a social work psychoanalyst and certified substance abuse counselor in New York, who urges us to reaffirm the connection between addiction and underlying unconscious fantasy process.

Dr. Joseph Cattano received his Ph.D. in Social Work from the New York University School of Social Work and his psychoanalytic training at the New York School for Psychoanalytic Psychotherapy. He has worked in addictions for most of his professional life, including being Executive Director of the Port Washington Counseling Center in Port Washington, NY, the Executive Director and clinical supervisor at Rapport Inc, an outpatient substance abuse treatment program and clinical supervisor of the Methadone Maintenance Programs for the county of Suffolk, NY. He has taught on the use of psychoanalytic therapy in the treatment of substance abuse at the Advanced Seminars in Ego Psychology in Holbrook, N.Y. He is now in full time private practice in Freeport, N.Y.

Now to our interview.

102 ALEXANDER: Dr. Cattano, we‘re here to talk about relapse and your perspective on relapse. You‘ve written something that you‘d like to read to our listeners.

CATTANO: I think that substance abuse remains one of the most difficult clinical issues that mental health practitioners face and when I talk about substance abuse, I‘m talking about addiction and even more so, relapse. Clearly, the multitude of strategies and approaches that have been implemented over the past half century, in my opinion, have had little enduring impact on the number of individuals that have used drugs. I think it would be fair to say that there has been no dramatic sustained decline in illicit drug abuse witnessed in our society in a long time.

Mental health clinicians working with substance abusers cannot help but experience the often futile and frustrating nature of treatment as patients are so prone to repeated relapses. For many practitioners, the symptoms appear to have an intractable quality, as if it possesses a life of its own. Within the mental health community, discussion and disagreement persist pertaining both to the theoretical understanding and the most effective treatment protocol.

In recent years, the treatment of substance abuse has experienced a shift toward a more biological or genetic perspective, thereby downplaying or disregarding traditional psychodynamic approaches. Certain studies have proposed a likelihood of a genetic predisposition for abusing certain substances, particularly alcohol and cocaine. In my opinion, too many clinicians have embraced this latest research as fact, rather than findings that are suggestive of possible causal considerations.

In a professional environment that is increasingly dominated by managed care, this perspective is welcomed as it provides a convenient rationale for precluding costly long-term psychodynamic treatment in favor of brief drug counseling and no fee self-help programs.

In my mind, Barbara, it is rather unsettling to observe skilled clinicians setting aside respected perspectives on pathogenesis and symptom formation by accepting these new cost-effective but

103 somewhat shallow positions. This new world of utilization review and managed practice has placed many clinicians dealing with substance abuse, addiction and relapse as a symptom of chronic emotional turmoil, character pathology, conflict, structural deficits or self-pathology in untenable positions. Unfortunately these coercive corporate pressures are forcing substance abusing patients into a brief, symptom-focused symptom focused therapy wherein the psychodynamic aspects of behavior are often bypassed. Within these frameworks, too often treatment is rendered by paraprofessionals, recovering addicts, and counselors lacking professional mental health credentials.

Clearly these approaches can be of importance in a comprehensive treatment plan for addicted or chronically abusing patients. However, treatment plans that do not take into consideration psychologically underpinnings and unconscious motivations are destined to leave the causal factors unresolved and continually reasserting themselves in the patient‘s psyche, that is, relapse.

The purpose of my discussion is to reaffirm the intimate connection between addiction and underlying unconscious process. Particularly, the discussion suggests that unconscious fantasies play a determining role both in the persistence and reoccurrence of patterns of substance abuse and addiction. Again, we‘re talking about relapse.

A patient‘s investment in these patterns of behavior, the drug abusing or addictive behavior is an indication of their ongoing powerful interplay with inner fantasy life. It is suggested in this paper and this discussion that there exists a very dynamic, reciprocal relationship wherein fantasy life provides the motivational fueling and psychological basis of addiction and relapse. It can be demonstrated in certain patients that their reality based behavior and activity can evoke and reactivate these powerful repressed fantasies which continually gain expression in behavioral phenomenon such as chronic substance abuse and the various addictions.

