This article discusses the causes of alcohol dependence and the difficulties of helping people who do not want to be treated. This will be of help to anyone whose family member or friend is suffering from the condition and would like information on the psychological effects of alcohol.
- A family disease
- Alcohol is a mood-altering drug
- Alcohol and other inappropriate self-medications for depression
- "Neuro-transmission disease”
- Lifting the inexplicable sense of inner emptiness
- Mere abstinence is not enough
- What is the purpose of rehab?
- Detox is just the first phase
- Treating the addictive tendency
- Reflection of a culture of entitlement and dependency
- “No, I shall not help you (kill yourself)”
- Healing the family
- It’s about education, or The University of Healing
- The caring philosophy
The delicate skills involved in treating alcoholism are not for the faint-hearted to attempt. People suffering from cancer, diabetes or heart attacks are grateful when offered help. People who have problems with addictive or compulsive behaviour of any kind will fight back: they want to protect their dependency and get rid of its damaging consequences.
Family members are either exasperated or unsympathetic or they are so tied into the problem that they get in the way of the solution. Doctors and other professional helpers get fed up with being abused and they become frustrated when their time and care, personal concern and sensible recommendations, are disregarded. They have other people to look after and other things to do. Politicians, health-care advisors, lawyers, teachers, probation officers, social workers and the public at large waver between advocating punishment and permissiveness.
Everyone has a firm opinion on what should be done. Gaining the necessary experience and insight in order to be able to intervene sensitively and effectively into a sufferer’s dependence tends to be a thankless task. It is for this reason that the most effective interventionists are usually those of us who have shared similar experience ourselves. We have an inner understanding and we cannot easily be bluffed. We ourselves had the same delusions, evasions, justifications and rationalisations and we played the same psychological games.
A basic misconception underlies the word ‘alcoholism’ itself. This description names the illness after one of its treatments. It is comparable to calling a sore throat ‘Penicillinism’.
Alcohol is a mood-altering chemical. People use it to change the way they feel. Some people chose not to use it at all. Many are able to use it occasionally and sensibly (and cannot see why everyone else should not do the same). Some use it stupidly (thinking that it is grown-up and clever to get plastered) and up to 15% of the population are dependent upon it (returning to a crashing depression or to determined and destructive self-will when they abstain.
Sometimes sufferers treat their sense of inner emptiness by cross-addicting into other addictive substances, processes and relationships. They may use nicotine, caffeine, recreational drugs, prescription drugs (such as antidepressants or tranquilisers or sleeping tablets or mood altering pain killers), gambling and risk-taking and sex and love addiction. These together form a particular ‘hedonistic’ cluster of addictive behaviours. A ‘nurturant of self’ cluster includes the use of sugar and refined carbohydrates, which are the mood-altering ‘drugs’ of people who have eating disorders, shopping and spending and work and exercise. A relationship cluster of relationship addiction itself (using another person as if he or she were simply a mood-altering drug) and compulsive helping (using oneself as a mood-altering drug for other people while disregarding the damage to self).
Some addictive individuals have just one of these clusters, some have two and some (like me: I seem to have been genetically driven towards this line of professional work) have all three.
The significance of the spread of addictive behaviour lies in the level of abstinence required (among other things) in order to prevent relapse. In this respect, it seems to me that there is no point in recovering from one addiction and then relapsing into another. Correspondingly, the intensity of individual outlets and their sum total will determine the intensity and depth of time for necessary treatment (if any).
I believe that the underlying cause of all addictive or compulsive behaviour, and the cause of the sense of deep inner emptiness (an involutional melancholia, a depression that has no specific origin, unlike the sadness that follows a distressing event) is a defect in the neuro-transmission systems in the mood centre of the brain. The origin of the three addictive clusters may be that each is determined by specific genetically inherited impairments. However, only in some particular medical conditions is a single gene responsible for the subsequent disability. More commonly, genes work in conjunction with each other and the over-all clinical state also has environmental influences.
