What is Addiction and how is it Treated?


There are three principles that are essential to understand about addiction:

  1. Addiction is a medical disease in the same way as hypertension or cancer are medical diseases. Addiction is a dysfunction of the pleasure centers of the brain.
  2. Addiction is not a personality disorder or a moral problem (i.e. being a bad person). An addict did not decide one day that they would destroy their life and the lives of their loved ones through their obsessive-compulsive behavior.
  3. Treatment works but it does not come in a pill nor does it end after detoxification. Recovery occurs when the addict makes the changes in their life necessary for them to have joy and happiness without their substance or behavior.

What is Addiction?

Addiction is a persistent, compulsive dependence on a substance or a behavior (i.e. gambling) even though the individual has experienced potentially harmful consequences while doing this substance or behavior. The compulsion to use a substance or to do a behavior comes from an involuntary biological drive located in the pleasure centers of the brain. Once an addict has had an experience that gives “pleasure” or relief, then the memory of this feeling is attached to the substance or behavior that caused it. This is called “biological conditioning”. Addiction is a disorder of the brain’s reward system.

“Pleasure”, here, is defined as any feeling that gives someone a sense of well-being or relief from a bad feeling. Pleasure could be the ability to laugh when someone is depressed. It can also be an escape from a sense of dread when someone is under constant anxiety, stress, or fear. Therefore, once the addict discovers that using a substance provides pleasure or relief, they are starting a process of biological conditioning. Whenever they are in an unpleasant or boring situation, they know that by using that substance they can get immediate relief.

Cigarettes are an example of this type of biological conditioning. A smoker smokes cigarettes when they drive their car. Assume they do this over 6 months or longer.  Then one day they get into their car and they do not have a cigarette. Driving does not feel right without a cigarette. They can try to drive their car without a cigarette, but they feel that something is wrong without a cigarette. Smoking a cigarette has become, for the nicotine addict, a biological conditioned response. This patterning would be the same for someone who is compulsively dependent on alcohol, marijuana, OxyContin or whatever other substance is involved.

When an addict, who has been depressed for the past year, realizes that they are not depressed when they are using their substance, then their addiction has become, not just a recreational way to get high, but a “necessary” way to deal with their depression. This response will override any concerns about the consequences of using this substance such as the dangers of driving intoxicated or having unsafe sex. They now have a functional as well as a recreational reason to use their substance.

A co-occurring disorder is a psychiatric disorder that occurs in someone who also has a Use Disorder (addiction). Those addicts who also have a psychiatric disorder have a dual-diagnosis. The psychiatric disorder can be caused by the Use Disorder or it may have been there before the Use Disorder. It is important to make this distinction because if the psychiatric disorder is a separate diagnosis, then without aggressive medical treatment of this psychiatric disorder, this will become the addict’s number one relapse risk factor. After the addiction has improved, the treatment of the psychiatric disorder must continue, and medications cannot be stopped.

You May be an Addict if —-

Someone who drinks a fifth of liquor a day for a year is an addict. Someone who uses heroin every day for 6 months is an addict. These are clear examples of addiction, but some people with an addiction, to avoid their need for treatment, will rationalize they are not as bad as these two examples. Here are a few examples: having two DUI charges over the past 5 years means that you have an addiction even though you only drink on the weekends. Falling down steps and breaking your leg while you were intoxicated along with being fired from a job because you are always too late in the mornings means that you have an addiction. Avoiding going to your grandparent’s funeral because you had gotten too intoxicated the night before along with having a history of one DUI means you have an addiction.

There are many more examples. Rationalization, minimization, and frank denial are our ways of avoiding the reality of the fact that we are powerless over our use of a substance or of repeatedly doing a behavior that is causing serious problems in our life.  No one wants to admit that they cannot manage a part of their life but until you can admit this, you will not ask for help. You will continue to be controlled by your addiction which will cause problems in your life as well as the lives of those who love you.


50% of Use Disorders have a genetic etiology. An alcoholic (someone who has an Alcohol Use Disorder) who has the variety of genes necessary to be an alcoholic may be able to drink a pint to a fifth of alcohol a day and not die from alcohol toxicity. An individual who is “genetically prewired” to have an Opioid Use Disorder can take a Percocet and become mentally clear; not worry about what is wrong in their life; feel comfortable and gregarious in groups even with an anxiety disorder; and be motivated to finish the term paper that is due tomorrow.

The other 50% of those who have an addiction are those individuals who were not born with the genes that cause a specific substance Use Disorder or an addictive behavior. These individuals develop an addiction because of what is going on in their lives. Examples of this include three groups of people: chronic pain patients; psychiatric patients; and young adults.

Patients with a chronic pain condition that is not adequately stabilized can abuse opioids. Even though they have overdosed on opioids in the past and almost died, they continue to abuse opioids trying to get pain relief because the pain is unbearable. They do not get a sense of wellbeing when they use the opioids like a “genetically prewired” opioid addict.

Someone trying to get relief from their Major Depressive Disorder may try stimulants, especially methamphetamine or cocaine, and become addicted to these substances because they get temporary relieve of their depression. With these drugs, intense cravings to use stimulants can develop such that they are unable to stop using these substances even when their life is shattered because of their use.

About 25% of all young adults meet the criteria for a Use Disorder. Once they mature past 26 years old, this percentage drops dramatically to that of other older adults. This is a cultural phenomenon of young adults in this generation. Just a generation ago, it was expected that by 21 to 25 years old, a male would be married and have a job supporting a family. Females were expected to marry earlier and to have children. All of this has significantly changed.  The typical age of marriage is now around 28 years old and having children is 30 years old. Young adults have much less responsibility, are more educated, and believe they can do anything without getting hurt. Many are bored and looking for excitement and purpose, unfortunately, in the wrong way.

The last category of people with a Use Disorder is a smaller percentage of the population who are capable of being addicted to any substance and any behavior that can alter their consciousness so that they feel “high”. They will abuse Benadryl, alcohol, opiates, stimulants, inhalants such as glue or paint, hallucinogens, dissociatives (i.e. PCP, ketamine), sex, gambling, eating, and many more.  We are not sure if these addicts have a series of genes that make them this way or if this is part of their personality structure. The treatment of this group of addicts is long and requires many different approaches to deal with the complexity of their life style.


According to the National Institute of Health (NIH) in 2013, 8.6% (22.7 million people) of the United States aged 12 or older needed treatment for an addiction and this number does not include those with a Nicotine Use Disorder. Only 0.9% (2.5 million) received treatment. Only one out of 10 addicts obtain treatment. This means that about 90% of people with an addiction will experience a lifetime of interpersonal and physical problems involved with their addiction and may die because of their addiction.

25% (80 million) of the United States has a Nicotine Use Disorder. Young adults ages 18 to 25 have the highest rate of use of tobacco products (35%). This is the worst addiction in the world. It earns the #1 position because of the loss of life caused by cardiovascular disease, cancer, and lung disease. According to the CDC in 2013, more than 480,000 deaths were caused by nicotine and cigarettes.

According to the World Health Organization in 2013, 7% of adults in the US (17 million) and 2.8% of ages 12 to 17 (700,000) had an Alcohol Use Disorder. Alcoholism directly resulted in 139,000 deaths and it reduced a person’s life expectancy by around ten years.

In 2015 the NIH said that 2 million people had an Opioid Use Disorder from pain relievers and 591,000 from heroin. This is about 0.8% of the 322 million people in the US. There were 33,000 deaths due to opioid overdose as per the CDC Injury Center. In 2017 there were 60,000.

Cannabis Use Disorder is the most common Illicit drug used in the United States. As this substance becomes more legalized throughout the country, more teenagers and young adults are spending their days getting high instead of taking charge of their life. About 9% of those who experiment with marijuana eventually develop a Use Disorder. According to a NIDA (National Institute on Drug Abuse) review, the rate goes up to 12.5% among those who begin use as a adolescent. The highest risk of cannabis dependence is found in those with a history of poor academic achievement, deviant behavior in childhood and adolescence, rebelliousness, poor parental relationships, or a parental history of drug and alcohol problems.

Neuroanatomy of Addiction

Addiction is a medical disease. Usually an addiction involves an activity that gives pleasure or relief. Addicts have memories of what made them feel good in the past (i.e. alcohol, sex, etc.). These memories can be made conscious by events going on in the addict’s life or by certain feelings experienced in the present. If they are sad, lonely, anxious or afraid, the brain remembers a solution that gives instant relief to deal with these bad feelings. That solution is the use of a specific substance or to do a specific behavior.

Brain has been sliced in half and you are looking at the right side of the brain.

Limbic System is located inside the center of the brain.

The Cortex is located outside of the Limbic System.

The part of the brain that initially responds to a bad situation or to a bad feeling is the limbic system. It does not necessarily care about the consequences of what may happen when the addict gets intoxicated as long as the individual gets relief from the bad feeling. In fact, the limbic system does not even have memories of the consequences. It only remembers what gives relief.

The cortex is that part of our brain that remembers all past consequences of behaviors. The cortex also stores what the person has learned such as that lecture on unprotected intercourse.  Normally, when a person experiences a bad feeling, the limbic system demands that the addict find immediate relief. The cortex filters these demands by flooding the person’s consciousness (awareness) with all the memories of the problems that occurred when they got intoxicated in the past.

The person then must decide whether they will respond to the demands of the limbic system. Unfortunately, some substances (i.e. alcohol and Xanax) come with a mechanism called disinhibition. This disconnects the input of the cortex and does not allow the cortex to bring to consciousness the possible consequences of that behavior. The addict then proceeds with their addictive behavior.

The cortex does not fully develop before the age of 26. The limbic system is fully developed by the age of 18. This means that in the young adult, the more mature limbic system has more control over actions taken than someone over 26. Young adults and adolescents who have a Use Disorder will need a more “structured treatment” to keep them sober long enough so that they can begin their treatment. It is almost impossible to treat these individuals as an outpatient coming from home because they have such a high rate of relapse.

 Aspects of Addiction

  • The Obsessive-Compulsive Drive
  • Biological Conditioning
  • Unmanageability
  • PAWS
  • Craving
  • Use Disorders as a Medical Disease

The Obsessive-Compulsive Drive

The addict’s repetitive use of their substance eventually causes tolerance which is a decrease in the response to their substance such that the addict must use larger amounts of their substance to get the same relief or high that they got the first time they used. With large doses of the substance (i.e. alcohol, Xanax, OxyContin), the awareness that usually would come from the mature part of our brain of potential danger (i.e. Do Not Drive at 100 MPH!) is blocked through disinhibition. The addict responds to the limbic system’s need for gratification. The rational, objective part of our brain, the cortex, is ignored to experience that immediate gratification, regardless of the consequences.

