OpEd in Response to The Atlantic's "The Irrationality of AA" by Gabrielle Glaser

By: Robert Schmidt, M.A.

Published in The Atlantic today, http://www.theatlantic.com/features/archive/2015/03/the-irrationality-of-alcoholics-anonymous/386255/?utm_source=SFFB.

A few thoughts: 

1. Why does it matter whether or not addiction is a disease? Labeling it as such only serves to leverage payment (rightly so) from health insurance providers for treatment. 

The use of the word “disease” should be a non-factor in the treatment of individuals who are tasked with creating unique personal narratives on their alcohol use in the evidence based psychological treatment models that Gabrielle Glaser correctly references here.  

Although, it is also clear that Glaser is a big supporter of the use of medication treatments for alcohol and substance use disorders, a topic which deserves consideration in long form on another day. 

2. Glaser argues that AA takes a cookie cutter approach, recommending complete abstinence for those who might be better served by “moderation” styled approaches.  However, there is another side to that coin... Yes, there is a danger that complete abstinence is an overreaction for some and that this approach is really meant for those on the “severe” end of the bell curve, but so is harm reduction! The whole idea of moderating one's use and limiting harms is based on the precedents set by the needle exchange programs and the legislating of prostitution in Amsterdam.  So, it is the same thing all over again: we are basing our treatment recommendations on evidence collected at the “severe” end of the spectrum, only this time we are taking the risk of under prescribing instead of over prescribing levels of abstinence.

3. To say that AA is unscientific is a lazy criticism. After having successfully met the standards of certain prescribed phases of scientific rigor, treatment approaches are labeled as “evidence based.” There are several factors that are considered in this process, including the efficacy of the treatment as well as the cost and the ease with which it can be dispersed. 

Efficacy is in interesting term which the Ms. Glaser uses several times: either incorrectly, or misleadingly. Treatment efficacy refers to either the statistical significance or (preferably) the statistical effect size of a treatment in a controlled setting. To be clear: efficacy studies are conducted in laboratories. So to say that there is no proven efficacy for AA is misleading because it cannot be conducted in a controlled setting. AA has long been implemented in the public sphere, so to bring it into a laboratory setting would be to alter it fundamentally. It is impossible to measure the efficacy of AA, because there is no way to design an experiment for it.

Scientific investigations of treatments outside of the lab (ie, real world applications of treatments) are known as “effectiveness studies.” This is an important distinction because in order for a treatment to be labeled with an “evidence based” endorsement it must first have been validated for efficacy and then for effectiveness.

This is important because of all the qualities that should be celebrated about AA (and there are many), perhaps the most heroic is the fact that AA is widely available and accessible: even to those who subsist on the lowest rungs of our socio-economic ladder. The value of that quality cannot be overstated. 

Note: I strongly believe that the average individual in our culture does not fully appreciate or even understand exactly how rigorous the scientific process actually is. Science moves at a much slower pace than most people think. And, when considering the science of psychology, we are talking about something that is so complex and difficult to control for that it has only really been in existence for about 60 years (give or take).

And, even that doesn't distinguish it from medicine very much. A prominent neurologist recently told me that 90% of the treatments he recommends for his patients are not evidence based: these are treatments like acupuncture, physical therapy, dieting etc… 

Glasser also references several studies comparing the long term outcomes of AA to evidence based treatments saying that AA's success rate is likely in the single digits. Three things to to keep in mind here: A) "success" is a loosely defined term, B) follow up's rarely go past six months, and C) outcome measurements are inevitably based on self reports, (ie. asking the alcoholics how much they have been drinking: ie, asking them to lie).

4. Glaser’s criticism of alcohol use disorder treatments as having been corrupted for years by the ubiquity of AA, fails to acknowledge the importance of that ubiquity. She is solely talking about the implementation of alcohol and substance use disorder treatment in centers and practices which actually collect money for their services. And undoubtedly, she has a strong argument in her call for quality assurance here. 

However; when one decides to use their finger to plug a hole in the dyke, there is always a good chance that a new leak may spring elsewhere. 