Thus, the children of someone with what I call ‘neuro-transmission disease’ (this gets rid of the stigma of the terms ‘alcoholic’ or ‘addict’, ‘anorexic’ or ‘depressive’) do not all necessarily inherit the specific addictive outlets of their parents or grandparents. Never the less, addictive or compulsive behaviour does run in families and I believe that the relatively small genetic pool is kept going when addicts of one kind or another have children with compulsive helpers. The addict’s ‘need to be fixed’ exactly matches the compulsive helper’s ‘need to be needed’.
There are three causes for addictive behaviour: the antecedent, underlying, cause is genetic; the contributory causes are environmental, in childhood or adulthood (with childhood being the greater influence because of the greater emotional vulnerability); and the precipitant, immediate, cause is the exposure to mood-altering substances or behaviours or relationships that ‘work’ for the individual. In this way, sufferers from neuro-transmission disease discover for ourselves precisely what has a mood-altering effect for us. For example, we discover that alcohol and cannabis, nicotine and sugar, ‘work’ whereas milk, paracetamol, potatoes and rhubarb do not.
Far from people becoming addicted to alcohol, or other specific mood-altering substances, those of us who suffer from neuro-transmission disease discover for ourselves that alcohol lifts our inexplicable sense of inner emptiness. Thereafter we see no reason why we should ever give it up and thereby return to our inner depression. We are born with an addictive nature. Sadly for many (the Samaritans estimate that at least 20% of all suicides are in people with alcohol problems), they find that they cannot live with alcohol, because it causes so many problems, but they also cannot live without it.
Consequently it follows that each of these three causes has to be countered by specific treatments. The precipitant, immediate cause has to be countered by abstinence. ‘Sensible drinking’ or ‘harm reduction programmes’ have no chance of success in people who have an addictive tendency. The contributory, environmental, causes are countered by therapeutic interventions. The three that I find most effective are psychodrama, that acts on thoughts and feelings and behaviour all at the same time, EMDR (eye movement de-sensitisation and reprocessing) which is particularly effective in treating post-traumatic stress disorder, and neuro-linguistic programming, that re-frames experience in order to make it more amenable to different interpretations from an assumed one. The therapeutic intervention that I find least effective is cognitive behavioural therapy (CBT) which attempts to treat an irrational problem with reason.
Sufferers from neuro-transmission disease know perfectly well that our behaviour is destructive to self and others. Our problem is in finding out how to stop it. The antecedent, genetic, cause cannot be cured: it has to be taken into account and accommodated. Just as people who are short-sighted wear spectacles or contact lenses but are still short-sighted, the sufferers from neuro-transmission disease need to work the Twelve Step Programme, first formulated by Alcoholics Anonymous, on a daily basis to counter the effect of our continuing genetic impairment. Reaching out to help each other anonymously is a mood-altering process in itself – a healthy one.
Mere abstinence produces the ‘dry drunk’ state, with all the blame and self-pity and other negative characteristics of the “-ism” despite the absence of alcohol. In fact the ‘dry drunk’ state illustrates neuro-transmission disease in its ‘un-treated’ state. The desperate inner emptiness, with anger and resentment boiling over, is clear for all to see. When the sufferer ‘treats’ it with alcohol or other mood-altering substances or processes or relationships, he or she feels immense relief. The family, having been utterly confused by the ‘dry drunk’ state, because of the belief that the problems are due to drinking alcohol, say “At least we understand you now” when the sufferer reverts to previous drunkenness.
The illness is progressive and destructive but not in a straight line downwards. There are times when the sufferer’s mood and behaviour, and the consequences of that behaviour do not get worse and they may even get better. These false dawns cause the next relapse (which on each successive occasion occurs sooner and falls deeper than the last one) to be even more painful for everyone.
Actors can portray a drunken person in three short steps on stage. Portraying a ‘dry drunk’ is more challenging because the audience does not naturally understand this condition. It is only those of us who see it every day who recognise it for what it is. The ‘suffering’ that we observe is obviously true for the families but it is also true for the individual who has the neuro-transmission disease: every aspect of his or her life is damaged and, far from receiving compassionate understanding, he or she is usually the recipient of abuse and rejection. This may indeed be just deserts for his or her own behaviour (and we are all of us totally responsible for our addictive behaviour as it affects other people) but we are not responsible for having this fearful disease in the first place.