Unfortunately, the drive to repeat the same behavior eventually takes top priority in the addict’s life. Every other aspect of their life becomes secondary to the need to “get high”. Family, school, job, relationships, God, and the law all become secondary to the addictive behavior.  Anyone who tries to prevent the addict from doing the compulsive behavior will be considered the enemy.

The addict’s rationalization, minimization, and frank denial become well refined responses to anyone’s questions and concerns. Addicts convince themselves that they are righteous in their statements of how others are interfering in their life. They feel that others are trying to take away their right to make their own decisions by questioning their judgment and treating them like children.

Addicts even become convinced that their behaviors and use of substances are necessary to deal with depression and anxiety, to calm down, to get to sleep, or to be able to focus. If OxyContin, alcohol, or marijuana were healthy treatments for anxiety, depression or attention deficit disorder, we would prescribe these substances as a standard of care for these problems, but they are not.

Many people in our society, who seem to be functioning well on the surface, suffer from addiction. You do not have to be passed out all the time secondary to alcohol or doing intravenous heroin to be an addict. You do not have to be a totally irresponsible person to be an addict. The reality is that most people with an addiction initially go about their lives as anyone else. The difference is their constant obsessions about when they can use their substance.

In the early phases of the disease the addict routinely goes to work or to school then at night uses their substance. This initial phase of the illness proves to addicts that they are in control of their use. They have proven to themselves that they can manage and control their compulsive behavior. Addicts use this fact to minimize, rationalize and deny that the behavior is dangerous. Rational, sane people would quickly admit that this behavior is dangerous and destructive. Addicts have a special type of insanity which is based on the delusion that they are in control of their behavior and that the behavior is essential to deal with life. They cannot or will not deal with life on life’s terms without their substance.

Biological Conditioning

Even if an addict can stop the compulsive behavior temporarily, this does not mean that they are not an addict. The problem for any addict is not stopping but staying stopped. Most biological conditioning requires repetition of a stimulus/response behaviors based on receiving a reward for an action that was caused by the stimulus. Thinking about alcohol (stimulus) leads to taking a drink (response). This either gives a sense of wellbeing or relieves anxiety (reward). Once the response is reinforced through repetition they believe that to have a sense of wellbeing or relief from anxiety, the addict must take a drink.

Whenever the limbic system experiences a pleasure that is quick and efficient, it never forgets. A substance that can give essentially instant pleasure or relief of fear and anxiety fits that bill. In fact, some substances do this so efficiently that some people are addicted to a substance after doing that substance only once. Crack cocaine and methamphetamine can affect some people this way.

The problem here is that what takes one second start an addiction, takes at least a year to find alternative coping techniques that can at least equal the “benefits” of using that substance. Teaching the limbic system to use alternative ways to get relief from boredom, anxiety, depression and fear is like teaching a dog to walk on their hind legs. Not only do you have to teach the dog to walk on their hind legs, but you must help the dog to want to.


After about 6 months of using a substance almost daily, most addicts begin to have unmanageability in their life because of their use. This unmanageability occurs in every aspect of their life. The addiction demands that using the substance is the primary purpose in their life. Those people in relationship with the addict begin to feel rejected and abandoned as the addict begins to withdraw. Most jobs require that the employee is focused on their job instead of themselves. When the addict must use during the day or has been using much of the night and not resting right, the addict’s performance begins to wane and is noticed by their employer.

Eventually, something significant occurs such as an auto accident, a DUI, or being fired from a job. Bills do not get paid because the income goes to pay for the substance. Physically, the individual becomes weak because of not eating or sleeping right and not exercising. The list goes on. The addict is not able to manage the casual use of their substance without more unmanageability. Hopefully, when this significant event occurs, either the addict or the addict’s loved ones will realize the unmanageability that has been developing in that person’s life because of their addiction and seek treatment.

Without unmanageability in the addict’s life because of the use of the substance, the addict would never stop using the substance. Even with repeated unmanageability in an addict’s life, if the addict does not want to stop the use of a substance, nothing can make that addict stop. That person may die through the continued use of that substance.


Post-acute-withdrawal syndrome (PAWS) describe a set of persistent impairments that occur after withdrawal from alcohol, opiates, benzodiazepines, antidepressants and other substances. In some cases, these substance-induced physical and psychological symptoms can persist long after detoxification, such as prolonged sleep disturbance, depression, irritability, and short frustration tolerance. A protracted PAWS can also occur with symptoms persisting for months to a year after cessation of use.

The severity and longevity of PAWS depends on the potency of the drug and the length of time the drug was used. Drinking a fifth of alcohol a day for 10 years will result in a PAWS for about a year. Daily use of a gram of heroin a day for a year will result in about 6 to 8 months of a PAWS. Of course, the severity of a PAWS progressively decreases each day that the addict is not on their substance and eventually it stops all together. What is different from one person to another are the exact symptoms that make up the PAWS. Usually, disturbed sleep is a problem for at least a couple of months. This disturbance may differ from frequent awakening to vivid dreams all night which may include “using dreams” or horrible nightmares such that the person is afraid to go to sleep. PAWS is the cause of many relapses.

What can be controversial in the recovering community is the use of medication to manage the severity of PAWS. Trazadone, Vistaril, mood stabilizers (Seroquel), gabapentin, and antidepressants are all used to target specific symptoms. If these symptoms are not stabilized, many newcomers to the recovery process will relapse. Benzodiazepines (i.e. Xanax, Ativan, Klonopin) cannot be used because of how this chemically recreates the addicted state in the limbic system and can lead an addict back to their drug of choice.


As part of PAWS, craving is the uncontrollable desire to use a substance. The longer the addict uses a substance that gives pleasure or relief, the more their limbic system feels that they must have this substance. The limbic system will create an urgency that many addicts cannot resist. Methamphetamine and crack cocaine addicts have some of the strongest cravings of any addiction though alcoholics and opiate addicts can also have just as severe cravings.

Use Disorder as a Medical Disease

A Use Disorder is a life-long medical disease. The cost of treating addiction over a lifetime is no different than any other medical disease.  If a Use Disorder is believed to be just a weakness of character, then, of course, the amount of money it takes to treat this medical disease over a life time seems like a waste of money. The saying, “Addicts need to just say no!” is an oversimplification of what it takes to treat this major medical problem. We all wish it were this simple. This way of thinking is from someone who does not understand addiction and what it takes to manage the disease.

Major-medical illnesses require constant education and reassessment to keep the individual taking their medication, eating the right foods, doing the right exercise, and living the right life style. It is human nature that most of the population will not do all that they are supposed to do even with the best education. It takes the same amount of resources to treat addiction as it does to treat the other major medical problems.

Adherence Rate to medical treatment:

  • Diabetes – ~60%
  • Hypertension – <40%
  • Asthma – <40%
  • Addiction – ~50%


Addiction is a family disease. If one person in the family has an addiction, then everyone in the family is part of that addictive disease. Each family member who loves the addict is changed because of the addiction. Anger, depression, and fear are some of the most common feelings. Codependency, avoidance, minimization, rationalization, and denial are some of the common behaviors family members use to deal with their relationship with the addict. The family needs treatment as much as the addict to understand how to live life with addiction. This treatment can involve individual therapy, family therapy, and group therapy.

Alanon and Naranon are two 12 Step meetings for families of alcoholism and drug addiction, respectively. For some family members this is an essential activity to understand addiction and how to cope with having a family member who is addicted. It works if you will agree to go to at least five meetings and participate in the meeting. Do not try to deal with all of this by yourself.


There are four stages of recovery from a Use Disorder; Acute, Subacute, Transition and Maintenance. The whole process takes at least a year to get into a full recovery if the addict is working their program of recovery every day. If they do not work their program of recovery, then the process takes longer with more frequent relapses. The reason it takes at least a year is because the changes that must happen in the brain to change the way the brain thinks are slow even with the best treatment for those willing to make the changes necessary. It took the addict a much longer time to develop their addiction and, during this time, the brain was changing slowly into the addicted brain.

Acute Phase of Recovery (one to two weeks)

Once the addict decides to stop using, their mind, their body, and their emotions react very much like a child that has had their candy taken away. Every addict will go through a “detox” stage and, for alcohol and sedatives, this is a medical emergency because of the potential for seizure, heart attack, and stroke. They must be admitted to a qualified medical detoxification unit so that they can be appropriately medicated and monitored by a medical team. The only thing that is required of the addict at this stage is the willingness to stop and to let people help them.

Opioid addicts need inpatient treatment as well so that they can get through their withdrawal without relapsing on their opioid. The danger here is if the person is physically debilitated and during the withdrawal loses too much fluid through vomiting and diarrhea, they could die. Healthy individuals are not in danger of death but will probably relapse if they are not in a contained inpatient unit because they feel so miserable both emotionally and physically.

Stimulant addicts, especially those abusing Methamphetamines, are usually physically debilitated through dehydration and lack of other nourishment. They may also be paranoid and convinced that you are going to either hurt them or try to humiliate them. They will need 3 to 5 days to sleep and to hydrate. Sometimes they are also physically weak and have lost a great deal of weight. Some individuals using crack (concentrated cocaine) may have the same symptoms.

Those stopping marijuana usually become irritable, have trouble sleeping and trouble with frustration tolerance. Their memory is not the best and they can be short winded so that exercise can be difficult.

With all of these substances, 3 days to a week will be necessary for the acute phase of detoxification. There is usually another week or two that the individual is cognitively and physically slow. Those who start an addiction treatment program during this time will find that many principles of the recovery process will have to be repeated once their brain and body become healthier. They need emotional and physical nutrition to deal with their debilitated state caused by their addiction.

Subacute Phase of Recovery (4 to 6 weeks)

Once the brain, body and emotions have stabilized from the active addictive state, the addict is now able to start looking at the principles of recovery. Understanding the medical nature of their addictive disease is crucial for the addict to realize that they are totally powerless to deal with their substance by themselves. Powerlessness means that they cannot use their substance in moderation and manage their use because when they tried to do this, their life became unmanageable.

It takes a special ability to drink a pint of liquor a day or two six packs of beer. Most people cannot do this every day and be able to function. You must be genetically prewired to be able to metabolize that much alcohol daily. A small percent of the population will respond to an opioid with mental alertness, increased motivation, and decreased anxiety.  When those who are not opioid addicts use an opioid, they are cognitively slow, have nausea, and it is not an enjoyable experience.  Again, you must be genetically prewired for an opioid to give a positive feeling.