Simply I suggest that this discussion contends that addiction and relapse are the pathological manifestations and behavioral corollaries of the persistence, and I emphasize the word ―persistence‖ of these unconscious fantasies. In a way, the addiction is to the fantasies.

104 Within this content of understanding, symptom resolution requires the working through of the underlying fantasy process and the establishment of healthier compromise formation. Treatment is, in essence, the establishment of healthier, more functional, compromise formations.

ALEXANDER: This is basically from your paper that was in the Clinical Social Work Journal, Volume 24, Number 4, entitled, ―The Influence of Unconscious Fantasy Process in Addictions and Relapse.‖

Now, Dr. Cattano, I think that in the world of addictions treatment, this is probably a rather provocative statement. You‘re saying that.....

CATTANO: You‘re throwing rocks through my windows.

(they laugh)

ALEXANDER: Are you saying that addictions are not a disease?

CATTANO: Well, I think that it surely suggests that addictions are not a disease. I am not comfortable with that notion, because when you say that addictions are a disease, I think that it detracts from the psychological notions that are really much a part of addiction.

Surely there is a pharmacological affect of drugs; there is an addiction to drugs. There is a real biological piece there and I‘m not overlooking that in any way. But, what I‘m saying is that people who abuse drugs with any regularity are people who are first, emotionally distressed, disturbed, and that pre-exists any use of drugs. I guess what I‘m saying very simply is this: an emotionally stable, an emotionally healthy person is never going to become addicted to drugs.

ALEXANDER: Powerful statement.

CATTANO: Well, I think if you look at the clinical material of people who work with substance abusers in a psychodynamic way, you will see the pre-existence of a tremendous amount of emotional turmoil, of all sorts of family problems. These things really pre-exist their involvement with drugs. When people develop in a relatively healthy

105 environment and are relatively stable emotionally, free of any really dramatic conflicts, the likelihood of their being involved in drugs, I think, is minimal. May they have a passing flirtation with drugs, may they experiment with drugs, they may even go a little bit too far at times? Yes. But, the notion of a continuing lifestyle with drugs -- I don‘t think that it would be there with an emotionally healthy person. They would not do that to themselves. Their ego strengths wouldn‘t permit it.

ALEXANDER: You know, we could talk for a long time about this very point and it‘s tempting to do so, but I think that our listeners would be better served and in a way I‘m saying this to my listeners as well, that I want to go ahead and talk about your views of relapse and help us to really get a clear picture of how you treat relapse and your perspective on it. Then we‘ll let our listeners make up their own minds.

CATTANO: Okay. When I talk about addiction and relapse, I think we are going to use, in these cases, the term ―addiction‖ as it is commonly used, maybe misused, that addiction refers not only to drug addiction, but the other so-called addictions such as gambling, addiction to sex -- although I disagree with the use of that term, in some of those instances, but for the sake of this discussion, I think I‘m going to use it in that fashion.

I think what‘s also crucial in my discussion is understanding the notion of unconscious fantasy. I think that is really pivotal, so I think at this point it would be helpful for me briefly, very briefly because it is a very involved and complex notion, to just touch upon that.

ALEXANDER: You know, we all talk about having a fantasy life, or ―Oh gee, I had a fantasy about this, that or the other thing,‖ could you make a distinction between that sort of daydream type fantasy and what you mean in ―unconscious fantasy?‖

CATTANO: Well, they are all very similar. Daydreams are fantasies. Dreams are fantasies. Some fantasies, many of them, are unconscious. We‘re not aware of the fact that they are operating in our psyche, but although they may be out of our consciousness, it doesn‘t mean, by any means, that they are not motivational, or that they don‘t influence our behavior in very powerful ways.

106 Let me start with Freud. The influence of unconscious fantasy upon symptom formation, perception and the unique manner in which the inner and outer world are organized is well documented in the psychoanalytic literature. Surely, in Freud‘s earliest works, the contribution of fantasy process in symptom formation is very apparent, although not necessarily referred to as such.