Does the promotion of medication treatments not serve to further empower the greedy pharmaceutical companies that make up so many of the top Fortune 500's already? The same companies that so mishandled the AIDS epidemic in the 80’s and 90’s that they are responsible for the deaths of tens of millions in Africa http://fireintheblood.com/ . The same pharmaceutical companies that produce Oxycontin, Percocet, Vicodin, and Xanax...

Does the promotion of evidence based psychological treatments such as CBT and Motivational Interviewing ensure that those techniques will be carried out with any more standardization than the current approach? 

I will tell you that it does not, because I have studied these techniques in depth and I have worked in centers which utilize them. In my experience it is just as easy for someone to say they are doing CBT and actually do nothing, as it is for them to say they are doing AA and do the same. 

What is the current approach anyway? I have traveled the country visiting treatment centers and I have taken courses on the treatment of substance use disorders in multiple settings at the graduate and the undergraduate levels. It seems like everywhere I go my colleagues are speaking in the same voice as Glaser in this Atlantic article. I rarely hear professionals say that they are using AA or the 12 steps anymore. Mostly everyone is using “evidence based” treatments now, and mostly everyone who actually works in the field (unlike Ms. Glasser who is a journalist) is aware of the changing trends towards evidence based treatments and harm reduction. As a matter of fact, I doubt there is any one who would really argue against the need to be more scientific. 

Yet, we are still fighting an uphill battle. It would be naive to think that we only need to do X,Y, and Z in order to reduce the impact of alcohol and substance use on individuals and on our society. It is a gigantic problem because it is not simply solved. Let’s not be so reductionist about this and let’s make sure that before we go ahead and decide that AA (something that is widespread and free and already functioning well) is no good, let’s make sure we really mean it.  

The Help that Helps

By: Carol Maxym, Ph.D.

After four inquiries from prospective clients last week, each of whom had a long story of turmoil where the help hadn’t helped, I thought it time to address the issue of what really does help kids and families.  I get that that sounds arrogant; I really do.  Still when one hears of kids or young adults who are hospitalized again and again with little to no amelioration of their symptoms,  diagnosed with made-up disorders, prescribed medications for which the data supporting their efficacy is mainly MIA, it seems to me that the obvious next step is to remember the second most common finding in research regarding what works in psychotherapy.  

That finding?  

What hasn’t worked up till now won’t start working by doing more of the same. 

Simple.  Obvious.  Generally ignored. 

I do not take suicide or suicidal thoughts lightly.  Ever.  However, redefining hopelessness as depression or even the more ominous Clinical Depression and prescribing medications (whose side effects absolutely include suicidality and/or suicidal ideation) doesn’t seem to be very sensible.

The help that helps is very likely to be sensible.

When kids are hopeless, it is the reasons for those feelings which are important and require help, guidance, love, direction, understanding, boundaries, and hope from adults.  When kids are feeling “weird” (to quote Graham Moore who won an Academy Award on Sunday), it is the context of their lives which screams for scrutiny. 

Kids who can’t/don’t find meaning in life and who cannot or just aren’t seduced by lots and lots of  expensive designer stuff and  facebook friends they’ve never met, aren’t disordered.  They aren’t sick.  They aren’t anomalies.  Adolescence is a time of seeking, questioning, wondering, exploring.  When all that is pathologized, we leave kids in a worse place than before.  Holden Caulfield jumps to my mind.  And Young Werther.  David Copperfield (Dickens)…Oh, and Hamlet.  This is not a new problem; only our ways of helping kids to move through the problem is new—and apparently not that much better.

“Life is not as easy as walking through a field” (Pasternak) and yet we keep on walking.

The help that helps is very much based in understanding people—kids, young adults, and adults as well.  By understanding I mean accepting the human condition and that life isn’t a long series of smiley faces.  Understanding is connecting, empathizing, noticing context—and holding to moral and ethical standards.  Understanding is about meaning, the lifelong endeavor to find meaning.  The help that helps is about talking to the person in front of you with no thoughts at all about a “diagnosis.” 