When you understand you are powerless over using your substance in moderation, you then can focus on finding a power greater than yourself that can help you to manage that powerlessness. This is not a statement of failure; it is an acceptance of our humanity and the medical disease of addiction. In fact, once an addict sorts out this step, they will open a door to a new and better life that they never knew existed. Willingness, honesty, and open mindedness are the three essentials needed by the addict to respond to treatment.

Relapse is always possible during the recovery process. Understanding this helps patients and families to realize that a structured daily program is necessary. This is usually a PHP (Partial Hospitalization Program) followed by an IOP (Intensive Outpatient Program). Young Adults and many other adults also need to stay in a sober living facility as well as attend the PHP/IOP. They are not yet able to withstand the desire to use their substance and will relapse. All addicts must stay sober long enough to develop a foundation of recovery.


After 4 to 8 weeks of developing the foundation of recovery, the addict will have enough internal structure and connection with their higher power, that they can leave the PHP/IOP and move to either a sober living home outside of Ridgeview or in some cases their own home. They understand the third step of the 12 Steps. This does not mean that they are well enough to stop treatment. The brain is still in a state of addiction such that they can relapse without the right structure. Recovery will take at least another 10 months of going to meetings, working with a sponsor, and understanding and working the last 9 steps of the 12 Steps.


Addiction is a medical disease just like hypertension and diabetes. After the addict has worked all 12 steps, they are “in recovery”. We cannot cure addiction, but we can manage it. The addict will have to continue to work the steps regularly to stay in recovery. Once the addict stops working the steps, they have a very high probability of relapse. This is no different than a diabetic that has finally gotten their weight right and is keeping their glucose normal.


Addiction is a devastating medical disease. Addicts do not decide to be addicts, they are either genetically predetermined to be an addict or there are circumstances in their life that predispose them to addiction. Once they have used a substance regularly or have repeatedly done a behavior (i.e. gambling) for at least 6 months, the brain changes such that life is not good unless they are active in their addiction. The addict is powerless by themselves to stop their active addiction, though this pattern of behavior can stop with the right kind of treatment. Once the addict has the willingness to get into treatment, addiction can be treated. The process of treatment takes time, but it works.

Heroin Summit @ the YMCA in Kennesaw

Ridgeview Institute – Smyrna was pleased to participate in the Heroin Summit @ the YMCA in Kennesaw over the weekend. Ridgeview Institute provides free assessments for mental health and substance abuse problems 24/7. Call us if you or a loved one is experiencing problems with addiction, 844-350-8800.

Playing cards

Know When To Hold ‘Em: When Falling Out of Love Can be Good for Your Relationship – Part 1 of 2

By Wendy Palmer Patterson LCSW, LMFT and Robert W Patterson LMFT, LPC

In the world of poker playing and five card draw, the temptation to draw 3 and go for the inside straight or full house is a lingering seductress waiting for the fool hardy to bet large and invite fate to bless or curse. So many of us know that sinking, somewhat airsick feeling of watching whatever fortune we risk slide smoothly across the table into the waiting grasp of the one upon whom fortune smiled so sweetly.

Falling in love and devoting our time, money, energy to capture the object of our desire is a bit like drawing those three cards. Even as we dream, plot, scheme, pursue, wait, distance or even become depressed, this special relationship can have us staring at our cards, with a lot on the table, contemplating the best draw and hoping we’ve played the best odds.

The book, Getting the Love You Want by Drs Harville Hendrix and Helen LaKelly Hunt was a break through for thousands of couples, giving hope and proven tools to help manage what seems to be a natural process of falling out of love. This approach identified what is known as the “Imago Match”. Imago is Latin for the word “image” and the theory proposes that within each of us is an unconscious map that drives the choices we make when selecting a mate or any significant relationship. The Imago approach outlines a predictable maturation of the long-term committed relationship that identifies separate stages that a couple will experience. In this two-part article, we will present the first two of six stages; Romantic Love and The Power Struggle. Our intent is to help couples understand what is really occurring in the world of attraction and the selection process and to explain why the romantic love experience is not supposed to last. We’re supposed to fall out of love.

For most of us our relationship didn’t begin with a hard cognitive assessment of strengths and weaknesses, or life skills or family and religious compatibility. We chose our beloved because of a convergence of factors, some conscious, some biological, some unconscious that all came together to produce the experience of romantic love that propels us to make deep a commitment to this person. All of these important motivations
and interests i.e.: availability, attractiveness, life stage, and the inevitable neurotransmitter releases brought you to the table. For most of us the business of compatibility was, at best, a nice addition to the composite of romance, nurturance and lust that helped pull the trigger of commitment and bet on the potential “full house”.
Nowhere else would we make a life decision based primarily on the emotional high of romantic love. In fact, most of the world, even in this day and time, believes that making the choice of a life partner should not be left to the whims and emotional undertow of romantic love. They might even say: “ Can you imagine choosing your life’s mate based on the fact that he has nice eyes or her legs are magnificent or he’s funny or brave or generous or a very bad boy.” Of course these kinds of choices do take place.

We’ve made a commitment either because we were attracted; infatuated or just plain head over heels in love with our beloved, while we were under the influence of nature’s most potent chemical cocktails. Nature’s agenda has the house odds and is calling the bets while we’re just starting to the figure out how to play the hand we’re dealt.

Although we may find it difficult to navigate this journey of Romantic Love when we are in it, we can often see the phenomenon taking place in our friends, relatives or, worst case, our children. It’s almost a cosmic joke, that the one who drives us crazy with passion or the promise of a better life, will later, just plain drive us crazy. It is a trick of nature that what attracts us in romantic love drives us nuts later. We are, perhaps, too familiar with the trick. He was brave when they first met and now she complains about his recklessness. She was beautiful and now she’s vain. She was nurturing and now she’s invasive. He was discerning and now he’s critical. He was direct and now he’s rude. These once positive traits that turn negative will surface in the relationship once the commitment is strong enough to handle the differences and incompatibility of the partnership. That’s right, incompatibility is the natural state of committed couples.
Learn to accept that fundamental reality and you are ready for the adventure and personal growth that will come from the most important relationship most of us will ever have.

So whether love shows up as a super sonic jet, a touring sedan or a pick up truck, we know that the experience of romantic love has the same destination. The vehicle doesn’t seem to matter. The destination is the second stage of the committed relationship and what we call the Power Struggle. It is the first major stop along the highway of the committed relationship. And, how well you play the cards you’re dealt along the way can make a huge difference in your enjoyment of the game and your personal growth as a spiritual being.

The Imago Theory provides a pathway for moving through these first two stages of relationship. We think it is predictable that the initial Romantic Love, characterized by attraction, bonding, hope and even ecstasy, is followed by the Power Struggle, most typically characterized by frustrations, anger and sometimes even disillusionment and impasse. Many couples are captured by the Power Struggle and either live miserably, end the relationship or in some cases engage in the nexus of personal change. This journey of change and growth begins through the Recommitment stage of relationship. The turn we can take at this junction begins moving away from the unconsciousness of
Romantic Love and the Power Struggle, into the intentionality and authenticity of the conscious relationship.

The next stop along the relationship journey is Doing the Work. Moving into Conscious Relationship is accompanied by the accumulation and application of new skills and discipline that can help couples achieve an extraordinary relationship. This fourth stage seems dependent on the three that have gone before. Living through the disillusionment of naïve relationship attachment into the power of awake and intentional attachment requires deliberate creation of new patterns and habits.

Doing the Work leads to the fifth stage: Transformation. The theory holds that through the utilization of dialogue, and creation of a new climate in the relationship, couples learn how to take care of themselves and actively engage in the healing of their partner and growth of the self. This stage is characterized by new insights, more positive and accepting perceptions of the partner and of ourselves. This is the time when we become competent in being in relationship; we know what is happening when we fall into a hole and we know how to get out of it. We also know how to nurture, protect and enliven our couplehood. We think that it is required that couples make this journey in order to live in the final destination of relationship: Real Love.

In part two of this article, we’ll be looking at the second stage of the relationship journey, The Power Struggle. We’ll be sharing ideas for understanding this important stage and tips managing the natural incompatibility of the committed relationship. The stress of this challenging time, when viewed in the context of the whole partnership process, becomes something of great learning and stretching. Check us out next time!

Wendy Palmer Patterson, LCSW, LMFT has worked with families and couples for 30 years. She is certified as one of only twenty Clinical Instructors, training therapists in Imago Relationship Therapy. She has trained extensively with Dr. Harville Hendrix for fourteen years.

Robert W. Patterson, LMFT, LPC has practiced in Atlanta for over 20 years and received certifications from Dr. Hendrix as an Imago Therapist in 1990 and as a Certified Imago Workshop Presenter in 1992. Both Wendy and Bob have presented at national and state conferences including the Psychotherapy Networker and for the GA Association of Marriage and Family Therapists.

Wendy and Bob have been married for over 25 years, have raised two precocious children, and have been humbled, at times confused and exhilarated, in the process of becoming a couple. Their offices are located at P2 Partnerships, Inc., 956 Euclid Avenue, NE, Atlanta, GA 30307. Phone: (404)584-7500.

Ridgeview Institute is a private behavioral health care system with inpatient, partial hospitalization, and intensive outpatient programs for adolescents, adults and seniors with psychiatric and addictive problems. We are located at 3995 South Cobb Drive, Smyrna, Georgia 30080. For more information about Ridgeview’s programs and services, call (770) 434-4567 or 1 (800) 329-9775.

For more information about the Ridgeview Institute’s Treatment Programs, visit our website at www.ridgeviewinstitute.com or contact the Access Center at (770) 434-4567.

Playing cards relationships

Know When To Hold ‘Em: When Falling Out of Love Can be Good for Your Relationship – Part 2 of 2

By Wendy Palmer Patterson LCSW, LMFT and Robert W Patterson LMFT, LPC

Last newsletter we shared the idea that being in the long-term committed relationship is like drawing 3 cards in the poker game of five-card draw. In poker, as in life, you often don’t know what you’ve got until the hand is already dealt, the bets are made and you’re committed. Years ago we, as couple’s therapists and coaches, were noticing that as the commitment level between a couple deepened, the power struggle often intensified.

This phenomenon seemed to help explain why couples ‘fall out of love’, and lend credibility to the idea that relationships have predictable stages. When we are in the first stage of the long term relationship: Romantic Love, we feel so connected or hopelessly attracted that making commitments seems the natural way, not unlike the strong temptation to raise the bet when you’ve got a full house.