As early as in 1894 in his paper, ―The Neuropsychosis of Defense,‖ he discusses the need for certain patients to defend against unacceptable ideas that threaten to intrude into their consciousness and cause severe emotional distress, otherwise known in his papers as, ―hysteria.‖ In this particular work, ―The Neuropsychosis of Defense,‖ the dynamic interplay between the inner and outer world in reactivating certain repressed fantasies and precipitating the symptoms becomes evident, so I‘m just going to quickly touch upon Freud‘s example there.

In this paper, he presents a young girl who was distraught by the obsessive dread of being overcome by the need to urinate and of being unable to avoid wetting herself ever since a need of this kind obliged her to leave a concert hall during the performance. This case excerpt reveals that during the concert, the young woman was stimulated by an attractive young man. Actually she had a fantasy of sitting next to him and being his wife. During this erotic reverie, she began to experience sexual feelings, which culminated in the need to urinate. From that point on, there emerged an irrational fear of losing control of her bladder.

What Freud described was a displacement of affect from the original pathological idea, the fantasy, or the little erotic reverie that she had, to the fear of experiencing relief through urination. In the unconscious, the loss of sexual control was displaced onto the loss of bladder control.

Thus, the symptom was constructed as a compromise that provided a restricted and disguised expression of the pathological idea that was organized by the unconscious fantasy process. So, that would be a very brief introduction into the notion of unconscious fantasies.

Unconscious fantasies are mental templates that organize the unconscious. So often, as practitioners, we talk about, ―Well, there

107 are issues in your unconscious.‖ Well, there are issues, but they are in the form of fantasies. So, fantasy gives substance, they give meaning to the unconscious. They lend what‘s called, in psychoanalytic terms, ―secondary process‖ to the notion of the unconscious. So, they give form and substance and they are very powerful and they organize around certain issues in people‘s lives as they occur.

So I hope that that would be maybe an introduction into the notion of fantasies.

ALEXANDER: Okay, let‘s move then to how that would apply in addiction.

CATTANO: What I think happens is, and it‘s proven in the case material and I think the case material will demonstrate this -- that these fantasies are motivational, that they demand expression and the lifestyle, the behavior associated with addiction becomes an expression of these fantasies. It becomes an acting out of the fantasy process. They, therefore provide capacity for gravitation.

The addict is really addicted to repeating the fantasy. The fantasies cause a repetition compulsion, in a sense. The compulsion to repeat is the persistence of these fantasies that have not been resolved. They have not been worked through and therefore, they keep on pressuring the mental apparatus for action that will satisfy them.

ALEXANDER: So, when you say that a fantasy is motivational, does that mean that buried in the back of our mind is some kind of a fantasy or a story or a belief that makes us have to act in a certain way? Is that what you‘re saying?

CATTANO: … that impels us to act, that drives the psychic apparatus, that motivates us in certain ways that are very idiosyncratic, very unique to that individual. If you want, maybe it would be helpful to talk about a case as an example of that.

ALEXANDER: Sure, let‘s do that.

CATTANO: I think that a case example makes this very real and takes

108 it from an abstract theoretical discussion. Let me talk about, well, we‘ll talk about a couple of patients, but particularly one which I think very clearly shows this process. I worked with an individual, a man, for a period of about five years. He came in very heavily addicted to drugs, all of his adult life, actually from his late teens into his mid 30s. He was also what was called ―addicted‖ to the use of prostitutes, and that was his exclusive form of sexual gratification. He had seen a previous therapist who claimed he had an addiction to drugs and an addiction to sex, particularly an addiction to prostitutes.

After I got to know the patient and heard about his developmental history, I learned that this was a young man who lived in the basement of his house during all of his growing up years. His parents‘ bedroom was situated directly above him. Almost every night he would hear his parents making love. They were very loud, they were very overt about it and he started to feel left out of their pleasurable pursuits. He felt like the hapless spectator, hearing his mother and father enjoying themselves and not respecting the fact that their son was directly below them.

Well, it so turns out that there developed a fantasy of revenge, the wish to humiliate the mother and the father in the same manner that he endured humiliation in growing up and listening to their sexual exploits with no respect for the fact that he was residing directly below them.