In all the 500+ pages of the latest DSM, there is nothing about feeling weird or hopeless or wondering what is the meaning of life or this child’s life at this moment and beyond.

The help that helps must look beyond the prevailing template [paradigm] which has morphed and degraded the human experience into something that is as often as not a mischaracterized as a “disorder.”

Bipolarized Life

By Carol Maxym Ph.D.

This morning (well, and for much of the day) the news was filled with the story of the Jordanian pilot murdered—executed---cruelly, viciously, by ISIS.  A deed, I suppose, committed by those for whom shock value is equal to a man’s life.  I cannot pretend to understand what makes someone think that burning another man alive is a worthwhile deed.

But here’s something else I don’t really get and that is a part of our everyday lives.  I watched coverage of the murder–it was on for a good 6 or more minutes uninterrupted..  Then came commercials.  So, suddenly I hear soft clincky music and I learn about a medication for a made-up disease.  Then comes the sexy lady with the Viagra pitch.  Then come the kids dressed like adults throwing phones trying to sell me I have no idea what because I’ve muted them.  Then comes the car insurance…Then, back to the news.

What about feelings?  What about the complete disruption of feelings?  The honest, authentic reaction to the vile, evil deed done by ISIS, then silly, manipulative, deceptive froth to make me buy stuff.  What does that do to feelings?

After the ads we return to more commentary, a bit of detail about the murder, and a few photos of the murdered pilot.  And feelings…once again justified outrage, disgust, horror.  And then, again, back to the manipulation, the manipulative music.  Murder.  Fluff.  Horror.  Silliness.  Whatever you may think of ads, compared to the reality of the execution by burning alive of the Jordanian pilot, it is fluff and silliness.  I am not saying we should grieve endlessly, but can’t we show some respect???

Is it really any wonder that kids (and adults) feel mood swings?  We are being programmed into constant, violent mood swings on a minute-by-minute basis.  How are we supposed to process those emotional swings? 

I think the answer is that mainly we don’t/can’t process that rapidity of mood change,  We don’t even exactly acknowledge them because they are a part of daily life.  It isn’t much different on the Internet.  Information stimulates this emotion then that one—horror to hope in 23 seconds or less. 

Honestly, I don’t think humans are really meant to be able to process emotions that way.  I don’t think that kids have a chance to be emotionally stable when they are being taken from hideous to cute in the blink of an eye.  And that is also true of lots of other parts of kids lives.  Think about it.

What to do?  Well, neither you nor I can change the world situation.  Nor can we change or influence the ads that come your way, your children’s way.  I think, however, being aware—acutely aware—is the key.  If you are aware of the way your emotions are being swung, tampered with, manipulated, it is much easier to avoid the swing.  Teaching your children about the swings and how not to become involved is a life lesson like teaching how to fish instead of giving a fish.

Happy Helicoptering

By Carol Maxym Ph.D.

Or, what do you get out of helicoptering?

I've just asked you a really hard question.  What do you get out of helicoptering?  Probably your first reaction will be to begin to list all the reasons why you must helicopter.  Slow down, please.  Read on and give yourself a chance to think it through in a different way.

Professional Mothering is the term I've coined to describe one of the main ways modern moms get caught in helicoptering  

In your job anticipating problems is a good thing.  Solving problems immediately is a very good thing.  Preventing problems adds real value to you as an employee or as a professional.  Having things well organized—another plus in the working world.  Tying up all the lose ends—another asset.  Rescuing your boss from a giant gaffe—big time good in the professional world.
Here’s the rub:  Doing all those things as a mother?  Yeah, no.  Not helpful.  Really.

There are so many “soccer moms” today who have a great education, many years of professional success before deciding to become moms.  Please don’t take this the wrong way, moms, but there are certainly ways, times when being a mom is very boring.  Very unstimulating.  You wonder what that great education was for.  I remember that very well from my days as a young mother.  Mothering just isn't always intellectually stimulating,  Mothering often isn't exciting.  Mothering rarely provides a sense of immediate success or reward—the kind that does occur in the work world.  Frankly, it’s seldom that anyone really thanks you (certainly not your toddler who cannot understand) or pays real and authentic tribute to what you do all day.