Romantic Love is a temporary state.
Romantic Love is supposed to end. The experience is emotionally driven with the purpose of bonding two incompatible people. That’s right, incompatibility is the natural state of committed couples. We just don’t get to appreciate the incompatibility until the Power Struggle stage of relationship, when we are staring at our cards, hoping that what’s being dealt next is a lot better than what we’re holding. This stage is also supposed to be a temporary state. You know you have entered the Power Struggle when your beloved goes from being the one who lights up your life, to being the one who keeps raising the stakes and making bets that keep you on the edge of your chair. The Power Struggle and your incompatible partner are there to get your attention – focus your energy AND – wake you up.

Turning Power Struggles into Growth Struggles
The very experience of ‘being driven crazy’ forces change because loving someone who infuriates and confounds us is intolerable. This is a relatively new and unshaped idea, that continuing to love and grow with the one who pushes our crazy buttons is a right and good thing. But thousands of couples around the world are discovering that the difficulties accompanying the Power Struggle phase of relationship can be used to grow,
stretch, wake up and allow more aliveness than ever before. These couples are experiencing the shift to Conscious Relationship and the accompanying stages that include recommitment, doing the work, waking up, and Real Love,

This idea is the essence of what has come to be known as “Imago Match”. Imago is Latin for the word “image” and the theory proposes that within each of us is an unconscious map that drives the choices we make when selecting a mate or any significant relationship. The New York Times best selling authors, Drs Harville Hendrix and Helen LaKelly Hunt coined the word Imago in their ground breaking book, Getting the Love You Want: a guide for couples. This book remains a great resource for any couple seeking to understand the nature of their commitment and the steps to creating an extraordinary relationship.

Imago suggests a way to understand and work with the struggles. Following are three Food For Thought Tips and three Action Steps that can help.

Food For Thought Tip #1.
The Good News and Bad News of your childhood shows up in your committed relationship.

The Good News:
Your unconscious mind had or will have a significant role in your choice of a committed partner. When it comes to attraction, we go to our blueprint from the past in hopes of generating good and wonderful feelings of connection and love. Our highest and most creative talents, such as language, poetry and art, are designed to get us into relationship, and committed to each other and the family. It is exactly these unique tensions that can evolve from the Romantic Love attraction to a particularly ‘creative’ partnering that will allow us to get on to the business we have next to complete, successfully growing and nourishing the relationship.

The Bad News:
We want it all. The repetitive or intense frustrations that we experienced growing up are also asleep in us, waiting to be reborn, this time in connection with our beloved. This is not a cruel trick of nature or as perverse as it might seem. These early frustrations that were unresolved just got buried because that was the best we could do at the time. We put ourselves partially to sleep while growing up in order to fit into our world, the world we saw from our child eyes. But we are not required to live in that drowsy state forever. In adult life we need the differences provided by another person in order to learn to be fully awake. This means that frustration can now become part of a growth strategy to ultimately replace the Power Struggle.

Action Step #1:
Patience and acceptance can go a long way. With very few exceptions, your partner is not trying to hurt you. More often than not, it is the unconscious relationship agenda that has disrupted the connection between you and your partner. This will happen all the
time, so don’t throw in your hand because of the loss of this connection. Just know that disruption will occur from time to time and when it does, it’s time to go to work.

First, own up to your part of the problem. Start the conversations with how you know you have contributed to the difficulties. This will allow your partner to focus on the issue without feeling so defensive and get a tough conversation off to a stable start. Start your sentences with: “I know I contributed to the problem by ………”

Food For Thought Tip #2:
What worked in the past, may not be working for you now.

Part of the waking up process is realizing that your habitual responses to frustration with your partner ARE the problem. An example might help here. Bob sometimes has the experience that Wendy gets so busy that she starts unloading various tasks on Bob. Well of course Bob thinks he has his own list to complete, (thank you very much) and if he’s not careful he can get captured by the experience of being ‘told what to do’. As a youngest child he goes right back to childhood and his older brother and emotionally he is churning the same feelings. Resentment builds and he’s got himself all ready to ‘show her’ and that she can’t “push him around”, ready to defend his integrity. Wendy will say something innocuous like, “Dear, did you follow up on that request about the next workshop?” By this time Bob has himself so fueled with hostility and defensiveness that he will respond sarcastically with “since when is it my job to be your secretary?” or “ you’re not the boss of me!” or some other statement that generates that palpable chill we all know. Bob is doing the adult version of what he did growing up to protect himself.
Instead, if he changes his childhood defensive behavior and opens a dialog about how he feels and what he needs from Wendy, connection can be restored.

Action Step #2.
If you think you’re partner is “not getting it” (not respecting you, not listening etc.), please remember that YOU may be “not getting it”. Consider what you are putting into the mix because of your own frustrations. Check in with yourself about your own perceptions of your partner and ask yourself, “Am I getting any benefit or payoff from continuing to see her/him as selfish or distant or depressed?” This helps break the attachment we can have of seeing our partner in a negative light.
Food For Thought Tip #3. Conflict is natural.

The well used metaphor of “getting upstream” to help manage conflict is apt here. To focus on down-river clean up without upstream prevention, will not solve the problem. Conflict is inevitable whenever creative, ambitious and motivated people are in the mix, so planning for conflict will reduce feelings of personal failure and negative evaluation that can lead to emotional injury. Once we have gone down that road, it is difficult to stay focused on resolution, rather than defending our ideas or actions.

Action Step #3:
Consider having your fights in advance. Most of us know the struggles we will have with our partners already. When you’re not in the middle of the fight, we are better able to keep strong emotions from taking over and beginning the repetitive nightmare all over again. Start now, having conversations with your partner that are positive and genuine.
Appreciate, in a genuine way, your partner everyday, including the differences. Assume competence in your partner and look for ways to express respect everyday. When you do this, it is like stacking the deck in your favor, and you’ll probably need those cards someday when the rupture in the relationship occurs again.

For most of us, the ruptures between us continue even when we are still waking up, requiring that we treat each other authentically, yet gently, practicing patience and acceptance along the way. The evolution of our relationships from the unconscious stages of Romantic Love and Power Struggle to the conscious relationship stages can make us all better people and strengthen our relationship capacities. The House will always have the odds, but we can play the game knowing how to increase our own odds of walking into the future, as winners.

Wendy Palmer Patterson, LCSW, LMFT has worked with families and couples for 30 years. She is certified as one of only twenty Clinical Instructors, training therapists in Imago Relationship Therapy. She has trained extensively with Dr. Harville Hendrix for fourteen years.

Robert W. Patterson, LMFT, LPC has practiced in Atlanta for over 20 years and received certifications from Dr. Hendrix as an Imago Therapist in 1990 and as a Certified Imago Workshop Presenter in 1992. Both Wendy and Bob have presented at national and state conferences including the Psychotherapy Networker and for the GA Association of Marriage and Family Therapists.

Wendy and Bob have been married for over 25 years, have raised two precocious children, and have been humbled, at times confused and exhilarated, in the process of becoming a couple. Their offices are located at P2 Partnerships, Inc., 956 Euclid Avenue, NE, Atlanta, GA 30307. Phone: (404)584-7500.

Ridgeview Institute is a private behavioral health care system with inpatient, partial hospitalization, and intensive outpatient programs for youth, young adults, adults and seniors with psychiatric and addictive problems. We are located at 3995 South Cobb Drive, Smyrna, Georgia 30080. For more information about Ridgeview’s programs and services, call (770) 434-4567 or 1 (800) 329-9775.

For more information about the Ridgeview Institute’s Treatment Programs, visit our website at www.ridgeviewinstitute.com or contact the Access Center at (770) 434-4567.

Teens playing cards at Ridgeview

Treating the Young Adult

Michael Fishman, M.D. and Lori Albert-Walker, MSW
The Young Adults Program at Ridgeview Institute was created to address unique and specific issues in the lives of young people suffering from the disease of addiction. We define this population from ages 18 to 26, though patients ages 17 to 30 may also be considered for this track. As with all programs in Adult Addiction Medicine, family therapy is an integral component. Dual-diagnosis issues must also be given careful consideration. The passage from youth to adulthood can be difficult enough without the complications of chemical dependency.

Connecting with the young adult is a critical component in gaining trust in the therapeutic relationship. Young adults will respond best to a straight-forward, respectful but firm approach from a therapist. They can perceive subterfuge or general discomfort if one is attempting to be too much of a peer. It is important to maintain boundaries with the patient and his/her family. This can be challenging since often there are issues of enmeshment as well as hostile family dynamics. There is an interplay between the need for disclosure with the families vs.
the patient’s need for privacy. There may be a history of parental drug use with their son or daughter. Cases of parental sabotage are not uncommon, some being more overt than others. It is important to educate patients and family members around their dynamics, recurrent patterns and potential for sabotage. Recovery may truly disrupt the status quo.

Treatment begins with containing all of the addictive behaviors. This not only includes alcohol and chemical dependencies but also eating disorders, sexual disorders and pathological gambling. This may include an inpatient detox. It is not uncommon for the young adult to experience post-acute withdrawal symptoms while in a partial hospitalization level of care. Living in a recovery residence offers added support and structure. A level system and therapeutic community sensitive to the needs of the young person is helpful. People of this age crave firmer limits to keep them safe though they often will protest with vigor.

It is important to recognize dual diagnosis issues. Effects of drug and alcohol use may mimic or precipitate underlying psychiatric disorders. Long term memory and concentration deficits are frequently seen with ecstasy and crystal methamphetamines/ ice. The jury is still out as to how long these effects may last. The atypical neuroleptics (Risperdol, Seroquel, Zyprexia, Geodon, and Abilify) may be especially useful with disorganizing anxiety, aggressiveness, delusions, and extreme irritability. Of course, one must weigh the potential side effects of these medications with the potential benefits.

Transference and countertransference need to be recognized when working with the young adult and their families. This can be used to the therapist’s advantage or interfere with the therapeutic relationship if not identified. In a safe and supportive environment, the patient should be allowed to explore these feelings and develop new ways to deal with authority.
Conversely, in recognizing their own feelings the therapist will be able to better serve the patient. Patients need education about appropriate ways to express their feelings. Respect for self and others is stressed as well as constructive assertion of needs. Therapists working with young people often find themselves feeling frustrated, agitated, intimidated or overly
sympathetic. It is helpful to process these feelings in supervision or with co-workers. Common themes which may be identified are: “I was never like that and I can’t believe how they behave.” “I was just like that and in fact I still smoke pot and drink.” “Teenagers were cruel when I was young and I still feel intimidated by people of this age.” “My son/ daughter is your age and I fear she may feel the same way or may wind up in the same situation and it scares me.” Through recognizing and processing these feelings it will be easier to separate and keep the internal and external reactions down allowing the young person to look at themselves.