So, what this young man did on a regular basis was to borrow his mother's car and go out and pick up prostitutes. He would never use his car. He would only use his mother's car. He would always make sure that the prostitutes left cigarette butts in the ashtray with lipstick on them.

Almost inevitably, his mother would ask him, ―What were you doing last night? Who were you with? Why there are cigarette butts in my ashtray; they have lipstick on them? Were you with a woman in my car?‖ He would sort of smile inwardly and say, ―Think about what I was doing Mom, as I had to think about what you were doing up in that bedroom.‖

109 So, what you see is a powerful fantasy of revenge that motivated his behavior that looked like an addictive lifestyle, an addiction to prostitution, or as a psychiatrist called it, ―an addiction to sex.‖

ALEXANDER: Let me interrupt at this point. Was he aware of the revenge motive?

CATTANO: No, he was completely out of his realm of consciousness. It came up in a session, interestingly enough, when he started to talk about the fact that he had a pet cat that used to try to get into his bedroom. It would stay outside in the hall and claw at the bedroom door. He brought that into his session one day and I said, ―Why did you bring that in? Why is that important for us to know?‖ He started to talk about how that cat wanted to be in that bedroom with him because it would be fun to be in that bedroom with him. He would play with the cat, he would feed the cat. The cat was missing out by being on the outside. That led, over a period of time, to opening up the whole notion of remembering something that he forgot: how he used to sleep under his parents bedroom and he used to listen to their pleasurable pursuits every night. So that started to organize this, ―I‘m going to get even with them.‖

ALEXANDER: So, when he would go to find a prostitute and take his mother's car, he wasn't thinking, ―I‘m gonna show them.‖

CATTANO: Absolutely not. In his mind, he was just cruising for prostitutes. He had no association with the notion that this had to do with his mother, although, he was in his mother's car. He said, ―Well, my mother's car was more attractive than my car.‖ But when he looked at it over a period of time, the years that he actually did it, he realized that there was more to it than that. And, when he talked about the notion of the cigarette butts in the ashtray and how that would make his mother question him every night, he started to realize that he wanted to cause her pain. He wanted to be caught. He wanted her to know that he was out doing exciting things that she was not part of. So, it becomes part of a revenge fantasy that motivates his behavior.

Once it became conscious and we talked about the psychological hurt that he endured with his mother and his father -- and, actually he had

110 older brothers who also brought women into the house -- he then completely gave up the behavior. He is still in treatment. He has not ever gone back to prostitutes.

ALEXANDER: How did this affect his addiction to heroin? It was heroin, right?

CATTANO: He only had a flirtation with heroin. He used a lot of other drugs: cocaine; and a lot of grass. What he would do is he would always use the drugs almost exclusively in the house. He would go down into the basement of his house in his room where he stayed and he would put pleasurable music on and he would do his drugs.

Over a period of time, we asked, ―Why was it always in that room. Why did you use drugs in the fashion that you used them?‖ He started to understand that this was the room he was going to have pleasure in as they had pleasure in the room above him, that he was going to indulge, as they indulged in their pleasures, in the room above him. So, again, it was a revenge piece at work: ―I am going to be in my room doing things that I should not be doing and I don't give a damn if you find out about it, if you smell the drugs, the marijuana. There is nothing that you‘re going to be able to do to stop me, just as I was not able to stop you.‖

ALEXANDER: Has his drug use subsided?

CATTANO: He has not used drugs in three to four years, nothing. He has not used any drugs at all and he has gone from being someone who was, in many ways, somewhat of a derelict, a very seedy looking character to a rather successful, middle-management employee in a rather large firm. I hate to brag about a success; sometimes we need to do that, but, he has made a miraculous turnaround. He had to understand how these powerful fantasies of revenge and hurt and feeling left out were motivating his behavior. Once he got hold of that, he would form different compromise formations. He didn‘t have to do the same thing any longer. He didn't have to use prostitutes. He could go out and have a normal relationship with a woman. He didn't have to sit in his room and get revenge against his parents.