The first observable characteristics of an addictive nature (we all have our own personalities) are seen in childhood as follows:
- Coming from an addictive family
- Feeling separate from other people
- Having wild mood swings, right up one moment and right down the next
- Trying to control everything
- Being easily upset
- Being easily bored
As time progresses, addictive children tend to become increasingly angry and resentful. They tend to fall behind in their school work, not achieving their previous potential, and they tend to lose interest in previous activities that they used to enjoy. They tend to make new friendships that give concern to other people.
Some of these characteristics are seen in any adolescent but having at least four of the first six characteristics are an indication of an addictive nature. To make this specific diagnosis would be extremely unpopular. Doctors, parents and teachers would tend to prefer to diagnose these children as having Attention Deficit Hyperactivity Disorder. One third of American children now have this diagnosis – or excuse for difficulties at school – and are prescribed Ritalin or other amphetamine-like substances that make them feel better. The same diagnosis in children in the UK is rapidly catching up. Alternatively, these children may be diagnosed as being depressed: anything rather than addictive. Families and environmental influences may be blamed rather than understood. Again, the crucial issue is that it takes an addict to spot an addict. It required that insight for me to develop the ideas seen in my YouTube clip on ‘Preventing Addiction’.
In adult life there are twelve common characteristics of an addictive nature:
- Preoccupation with using – or not using – the addictive substance, process or relationship
- The tendency to use it preferably by oneself
- Using it primarily for its mood-altering effect
- Using it as medicine, as a tranquiliser or antidepressant or pain-killer
- Protecting its supply
- The tendency to use more than was planned
- Having a higher capacity than other people to use it without serious damage
- Continuing to use despite damaging consequences of use.
- Continuing to use despite the repeated serious concerns of other people
- Having the tendency to cross-addict into use of other mood-altering substances, behaviours and relationships
- Exhibiting ‘drug’-dependent behaviour, functioning more effectively when using it
- Exhibiting ‘drug’-seeking behaviour, going out of the way to find it
Again, having any four of these characteristics is an indication of an addictive nature.
To identify a specific addictive relationship with alcohol there are ten statements that have to be scored on a scale from 0 to 5, indicating the range from 0 ‘not like me’ to 5 ‘very like me’:
- Feeling light-headed does not usually lead to me deciding to stop drinking alcohol on that occasion.
- I find that having one alcoholic drink tends to make me want more.
- I sometimes have a complete blank of ten minutes or more in my memory when trying to recall what I was doing after drinking alcohol on the previous day or night.
- I use alcohol as both a comfort and a strength.
- I tend to gulp down the first alcoholic drink fairly fast.
- I have a good head for alcohol so that others appear to get drunk more readily than I do.
- I find it strange to leave half a glass of an alcoholic drink.
- I get irritable and impatient if there is more than ten minutes conversation at a meal or social function before my host offers me an alcoholic drink.
- I deliberately have an alcoholic drink before going out for the evening to a place where alcohol may not be available.
- I often drink significantly more alcohol than I intend.
A total score of 5 is of no significance. A total score between 6 and 19 indicates the possibility of an addictive tendency that might grow, particularly if another addictive outlet is closed down. A total score of 20 or more indicates a significant addictive problem that requires appropriate treatment, possibly on an in-patient basis.
In 1988 I wrote a full set of questionnaires to identify addiction in 16 different outlets. The initial 30 questions on each outlet were reduced to 10 when it was found that these 10 provided sufficient information for an accurate indication of an addictive problem. This set of questions becomes known as The Shorter PROMIS Questionnaire (SPQ) and it is used throughout the world by individuals and by researchers. On the creation of my new in-patient treatment and training enterprise, ‘Doctor Robert Creative Coaching’, I have made further minor modifications. This, definitive, Dr Robert Lefever‘s Addiction Questionnaire can be seen here.