Normal development stops when someone starts bonding to chemicals. Patients describe feeling they are back in junior high, reliving puberty. They express feeling a lot of anxiety in social situations, as well as shame and guilt associated with past relationships. They are relieved when educated about this and respond well to containment around pairing off and guidance toward healthy relationships. If young people are using drugs to quell disquieting emotions and to deal with normal interpersonal anxieties about dating and peer pressure, they never learn to deal with those issues. It is recommended that young people abstain from romantic relationships for one year and that dating not begin prior to 6 months clean. During the dating period great work can be done in therapy.

It is crucial to consider normal physical, emotional and mental adolescent development when trying to understand the delays caused by chemical dependency. Often the young person is still feeling self conscious about physical changes that occurred in puberty. Patients relate that they never really learned about sexuality. They describe acting out sexually without any exploration or development of a self concept i.e. values, morals and intimacy. Mentally they may still demonstrate more concrete thinking affecting decision-making and problem solving skills. They struggle with delaying gratification and frustration tolerance and don’t see the relationship between cause and affect. A 13 to 15 year old has no time measurement; using and the lifestyle perpetuates
this behavior.

Support must be given to assist in correcting the developmental process and raising the chances for success as the young person transitions out of treatment. Patients express feeling overwhelmed with transition tasks. A transition group is provided to guide the patient with return to work or school issues, making appointments with individual therapists etc. Patients are introduced to the Young Adult Aftercare group and the Alumni group prior to discharge. Referral to a recovery residence provides a safe, structured environment to continue on the path toward separation-individuation.

The peer group is the most important component in assisting in the development of autonomy and individuation. At Ridgeview Institute, patients are separated by gender in therapy groups and combined for other age-specific psycho- educational and team building groups. A peer assessment group allows patients to give and receive anonymous feedback to each other regarding their progress in treatment. 12-step meetings and sponsorship are stressed. Patients in treatment are connected to alumni and young people in the recovering community who speak monthly about sober living and take patients to young peoples meetings. This is crucial as patients feel like “fish out of water” when trying to connect socially in meetings. Education on the disease concept and cross addiction are essential. Patients respond well to self assessments in determining whether or not they meet criteria for chemical dependency. A four day family workshop offered monthly provides the opportunity for patients and families to express feelings and learn about addiction and recovery. Prospects for recovery are good if young adults are abstinent, develop cognitive and visceral understanding of addiction, and begin to take initiative in their lives.

Through the years, we have searched for resources that would provide support for young people in recovery who are also pursuing their education. The following are two very helpful resources for sober support on college campuses: www.recoveryschools.org and Dr. Carl Andersen, Center for the Study of Addiction, Texas Tech University, Box 41162, Lubbock, Texas 79409.

For more information about Ridgeview’s Young Adult Program, visit our website at www.ridgeviewinstitute.com or contact the Access Center at (770) 434-4567.

Michael L. Fishman, M.D. has been in private practice with Earley Associates, P.C. since 1990 specializing in addiction medicine, anorexia nervosa and bulimia treatment, and the treatment of nicotine dependence. Dr. Fishman has presented on numerous topics concerning addiction and nicotine dependence, as well as having authored or co-authored several articles for industry publications.

Lori Albert-Walker, MSW is a Case Management Coordinator with the Ridgeview Young Adult Addiction Program. She has been with Ridgeview for 11 years and was instrumental in the development of the young adult addiction treatment track at Ridgeview Institute. Lori is also a talented songwriter and musician, often displaying this talent for the pleasure of staff and patients alike.

This article is the property of and was originally published in the Ridgeview Quarterly Newsletter entitled A View From The Ridge, November 2003.

Road to recovery

The Road to Recovery

Chemical Dependence and Treatment Today
by Paul H. Earley, M.D.
& Michael L. Fishman, M.D.


It is no longer surprising when a movie star, a politician, or a sports hero, reveals to the news media a personal struggle with the perils of addiction. The disease is common; we now know that it afflicts an estimated 10% of the population. In Atlanta alone there are thousands of people in various stages of addiction and recovery. Alcoholics Anonymous, the oldest and largest self-help group for alcoholics in recovery, reports that more than one thousand AA meetings are held each week in the greater Atlanta area.
While these numbers are remarkable, the number of addicts who continue to suffer with their alcoholism or drug addiction remains much larger. The disease of addiction is still misunderstood, and the consequences of this misunderstanding are gravest for addicts themselves. The most formidable barrier to a rational understanding of the disease is the mental image people have of addicts, based on nothing more substantial than prejudice. When people think “alcoholic” or “addict,” they envision a down-and-out street person cradling his bottle in a torn brown paper bag. Despite the celebrity confessions and the odds that most of us have a family member, colleague, or neighbor with chemical dependence, this image persists in the back of our minds and interferes with awareness of our own addictive behavior. We struggle instead with the more palatable idea that next time, by handling our drinking or drug use differently, we will prove ourselves immune from this haunting mental image.

Dr. Paul Earley and Ridgeview alumni will be featured in a new five-part documentary on treatment and recovery by renown journalist Bill Moyers. Close to Home: A Moyers Report on Addiction will air nationally on public television, March 29, 30, and 31, 1998, 9:00 P.M.

Reprinted from Insight Magazine, Vol. 18 No. 2 Fall 1997, a publication of Ridgeview Institute. For permission to reprint, call (77034-4568, Eat. 3006. For more information on Ridgeview’s programs and services, call (770)434-4567, or 1 (800) 329-9775.
Some patients describe the increasingly unfamiliar way they were before, as if they had been
looking at life from atop a strange mountain. To the individual entering this phase everything looks different, though it is in fact he who has changed.

Addiction to alcohol or drugs is the final common pathway. Many factors may propel an individual along the road to addiction; once there, however, one cannot go back to the days when drug use was voluntary or casual. One of the most powerful factors leading to addiction is a genetic tendency. This does not mean that people inherit addiction, but that they inherit the propensity for it. Whether they go on to develop an addiction depends not only on genetics but on the repeated consumption of addicting substances, and factors like family structure, personality, and environment. Children who have grown up in an atmosphere of shame experience a high incidence of addiction. People who tend to be anxious and driven or who have other psychological problems seem especially vulnerable to addiction. Childhood trauma-whether intentionally inflicted, like sexual abuse; or unintentionally inflicted, like the death of a parent-can result in an emotional injury that leaves us susceptible to becoming addicted. Stress can also lead a casual substance user along the road to compulsive use of chemicals. Each of these factors link in various combinations to reach the final common pathway: the disease of addiction. Regardless of the particular combination of contributing factors, once a person has developed an addiction, complex alterations in the brain’s chemistry make it impossible to return to an earlier phase of moderation and control. Unfortunately, people spend a lot of time and energy wishing to return to what is already irrevocable.

Another barrier to recognizing chemical dependence is that people addicted to drugs tend to misinterpret the source of the chaos in their lives. Alcoholics and addicts invariably define their problem as something external to themselves: a nagging spouse, hormones, a stressful job, or the drug itself, which they have come to both hate and crave. Research during the last decade has revealed that many individuals suffer from more than one addiction-6o% of people with bulimia nervosa are also alcoholic, 8o% of gambling addicts are addicted to chemical substances-that we now realize the problem of addiction occurs in the relationship between the brain of the addicted individual and the substance or behavior.

Whatever the addictive substance or behavior, symptoms of addiction are the same. One of the primary symptoms is denial, which makes it very difficult for the addict to seek help. Other manifestations of chemical dependence include physical dependence and increasing tolerance for the drug. Once the person is under the sway of addiction, what began as apparently harmless and voluntary social drinking or occasional drug use becomes the ruling passion of his life. Nothing–the entreaties of his wife, tears of his children, loss of a job, skirmishes with the law-is as important, or even appears to get through to him.

Understanding how addiction affects the brain helps explain these perplexing symptoms. To appreciate the process that goes haywire in the addict, it is helpful to visualize the basic structure of the brain. The cortex is the part of our brain in which conscious thought occurs, and the part of the brain that makes us distinctively human. The cortex is also called the “new brain” because from an evolutionary point of view, it appears in more highly evolved species such as lower primates and humans. The cortex houses the superior mental faculties-memory, learning, and judgment-of which we are understandably proud; it is, in fact, the part on which all conscious thought is based.

Despite its amazing properties, however, the human cortex is baffled by addiction. To see why, we must look at another part of the brain, the midbrain. The midbrain is the seat of the basic drives: hunger, thirst, the fight or flight reaction, sex, and the pain regulator. No conscious thought occurs in the midbrain; instead, pressure from the midbrain is transmitted to the cortex, where it registers as conscious thought (“I’m hungry.”). Although the cortex may appear to be running the show, the midbrain wields deceptive power. Several times in life-at puberty, for instance-the midbrain totally rearranges the way we see the world

From the perspective of addiction, the midbrain is where the action is. In people who become addicted-to alcohol, other drugs, compulsive behaviors-the midbrain takes on a sixth activity in addition to the five basic drives. This sixth activity is a primitive push for the addictive substance or behavior, which feels to the individual exactly like a basic drive. But there are two fundamental differences between this sixth function and the basic drives. The sixth (addictive) function eventually grows so powerful that it

eclipses all the drives. And whereas the drives push the individual toward self-preservation, the sixth “drive,” the pressure to get drunk or high, leads ultimately to self-annihilation.

The midbrain sends its signals to the cortex through the motor cortex, which controls movement. First there is the pressure from the midbrain followed by a motor event. For example, the midbrain transmits pressure for alcohol. The alcoholic turns into the liquor store parking lot. Only then does what cortical neurophysiologists have dubbed the interpreter in the brain kick in to analyze the action: “You deserve a drink.” The interpreter tries, in retrospect, to make sense of the action triggered by the midbrain and carried out by the motor cortex.

Such an assessment mechanism is doomed to fail because of the discrepancy between the raw drive for a drug and the individual’s rational functioning. Errors in interpretation multiply, entrenching the person in denial. These misperceptions and rationalizations are the hallmark of addictive thinking.
For treatment to be effective, the brain must be educated about the errors in circuitry by which it has been baffled. From our current understanding of the subtle changes in chemistry that occur in the brain during addiction, two important corollaries emerge:

You Can’t Think Your Way Out of Addiction.
specializes in long term psychotherapy with individuals in recovery. Dr. Earley is the author of The Cocaine Recovery Book and The Cocaine Recovery Workbook. He serves on the Board of Directors and is a Fellow of the American Society of Addiction Medicine.