111 There was another fantasy that was at work too, and that was that his mother was a prostitute, that she betrayed him and his love for her. And, he got even with her by going out with prostitutes. So, prostitutes sort of became a mother stand in. By the way, this is a dynamic that is often behind a lot of people who are involved in serial murders when you see what they are murdering is exclusively prostitutes. We have a couple of cases of that in Long Island.

ALEXANDER: Now would you say, Dr. Cattano that if you had the time to work with every addict in this way, that you would find that every addict that there is some unconscious fantasy that propels the addiction?

CATTANO: I would say, based on my experience, first of all, whether we are addicted or totally healthy in our lifestyle, we‘re all motivated by unconscious fantasies in one way or another. So, if we look into the psyche and the unconscious of any person, we are going to find unconscious fantasies that are motivational in our behavior. I always like to say that everything is idiosyncratic; it is very unique to the patient that you're working with and the fantasies that you find in each patient are going to be different. That is the job of the therapy.

Surely, there are other factors too that contribute to substance abuse and I don't want to be so naïve as to say that there are not. There are environmental pressures that contribute to drug abuse, socioeconomic factors. I know that group pressure is a factor, things like that. There may be a genetic predisposition but I don't think that it is as crucial as it is being made out to be. I think that other factors are really more important.

ALEXANDER: One of the things that many addictions specialists talk about is that there is a void in the person that they try to fill with the addiction. Can there be a void and a fantasy at the same time?

CATTANO: I really must say I don't know what that means. I know that some people have suggested that -- maybe this is what you mean by a void, and I don't know if this is what you mean -- but certain people have talked about failures at internalization with substance abusers, that they have failed to internalize some of the functioning of the maternal object and therefore there are deficits in their ego

112 structure which they try to compensate for with the use of drugs. I don't know if that is what you mean by void.

ALEXANDER: Yes, and basically it, lets say to simplify, the lack of a soothing function, perhaps.

CATTANO: Yes, that people will claim that substance abuse is a way of dealing with deficits in ego functioning such as the self-soothing mechanism. I wouldn't necessarily disagree with that. But, I think that I would like to know what is so irritating to them, and then you might get into the notion of fantasies. What is so disruptive to them that they cannot soothe it? When someone says that, ―You don't have a self soothing mechanism,‖ I think, ―Well, that's sort of an empty statement. What's going on with the person? What do they need to soothe? What is bothering them?‖ And then, you might get into the notion of these powerful fantasies that are very overwhelming.

ALEXANDER: You know, in a way, your view of addiction and of the addicted person is rather healthier than a lot of people's views.

CATTANO: Absolutely, absolutely. To be a reductionist to the extreme in this case, it is really a matter of an unhealthy compromise formation. Once the patient sees the basis of this compromise formation -- all behavior is a compromise formation -- I think that we would agree on that -- the goal of therapy is to lead them to creating a better compromise formation for the issues that they are facing and to deal with it in a more effective, more functional manner.

ALEXANDER: Let‘s just go back for some of our listeners who might not know these terms, can you define and explain to us, ―compromise formation?‖

CATTANO: A compromise formation, if we talk along lines of ego psychology, is a manifestation of the organizing function of the ego, but a compromise formation is the way that the psyche tries to deal with the various demands that are placed upon it from the inner world: the drives; the sexual drives; the aggressive drives; and then the restrictions that are placed upon that by reality, by the environment that you live in. You then create a compromise formation. If you are very angry at someone and you would like to kill them because they

113 have hurt you, if you grew up in a ghetto where violence was commonplace, the compromise formation that you might form is one of acting out on that and maybe hurting the person that has wronged you. That would sort of be a compromise formation and it would be a poor one, it would be a poor way of dealing with that hurt and that aggression.

Another person who grows up in a healthier environment might say, ―Well, that person has really hurt me. At some point in the future they will have their day and I just choose at this point not to deal with them and their aggressive attack on me.‖ That is a healthier compromise formation. Or, ―I'll go out and play basketball today instead of punching Jerry in the face.‖ That would be a healthier compromise formation.

I might give you another case example of a man I worked with..

ALEXANDER: Okay.