The purpose of an addiction treatment centre (rehab) is to get a larger number of sufferers into long-term recovery than would do so through attending Alcoholics Anonymous (or other Anonymous Fellowships) alone. However, the recovery rate of a rehab on its own is zero: the precise treatment for an addictive nature (that is probably genetically driven) is regular attendance at meetings of appropriate Anonymous Fellowships (where we counter our ‘denial’, the psychological flaw that tells us that we do not really have an addictive problem) by seeing other people who are like us. We see ourselves reflected in the mirror of other people. We counter our depression (the inexplicable sense of inner emptiness) and other mood disturbances by working the Twelve Step programme, first formulated by Alcoholics Anonymous but now adapted to combat any addictive tendency. By following specific suggestions, such as observing our own behaviour and recognising that is out of control and that our lives have become unmanageable, coming to believe in a Higher Power than self of some kind (in my own case I have a sense of a Universal Spirit of which we all share a part, but I have no religious belief) and by reaching out to help other people anonymously (when A reaches out to help B, it is A who gets better), we are able to reverse the dreadful widespread damage and live creatively and constructively and be the people we really can be.
In this way, medicinal treatments (with antidepressants, tranquilisers, sleeping tablets and other ‘magic helpers’) are completely superfluous other than for initial detoxification in order to counter the physical symptoms and risks of acute withdrawal. Indeed, these drugs may come to be the basis of a prescription drug addiction, which can be fiendishly difficult to treat precisely because of the relatively impregnable justification “My doctor gave them to me for the treatment of clinical depression”. This diagnostic term is not a clear category, such as diabetes or heart failure, but an opinion: a convenient one for both doctor and patient who wish to avoid what they may see as a stigma in the diagnosis of an addictive nature. Doctors are principally trained to prescribe and, despite the fact that half of them work in general medical practice, they have little or no training in counselling skills other than in Cognitive Behavioural Therapy (CBT), which helps people who did not have significant problems (certainly not of an irrational nature) in the first place.
Addictive problems with nicotine and sugar, alcohol and drugs underlie, and significantly contribute to, all the major killing diseases e.g. cancer (nicotine and, to a lesser extent, sugar and alcohol and drugs), heart disease (nicotine, sugar, alcohol, drugs – especially cocaine), diabetes (sugar) and liver disease (alcohol, drugs, sugar). To treat an addictive tendency is the most significant preventive Medicine of all. In the UK, recreational drugs kill fifteen people a day, alcohol kills one hundred a day, sugar kills two hundred a day and nicotine kills three hundred a day: a jumbo jet full of nicotine addicts crashes every day.
Many people who smoke cigarettes (a foolish pursuit at any time) are not addicts. Nor are all those who eat sugar, drink alcohol or even use recreational drugs (an even more foolish and self-disrespectful pursuit). None the less, I am no prohibitionist. I do not believe that laws should be made for the whole population when only ten to fifteen percent have a significant problem. The difficulty is that those who do have a problem tend to be those most determined to prove that they do not. The solution is to give consequences to behaviour. When families, employers and governments let addicts off the hook for their disruptive behaviour, they help to perpetuate it. The entitlement and dependency culture is utterly destructive of addictive individuals, their families, their occupations and of society at large.
Learning how to say “No: I shall not help you while you continue your destructive behaviour” goes against the grain of our social and clinical culture - but it is what we have to do if the terrible scourge of addiction is to be tackled effectively in individuals and in our society. Helping families (particularly those members who are compulsive helpers, who deny their own needs and take on responsibilities for others, regardless of evidence that this is counter-productive) is a vital part of all intervention into addictive behaviour.
My own approach to patient care, for which I am immensely grateful to my wife Margaret, is to give significant care to family members. This is sometimes on an in-patient basis, because we recognise that an addiction problem (unlike the physical problems of cancer, heart attacks and diabetes) in one family member has a significant knock-on effect on others. By helping to heal the family, we have a better chance of helping to heal the sufferer from neuro-transmission disease.
Our aim is far broader and deeper than simply to help a few suffering individuals and their families. Through training programmes we wish to influence the whole recovery (rehab) field and the medical profession and other health-care and social-care professions and even the government.
The problems are so vast that they need creative solutions. The advantages of the Twelve Step programmes of the various Anonymous Fellowships are that they are free and readily available and effective for those who are prepared to be totally committed to recovery. They also embody a beautiful personal philosophy: helping self through helping others.