Treatment helps the addicted person reconcile the basic conflict between the cortex and the midbrain, or the old brain and the new brain. The critical role of the midbrain shows why even the most sophisticated analytical thinking cannot lead a person out of his addiction. Professionals often seem to have an especially difficult time in coming to terms with addiction. They may have achieved brilliantly in their careers and highly value their analytic abilities and reasoning powers. The mental capacity that has served them so well and distinguished them from their peers, however, is unreliable as an ally in this struggle. To recover, one needs the cooperation
and integration of the midbrain, which is the common denominator not only of our humanity but also our relation with the other animal species.

A tragic error in treatment for addiction early in the century was the mistaken belief that if the addict could develop enough insight into his problems and come to feel better about himself through psychoanalysis or another form of psychotherapy, he could stop the addictive behavior. Sadly, the relapse histories of countless patients proved this a critical and often fatal error. To the addict, no amount of insight about underlying causes is enough to overcome the craving for chemical relief that occurs when one is actively using drugs and alcohol.

Recovery Takes Time.

When a drug is introduced to the body of a person who will become addicted, it leads to a surge of euphoria that is quicker and more intense than any “high” the body can produce. This artificial activation of the brain’s reward system increases the release of certain chemical substances, or neurotransmitters; however, this surge of euphoria does not last. After the body develops tolerance, larger quantities are needed; the addict begins to need the drug not to feel high but to feel normal. This happens because the brain’s chemistry develops tolerance for the artificial surge produced by addictive drugs. When the addictive drug is withdrawn in treatment, it takes the body awhile to resume production of substances that make the person feel a sense of calm and well-being. This process of detoxification and normalization of thought takes time, usually months or years.

Once detoxified, the individual in recovery must hack through the thicket of excuses and rationalizations by which his brain has attempted to make sense of his bizarre behavior. This also takes time. When the addict finally and deeply understands the havoc wrought by drug use in the brain’s natural chemistry, the midbrain essentially gives up, and the individual feels set free from the compulsion to drink or use drugs.


The Phases of Recovery

Based on our current scientific knowledge about addiction and treatment, the treatment process at Ridgeview Institute encompasses four distinct phases.

1. Behavioral Intervention The first step in treatment involves behavioral containment, stopping the drug from entering the body. Once the individual feels the tug of addiction as a primitive drive, no therapeutic change can occur until he stops taking the addictive
drug. Acute detoxification usually takes several weeks; it may take months before the brain’s chemistry returns to normal. During this early phase, alcoholics and other addicts often feel like they have lost their best friend or lover and experience enormous grief and/or anger, as well as depression.
Among the most destructive cultural attitudes toward alcoholism and drug addiction is the notion that the addicted person is morally weak and lacks self-discipline.

2. Cognitive Insight The phase of cognitive insight is the “Aha!” phase, during which the recovering person begins to recognize and make sense of his formerly perplexing behavior. This usually occurs in a series of fits and starts over a period of about a week.

3. Emotional Integration During the phase of emotional integration, the recovering person begins to rediscover his feelings. This process takes weeks-feelings may have been buried for a long time, and they are usually covered in shame. Among the most destructive cultural attitudes toward alcoholism and drug addiction is the notion that the addicted person is morally weak and lacks self-discipline. When internalized, this attitude interferes with the alcoholic’s realization that he has a disease and with his understanding of the insidious disease process. We sometimes call the phase of emotional integration the “Ugh” phase because it is difficult work-work that requires courage. Most people who do not recover from chemical dependence give up or attempt to sidestep this painful phase.

4. Transformation Transformation is the last stage of change-the transition into recovery. Transformation does not mean changing one’s mind about using drugs. It means nothing less than seeing the world in a different way. The transformation phase is what recovering addicts often describe as a spiritual experience. Some patients describe the increasingly unfamiliar way they were before, as if they had been looking at life from atop a strange mountain. To the individual entering this phase everything and everybody looks different, though it is in fact he who has changed. People who make it to the transformation phase generally lock in their recovery and go on to live life free of drugs and filled with an inner peace that often surprises them and those around them.
The disease of addiction knows no demographic boundaries; it affects people of both sexes and all ages, races, lifestyles, job classifications, and income brackets. Recent years have witnessed some shifts in the patient groups seeking treatment for chemical dependence. Although Ridgeview Institute has always drawn a large proportion of alcoholic patients, the number of alcoholic professionals-physicians, nurses, pharmacists, attorneys, ministers-has increased considerably, with the steady growth of the Impaired Professionals Program. In the past, more chemically dependent patients at Ridgeview were men; at present, the numbers of men and women are nearly equal. People now tend to seek treatment at a greater range across the age spectrum. While the number of patients in treatment for cocaine addiction has declined during the past few years, there has been a resurgence in heroin addiction. The heroin-immersed popular music culture has unfortunately attracted a large crowd under 28; many of these young people have become addicted to the drug either by snorting, smoking, or injecting it. Whatever the addictive drug, the chemically dependent patients we see tend to be psychologically fragile and to experience great fluctuations in self-esteem.

The shift toward managed care has profoundly changed the American health care delivery landscape, and specifically the way treatment is provided at Ridgeview. Some of these changes have led to serious concerns among those responsible for offering effective treatment for addiction. Whereas addicted patients used to be admitted for an inpatient stay of 21 to 28 days followed by tapered care, today’s patients stay in inpatient treatment more than three days only in cases of severe medical problems or if the attending physician is con- cerned that drug withdrawal may lead to suicide or homicide.

The compressed treatment schedule required by managed care is potentially dangerous because recovery takes time. In fact, time is the greatest ally in mobilizing the recovery reflex. Now patients are required to make important treatment decisions when their brains are still toxic from their drugs and lifestyle.

M.D., specializes in chemical and nicotine dependence. Dr. Fishman is the author of “Treatment Centers: The Next Challenge,” published in the Journal of Substance Abuse Treatment. He is a member of the American Society of Addiction Medicine, and a medical review officer.
Page 5
But there is a brighter side. The pressures of managed care have forced treatment to become more efficient and cost-effective. With the uniform, 28-day inpatient treatment model of the past, some patients may have been hospitalized longer than necessary. Today’s shorter inpatient stays tend to. be less disruptive of patients’ lives. For some patients, inpatient detoxification is not necessary, and can be managed in partial hospitalization or intensive outpatient

treatment. The advantage of outpatient detoxification is that limited care dollars can be spent at a time when patients are better able to comprehend the treatment process. Finally, payors have forced treatment programs to pay more attention to the particular outcomes of treatment. Those who have a basic and abiding interest in helping the addicted person recover are now challenged to accomplish as much as possible within a shorter time.

Partly because of managed care, the standard treatment program of the past has been replaced by a continuum of care options. Before treatment begins, a team of addiction specialists assesses the patient’s condition, determines a treatment plan, and prescribes an appropriate level of care. The continuum of care ranges from outpatient detoxification to intensive inpatient treatment, with several intermediate levels, depending on the needs and circumstances of the individual.

Patients with severe drug dependence or other medical problems may require intensive inpatient care for medical stabilization, after which they will transition to one of the other levels of care to continue the recovery process.

Partial hospitalization or day treatment is an option for patients who need more support and structure than outpatient treatment can provide, but do not require 24-hour medical supervision. Recovering alcoholics and addicts in the partial hospitalization program typically spend 6-8 hours per day in treatment, and return home or to a recovery residence in the evening.

Intensive outpatient treatment, day or evening, offers a flexible schedule of treatment-usually 3 to 6 hours per day. This allows patients to live at home and maintain a work schedule. Some patients in partial hospitalization or intensive outpatient care live in Ridgeview’s on campus Recovery Residences, which provide a supportive living environment, and help the alcoholic or addict reconnect with their humanness.

Specialized treatment tracks and groups target the particular needs of recovering addicts. These include groups for African-Americans, for people who have struggled with relapses, and for those trying to overcome addiction as well as depression or other psychiatric disorders. In addition, family support groups and activities help husbands, wives, and children come to terms with the addict’s disease and attempt to integrate his or her recovery process into the fabric of family life.

The 12-Step Programs are the backbone of recovery both in the initial treatment phase and in sustaining the benefits of treatment. Intensity of care has been shown to be less significant than duration of care in galvanizing successful recovery. Before they leave Ridgeview, patients make a commitment to participate in AA, Narcotics Anonymous (NA), Cocaine Anonymous (CA), or another 12-Step program as a lifelong part of their recovery. Twelve-Step programs offer the power of group support and collective life expe- rience. In a safe setting, recovering alcoholics and addicts can continue to discover and explore a new way of life that involves expressing feelings rather than anesthetizing them.
For people who suffer with alcoholism and addiction, it’s not about will power; it’s too late for just saying no. In fact, acknowledging that your problem is beyond you and asking for help are the first steps toward recovery.

At Ridgeview Institute, we have helped thousands of people take the difficult first steps toward recovery and gain control of their lives. Our programs help you learn to live clean and sober, build self-awareness, heal family wounds and gain support from 12-Step meetings.
This kind of treatment is now available in day and evening programs that are less disruptive than in-patient treatment, yet are remarkably effective.
If you have reached a point where you are ready to accept help, take action now. Our counselors are available seven days a week, 24 hours a day. For more information and a free and confidential evaluation, call (770) 434-4567.

Mental Illness treatment

Racing Against the Iron Clock – A Heroin Addict’s Story


By Scott Bradford

Any addiction is your advertisement to yourself that you’re incomplete, you’re not enough. Because you can’t possibly find happiness within yourself, you’ve become dependent on something outside yourself. In your search for control of your emotions, you’ve given up control of your life.

Heroin enforces this perception with an iron clock. When I was an addict, I lived in fear of the passage of time, knowing that the drug was leaving my body and that I would have to buy my freedom again within a matter of hours. Heroin sickness is indescribably bad. It’s like the worst viral or bacterial infection you’ve ever had, combined with the weakness that comes with mono or hepatitis, combined with the worst depression in the world. When I hear Bill Wilson’s words, “pitiful and incomprehensible demoralization,” I think of heroin withdrawal.

On heroin, you’re never free of the iron clock and its reminder that you’re an addict. Even when you’re high and feeling good, the sand is running through the hourglass. You’re doomed.

I used heroin because it was the first thing that made me feel okay inside my skin, that made it seem okay to be Scott. Other people were lovable, and so was I. Heroin works through the body, using the pleasure receptors. It’s a way of using your body to tell your mind that everything’s alright. It’s a lie; things couldn’t be worse.