CATTANO: .. to show you how these powerful unconscious fantasies will motivate their behavior and the conflicts it causes in them. And, if you can grab hold of that as a therapist and realize that your patients are under the influence, if I may, of these powerful fantasies that are motivating them, then you might understand better how vulnerable they are to relapse. Because you explain to someone the dangers of substance abuse and because you detoxify them and put them in a rehab program where they're not exposed to drugs for a long period of time, it doesn't mean that these fantasies have gone away. So when they leave that facility, the fantasies reassert themselves, and when they get into an environment where those fantasies have an opportunity to be played out again, they often are played out and the patient says, ―I don't know why I did it, you know, I don't know why I ended up in that bar drinking again.‖ Well, they ended up in that bar drinking again because that bar is possibly a place where they could pick up a woman and maybe they were motivated by an unconscious fantasy, a sexual fantasy, that they walk into a bar like they did many times in the past, that they would meet some young woman and engage in some kind of sexual activity. So, they are under the pressure of the fantasy. The fantasy gets enacted in the bar. So, they

114 naturally gravitate to the bar to fulfill the fantasy, not to drink, but to fulfill the fantasy.

Also when they are drinking, then their inhibitions may drop and their ego controls or functioning may diminish, and they will act on the fantasy. The fantasy becomes more powerful as the ego weakens under the influence of substances.

ALEXANDER: There was an article in the New York Times about the shortage of methadone clinics. It brings this question to mind: what is your opinion about the use of methadone and the use of Annabuse, prescribed, to help a person deal with their addiction?

CATTANO: I‘m not opposed to the use of methadone. I was director of two large methadone maintenance programs in Long Island for a period of about four years, so I am quite familiar with methadone maintenance. In fact, the patient I describe in my article in the Clinical Social Work journal, I put on methadone. Well, I don't ―put them on,‖ I suggest that he enter into a methadone program and he does, because he was addicted to heroin for many, many years and the use of methadone gave us the opportunity to deal with the psychological issues that were motivating his behavior. But, I don't want to claim that by putting a patient on the couch or sitting in an office with them and doing talk therapy, you're going to have the ability to be more powerful than those drugs. I think that would be a silly notion. So, you do have to use things like methadone maintenance.

What I am against is what I call, ―the revolving door:" shoving them in methadone maintenance programs, they get their methadone every day. A lot of that they sell out in the street and they just end up forever going through methadone maintenance programs and they never really establish any quality of life. They never really deal with the issues that led them to substance abuse in the first place. They live much diminished lives in many respects. Yes, there are a few that by some, maybe act of God, I'm not sure, will use the opportunity of being on methadone as a way of straightening their life out. I think that methadone can be an important adjunct to a total treatment plan. But, if you don't look at these underlying powerful issues, the possibility of relapse is very, very strong.

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ALEXANDER: Dr. Cattano, is there anything that you'd like to add before we close?

CATTANO: The only thing that I would like to add in closing is that I think that substance abuse is first and foremost a mental health issue. I know were trying to make substance abuse into a totally separate field of practice, and I think that is a mistake because, by doing such, were not going to look at the psychological motivations that are so evident in people that are addicted and are so motivational in relapse. I think that it is a mistake to treat substance abusers in any setting that does not have well credentialed mental health professionals leading the charge.

ALEXANDER: Thank you Dr. Cattano, we've enjoyed this very much.

CATTANO: You‘re welcome.

Listeners interested in Dr. Cattano‘s work may contact him at 36 E. Woodbine Dr.; Freeport, NY 11520.

This concludes our interview with Dr. Joseph Cattano and our interviews in ―Addictions A.‖

You‘ve heard a number of competing ideas and differences of opinion on key points. For example, should the substance abuser be confronted with his behavior? Are addictions a disease? Do addictions fill a void or are they a compromise formation? How do we understand relapse? And should the childhood and past experiences of the substance abuser be looked at.

We hope you‘ll follow up on your own by further reading and study. Especially, we hope that you learned from these interviews and that you enjoyed them.

As always, I must say here that the views expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority.

On behalf of On Good Authority, this is Barbara Alexander. Thank you for listening.

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