Addiction sneaks up on you with heroin, because you don’t know where to look. A yawn? Watery eyes? These seem like innocent, normal things. But they are like the wisps of high clouds that precede the hurricane. Soon your skin will feel raw, unbearably sensitive. Your bowels loosen and cramp; you retch uncontrollably; you’re freezing or boiling up form the fever, you’re too weak to move and your only wish is that it would all stop, either with a fix or with death. It really doesn’t matter which.

It’s funny that we call it a “fix.” It fixes you, alright. But not in the sense of repairing you; it fixes you like a butterfly is fixed on a pin. You can’t move. Literally, you can’t move away from your connections, it’s too risky. And you can’t move in other ways, too. You give up social life, friends, sex. It all goes away.

My fear as an addict was that I would run out of time; that I would get too sick to be able to go through the process of copping the next fix. It took a lot of time. You had to get the money somehow, then you had to find a dealer. I spent a lot of time waling around New York, looking to cop. A lot of the time, I was sick.

Like all addictions, heroin stops working. It no longer gets you high; it just buys the monkey off for a while. It has become a part of the cell structure of your entire body, and when you don’t have enough coming in, every cell in your body lets you know. Like no other addiction I know of, heroin has a way of taking priority. It’s not subtle at all; it’s very heavy handed. No more Mr. Nice guy.

So, to paraphrase Deepak Chopra, you go on never getting enough of what you have come not to want in the first place. But you can’t get out. It’s like the Mafia; you can’t quit.

This article originally appeared in Ridgeview’s Insight Magazine – Volume 15, Number 2 – Fall 1994.

Scott Bradford has ten years clean and sober. A former jazz musician, he is now an advertising writer and head of his own agency. He believes that addiction is “among the most karmically challenging curricula offered here in Earth School, but the benefits of graduation are great.”

Ridgeview Institute is a private behavioral health care system with inpatient, partial hospitalization, and intensive outpatient programs for children, adolescents, adults and seniors with psychiatric and addictive problems. We are located at 3995 South Cobb Drive, Smyrna, Georgia 30080. For more information about Ridgeview’s programs and services, call (770) 434-4567 or 1 (800) 329-9775.

For more information about the Ridgeview Institute Addiction Medicine Treatment Programs, visit our website at www.ridgeviewinstitute.com or contact the Access Center at (770) 434-4567.

Doctor consulting at Ridgeview Institute Smyrna

The “M.D.eity” Syndrome

Help for the Impaired Health Professional
by Paul H. Earley, M.D. & Michael L. Fishman, M.D.
Gray pinstripe, his suit is immaculate. His bearing, too, at first seems flawless, and as he turns toward the counselor, the resemblance is marked, Marcus Welby, M.D. Avuncular, confident, the man could pass at least for the brother of one of television’s most warmly remembered physicians. But the counselor’s trained eyes detect tell-tale signs: a slight sweat beading the patrician forehead, an even slighter tremor as the 53 year-old doctor adjusts, with just a hint of nervousness, his fine silk tie.

Then he finally admits: “I just can’t stop drinking.” His voice catches on “can’t” – as though any admission of failure is something he must not countenance. And it’s hours later that he concedes, too, a dependency on tranquilizers – prescription synthetic opioids few laypeople know even the names of.

Scott Aldren, a surgeon in residence at one of his city’s better hospitals, has just shown as much courage as he has demonstrated at any point in his life. And it’s been a life marked by courageous action: the decision to embark on a medical career despite family misgivings; the long hours in med school spent in arduous training; the daring he’s recently displayed in pioneering new surgical methods as he works harder than ever. There has been strain: his 18-year marriage, even he now realizes, is in peril.

Having supported him throughout his schooling, Aldren’s wife has witnessed his subsequent professional peaks but also his personal valleys – the days he seems a shadow of his accustomed self, the times his anger has erupted. And, although it’s seldom mentioned, there’s the D.U.I. charge that hovers; the unresolved case has helped dwindle the family’s finances. She’s found no evidence of the marital infidelity that often accompanies chemical dependence, but the intimacy the two once cherished is mainly a memory now.
Elaine tries to swallow her resentment at the man his patients still regard as omniscient, infallible, but it’s hard.

It will be hard, too, Aldren’s next passage – through the Recovery Professionals Program at Ridgeview Institute. Elaine, however, is grateful, full of hope that Scott will find help. Scott is eager as well, but anxious – and even now defensive, even now in denial that his chemical dependence is real.

It’s known as the “M.D.eity syndrome” – that particular sense of invulnerability that a physician’s practice and training can aggravate. And it can make the denial that is part and parcel of addiction especially acute. Aldren exemplifies that arrogance – in the early stages of treatment he’ll employ his considerable intelligence to sabotage the recovery process. He’ll rationalize, evade, lash out at the colleagues who’ve confronted him about his addition and the doctors who work to help him heal. In time, however, he’ll turn that intelligence – and the sense of duty and care that marks all good doctors – inward, and from an epiphany of realization, will begin to heal himself.

He is not alone. Not only will he find support from family and friends and the doctors and counselors in the Recovering Professionals Program, but from peers who suffer also from the disease of addiction. A study in the November 1992 issue of the American Journal of Psychiatry finds that rates of chemical dependence in physicians are roughly equivalent to those of the rest of the population.

Intervention at Ridgeview Institute

Intervention: The Beginning of The Beginning

By: Brian L. Moore, Ph.D.
The last fifty years have seen a great deal of change in the way society views addiction. The American Medical Association determined that addiction is indeed a disease and efforts have been made to help people understand the nature of this disease. Salient characteristics include that addiction is a primary disease – not one that is secondary to another disease process; it is a progressive disease – one that gets worse over time without treatment; it is a chronic disease – it persists over time in no small part due to the fact that we do not have a cure for addictive disease – merely treatment which can be effective at arresting the negative impact of the disease in a person’s life.

Compounding treatment limitations is the fact that addiction is a disease that tells the people that have it that they don’t. Denial is a prominent characteristic of addiction. Whereas most disease creates discomfort for the person who is sick, addiction – through the use of denial and other defenses – tells the individual that they are problem free. The addict will often admit to having many problems – stress problems, marital problems, money problems, family problems, and health problems. The one problem they do not have is chemical dependence – in fact, they often believe that their drug of choice is the only thing that helps them cope with their problems; indeed, if all of their problems would “get off their back,” they would probably use/drink a lot less.

It is because of this denial that many families are frustrated in their efforts to get help for an addicted loved one. Intervention is the answer for many of these families.
Intervention is a structured process focused on piercing their denial and influencing an individual to accept the opportunity to get help. First championed by Vernon Johnson forty years ago, intervention is hardly a new procedure, yet the majority of people remain unfamiliar with it.

An intervention is a structured process in which a group of people who are significant in the addict’s life come together to express how much they care for the addict and present facts that highlight their concern about the person’s addiction. They also explain how these facts have impacted them and individually ask the addict to accept appropriate help
for their addiction. Lastly, they inform the addict about the boundaries they will set for themselves should the addict not choose to get help.

Of those who have heard of intervention, many hold distorted beliefs about it. For example, people have been heard to repeat the saying,

“You can lead a horse to water, but you can’t make him drink…”

This myth promotes inaction by reminding people of their inability to control the addict and their helplessness in making them better. While it is true that treatment for addiction is done with the addicted individual and is not done to the individual, it is imperative that we provide adequate opportunities for addicted people to engage in treatment.
Intervention provides this by giving the individual a concrete plan and steps they can immediately take to enter a treatment program. While we might not be able to “make the horse drink,” with intervention, we can “make him thirsty.”

Many people believe that

“A person has to hit rock bottom before they get better.”

There is a certain degree of truism about this statement – clearly when one hits “rock bottom” the only direction to go is up. It is, however, absolute folly to believe that this is necessary for addicted people to get better or recover. Even a cursory examination of the case files in a typical treatment program reveals that many people both enter treatment and establish significant recovery without ever hitting “rock” bottom. It would be more instructive to see that all people in recovery can reveal that they hit a bottom (though not rock bottom). The nature of these bottoms is varied – for one person it may be a DUI arrest, for another it may be the loss of a job, for another it may be the breakup of a relationship or family. Intervention has been called the “caring crisis.” It is a process that creates a decision point for the addicted individual where those who care for the addict can present their personal boundaries in order to change their enabling behavior and stop their unintended support for the addict’s disease. By establishing these boundaries, the intervention team builds a bottom for the addict – a chance to enter recovery without hitting rock bottom.

Another commonly held belief about chemical dependency treatment is that “A person has to want help before it can work.”
Addiction treatment is provided primarily through psycho-educational, psychotherapeutic, and psychosocial modalities. None of these methods are particularly successful in the absence of the addict’s cooperation or participation. It is, therefore, particularly impressive that so many addicts do actually achieve significant recovery.
After all, most addicted people enter treatment in an ambivalent state. Most addicts do not simply wake up one day and declare, “Today is a good day to get clean and sober.”
In reality, most addicts enter treatment post intervention. If they have not been afforded a
structured intervention a la Johnson or other model, they have probably experienced what may be called a “world” intervention. A world intervention is one where the world intervenes through circumstances such as arrest, injury, incarceration, other disease process, or some type of real or threatened loss – for example a job, a spouse, family or home, or significant loss of function in the person’s work or interpersonal life.

The difference between a professionally facilitated intervention and a world intervention is the approach to the addict. In the structured intervention, the addict is approached in a caring, concerned manner. The world intervention rarely provides this. The structured intervention is planned – the world intervention is unplanned occurs in a chaotic fashion.

The structured intervention involves putting together a team of people who care about the addict to learn how to effectively present their concerns to the addict to facilitate the addict’s acceptance of treatment. This treatment has been pre-arranged to facilitate the addict’s immediate admission to the program.

It is common for people seeking to do an intervention for a loved one to relate the many efforts they have made to get the addicted person in their lives to get help. They often say that the intervention is their “last ditch effort” to help the person. It is unfortunate that intervention is the last thing done to help the person – nor should it be thought of as “the end of the line” should it not succeed in getting the person to agree to enter treatment. Intervention is a voluntary process – those agreeing to be a part of the intervention team do so voluntarily and the addict must ultimately make a voluntary decision to accept help. Though the intervention will be an event at a given point in time, it is merely a part of the process of recovery.

If the person does not choose to accept help, it is not “the end.” The intervention team will put their boundaries in place and continue to make efforts to influence the person to seek help.

Perhaps one of the most notable examples of this persistent effort is the case of First Lady Betty Ford. Her family completed an intervention with her at the White House and she refused help – it was only a few weeks later that Mrs. Ford would agree to get help for her addiction.

It is widely recognized that addiction is a disease that affects families as much as it does the individual. A good intervention addresses this by helping the intervention team to make positive changes in their own behavior and in the manner in which they relate to the addicted individual in their lives. Addressing codependent behavior and enabling behaviors allows those who care for the addict to know that they are a part of the addict’s solution and no longer a part of their problem.

If the person accepts the opportunity to get treatment, it is just the beginning of the beginning – the person will need to accept that treatment provides tools and strategies to manage this disease, not cure it, and come to the realization that recovery will be a daily process for the rest of their life.

Readers are encourage to learn more about intervention by contacting the author, Dr. Brian Moore at: Serenity Solutions, 3500 Lenox Road, Suite 1500, Atlanta, Georgia 30326 or by phone at 770-590-4441 or 866-590-4441.

Ridgeview Institute is a private behavioral health care system with inpatient, partial hospitalization, and intensive outpatient programs for children, adolescents, adults and seniors with psychiatric and addictive problems. We are located at 3995 South Cobb Drive, Smyrna, Georgia 30080. For more information about Ridgeview’s programs and services, call (770) 434-4567 or 1 (800) 329-9775.

For more information about the Ridgeview Institute Addiction Medicine Treatment Programs, visit our website at www.ridgeviewinstitute.com or contact the Access Center at (770) 434-4567.

Road to recovery

From Heaven to Hell: Heroin’s Double-Edged Sword

Paul H. Earley, M.D.

Opium, it would seem, was place don this earth to alleviate suffering. A soldier, injured in battle, is given two grains of morphine intra-muscularly to reduce the pain of his shattered leg. Or a cancer victim sips a “Brompton’s cocktail” (containing mostly heroin) throughout the day to reduce the intense and chronic pain produced by tumors throughout her body. Modern medicine has changed the morphine molecule to produce heroin and codeine, and has produced synthetic drugs, including hydrocondone, oxycodone, meperidine, and methadone, which the brain interprets as morphine. Chemists have even produced drugs such as Fentanyl, a narcotic 1,000 times as potent as morphine. But modern chemistry has never improved on the pain relieving effects of one of nature’s oldest remedies, opium. Once consumed, these opiate drugs are indistinguishable to the brain. They move from the bloodstream into the brain and bind with receptor sites on specific cells. The brain responds by shutting off its response to pain, reducing anxiety and allowing the recipient to relax and feel peace. Pain relievers that work in this manner are called narcotics. A narcotic does not decrease the response at the site of the injury, but rather fools the brain into thinking that the pain is less.

Pain researchers tell us that the reduction in the brain’s perception of pain is an important effect of the narcotic drugs like heroin, but that it is in some ways incidental to the true value of narcotics in the management of pain. What seems to be just as important is the ability of narcotics to reduce anxiety, produce a sense of well being, and even euphoria. These effects counteract the crisis of the situation that produced the pain; the soldier rests easier and is less panicked about his battle injury, and the cancer ridden patient is less grief stricken with her slow, painful death.

Human suffering is not limited to these situations, however. Suffering is part of every person’s life, from the grief of losing loved ones to the loss of physical health, to the pain of social and political injustice. Every one of us has or will endure suffering at some point in our lives. How one responds to this suffering is often the key to a successful life. If we have the tools to move through the suffering, we become stronger and better able to endure the next blow that comes our way. If we lack the tools to endure suffering, either by our genetic nature or by our upbringing, we may wind up susceptible to becoming addicted, especially to a drug like heroin.

Let’s examine the case study of an individual who has become addicted to heroin. Michael is a 30-year-old man who, from outward appearances, seems fine. He grew up in suburban America, the product of parents who tried to give him more than they had when they were young. Michael’s father worked hard and was not home much. His mother retreated into a bottle, becoming an alcoholic by the time Michael was in high school.

As an adolescent, Michael thought he was having fun. He began experimenting with alcohol and marijuana at age 15, and tried hallucinogens at age 17. He thought that the fact that he was not noticed by his parents was a blessing. He was able to stay out later than many of his friends, and began spending time with a rougher crown. But the inattention of his parents produced a subtle emptiness, a lack of direction. One night, jilted by his girlfriend, he tried snorting heroin. That night Michael was feeling pain, pain that felt deep and enduring. Drifting in life, without a place in his parents’ life, and grieving the loss of his girlfriend, Michael knew what suffering was. But that night he also learned of the tremendous sense of inner peace that narcotics produce. After snorting the drug, he suddenly felt that everything was going to work out. He was able to look at his recent loss without wrenching in pain. He felt that maybe the loss of his girlfriend was for the best. He laughed again, and in speaking of his recent loss to the guys he was using with, he felt a comforting sense of comradeship and belonging. He went home late, thinking that he had charted a new course for his life, and fell into a dream-filled slumber.

Michael’s use of heroin might seem on the surface rather inconsequential when compared with the overall picture of his drug abuse. After all, he simply used a new drug with a few friends, experienced no toxic effects, and talked over his problem with sympathetic ears. The reality is, Michael’s use of heroin would dramatically alter the course of his life.

The heroin alleviated Michael’s psychic pain as effectively as it would alleviate physical pain in the cancer victim. It short-circuited the process of working through loss and grief and produced a welcomed sense of peace. The drug produced a false sense of understanding that appeared to solve the problem through anxiety-less eyes. This is the subtle but powerful damage that heroin produces in its victims. Unlike cocaine, heroin does not produce paranoia or agitation. It does not cloud thinking, slur speech and disorient, like alcohol. In fact, in may users who are anxious, heroin removes the anxiety and seems to produce clear thinking. But removing anxiety has its costs. Human beings use anxiety and other emotional experiences to make wise choices and to plot routes through life that are careful and balanced. The real damage produced by heroin and similar narcotics is that, with repeated use, they rob us of the experience of emotional pain and the growth that pain produces.

Michael did not immediately enter into a daily, downhill course of demonic heroin use, but a seed was planted. He knew from that day forward that if things became too painful, he had a friend to turn to. He continued to drink too much alcohol, but managed to find a good job and move out on his own when he completed high school. He had inherited his mother’s predisposition to lose control when he consumed addicting substances such as alcohol and marijuana. He began a predictable pattern of drinking, 4 or 5 beers on week nights, with heavier use on the weekends.

At the age of 26, Michael was re-introduced to heroin. A friend at work told him of his “casual” use of the drug, and invited Michael to try injecting the drug with him. After several weekend binges on heroin, Michael found himself suffering withdrawal symptoms on Mondays and Tuesdays. One Monday night, in an attempt to ward off the effects of the drug withdrawal, Michael began a daily drug habit. He continued to work, but more and more of his thoughts and plans centered around obtaining heroin. At first, the drug seemed to have little effect on his ability to work, think, and plan for the future. Soon however, he developed the short sightedness and emotional immaturity of the full fledged narcotic addict. The very effects that the addict finds so appealing about heroin, the calm and peace that it brings, reprograms the brain of the heroin addict from enduring and learning from pain to using narcotics to quell pain and stunt emotional growth. The addict moves from his pre-addicted level of emotional maturity to avoiding and evading pain. He develops a thin skin to his emotions progressively narrowing his lifestyle to allow a shallow range of emotional experiences. He becomes obsessed with preventing the withdrawal effects, because withdrawal feels like all the emotions he wishes to avoid, only 100 times more intense. He develops a web of lies, deception, and distortion to insure that he can keep using the drug, because his body and mind have become habituated to heroin’s effects.

The heroin addict’s experience in withdrawal is exactly the opposite of the experience of a heroin high. He is filled with pain, anxiety, remorse, and grief. In addition, his heroin habit has seriously crippled his ability to tolerate the normal ups and down so of life. This double-edged sword is the crux of heroin addiction. In using narcotics to fight normal human strife, the addict has lost all of the internal skills needed to manage and fight the creeping return of drug withdrawal.

Michael can’t quit because heroin has robbed him of the emotional skills he needs to tolerate life without the drug. At first it seems that heroin withdrawal, with its agitation, restlessness, sleeplessness and emptiness, is the difficulty to overcome. As painful as opiate withdrawal is, it is the experience that occurs after withdrawal that is the problem. Addicts like Michael may go on for days, even weeks, feeling as if each movement is filled with physical pain. Slowly, this pain subsides and the addict wants to believe that the worst is over.

Shrouded in a heroin cocoon, Michael has not only been able to avoid the emotional dilemmas of a 30-year-old man, he has regressed to being avoidant of almost any emotional experience. Recovering heroin addicts who relapse will often say: “It’s like someone has turned up the volume on all my feelings, good and bad, and I can’t stand the noise!”

In a perfect world, recovery from opiate addiction, including heroin, might best be served by a slow, persistent re-acquaintance with one’s emotions. Unfortunately, no physical setting can prevent the addict from the worst of feelings, the pain that comes from within. Every addict has to face what they have become, and the shame from this realization can be unbearable. This produces the frequent “drop-out” that we see when heroin addicts enter a treatment setting. Not understanding that his dilemma is internal, he often blames his external surroundings for his problems and leaves the treatment setting.

In order to stay on the road to recovery, the heroin addict will need to come to grips with his life and what he has become. Even though it seems unbearable, looking at the wreckage of one’s life is the beginning of reclaiming one’s life. Every addict has a tendency to avoid feelings and to repress the strife of everyday living; but the heroin addict will need to develop better than average life skills to keep himself from retreating from the day to day pains of life into drugs. The heroin addict needs emotional conditioning that is similar to the physical conditioning of the athlete. Treatment is the coach, ever pushing him to observe his pain, engage with it, wrestle with the internal turmoil it produces and, with each repeated exposure, develop the strength to triumph over life’s traumas.

This article originally appeared in Ridgeview’s Insight Magazine – Volume 15, Number 2 – Fall 1994.

Paul H. Earley, M.D. specializes in long-term psychotherapy with individuals in recovery. His work at Ridgeview was featured in Bill Moyers’ 1998 PBS documentary, Moyers on Addiction: Close to Home. Dr. Earley is the author of The Cocaine Recovery Book and The Cocaine Recovery Workbook.

Ridgeview Institute is a private behavioral health care system with inpatient, partial hospitalization, and intensive outpatient programs for children, adolescents, adults and seniors with psychiatric and addictive problems. We are located at 3995 South Cobb Drive, Smyrna, Georgia 30080. For more information about Ridgeview’s programs and services, call (770) 434-4567 or 1 (800) 329-9775. For more information about the Ridgeview Institute Addiction Medicine Treatment Programs, visit our website at www.ridgeviewinstitute.com or contact the Access Center at (770) 434-4567.