There is no respite from mothering.  You are on duty 24/7 for years and years.
So, mothers, let’s face it:  You look for something to do, something stimulating, something you can really sink your teeth into.  You are trying to bring into your mothering world the parts of your professional world that you really liked, that kept you stimulated.  Understandable.  The question is more if it is useful.

Helicoptering is one of the ways to feel busy, useful, important.  The more you helicopter, the more your child [appears to] needs you, so the more you have to do.  I mean, if he’s forgotten his lunch, well, you must take it to him.  Same goes for homework.  And what about the project for science?  Getting her ready for camp—certainly she can’t pack her own things.  She wouldn't know how.
Here’s the deal:  Your child will never learn how to be independent and highly functional if you helicopter.  As you child feels less than competent because he/she isn't as competent as you are (well, of course—you are an adult, you child is…well, a child), anxiety can take hold because your child cannot feel competent to do whatever the task, remember what needs to be remembered, take care of whatever needs to be taken care of.

So, I’ll be really blunt:  Helicoptering is selfish and it isn't good mothering (or fathering).

Think about it.

Plain Speak

By: Carol Maxym, Ph.D.

Please, please read this article. It’s short and well-written and really important.

Last week I caught just part of a radio discussion about “new research” that demonstrates how the context of one’s life matters in how one acts, reacts, etc., that connections among people and communities effects how one lives in the world. Well, my first reaction was a sort of “duh?”  I mean who didn’t know that. Then I thought for a moment more and realized that as we have created a [false] idea that behavior problems, “mental health” issues, depression, anxiety, bi-polar “disorder” –well, really all the so-called disorders, are intrinsic to the individual, we have created an illusion that we all act and react in the vacuum of ourselves and some rather loosely defined neurotransmitters that create a so-called chemical imbalance (for which there is zero real data, but it’s been a fabulously successful marketing tool) and that drive our feelings, emotions, attitudes, behavior, social behavior, and our being in the world.

Ok, so, really, let’s get serious.  Do you really—from your own life experience—believe that life, situations in life have no effect on how you feel emotionally, how you act and react?  I mean, anecdotally from your life and the lives of those you know (and forgetting all the advertising hype you’ve heard), do you really believe that what happens in your life is less important than neurotransmitters in how you feel.  I mean does this make sense?  One day your lover tells you he doesn’t ever want to hear from you and somehow simultaneously your chemical imbalance takes over and you feel depressed?  Or your son brings home a report card full of Fs, but it’s all about chemical imbalance?  And, your reaction is also just those neurotransmitters? 

Life happens, and we all act and react in ways we’ve learned.  If you come from a family where difficulties were met with anxiety, probably you learned to react with anxiety.  It isn’t about genetic material that makes your neurotransmitters fire, blah, blah, blah.  Think of this:  Schools have cultures.  In some schools, being “cool” means that you work really hard academically. In others it means being particularly kind.  Etc., etc.  Corporate cultures are exactly the same. So, yes and obviously, we do mimic the culture in which we live. It isn’t your neurotransmitters that are deciding to be kind or smart or snarky or depressed or anxious. It’s your life, your world, your experience and how you interpret your life and world and experience. 

Let’s not pretend that the brain has nothing to do with how we feel and emote and act and react. Let’s also not pretend that very much is known about that. Let’s free ourselves from the tiny, simplistic, false world or diagnosis of disorders. 

Think about it. Think how much richer your life could be minus disorders. Think about starting the discussion about your feelings not stopping it with a foolish disorder diagnosis.

     

Pivoting Round Y2K

By: Carol Maxym Ph.D.

One of my first thoughts this morning upon really going back to work after the long holiday break was that we are equidistant in time from 2000 as we were in 1986.  I am quite certain I didn’t think about that on January 5, 1986.  Reagan was President, no one had a computer or cell phone.  No one had imagined the Internet, Blogs, e-mail…. Kids abused drugs but not really prescription drugs.  Kids weren’t really being diagnosed with all sorts of diseases, disorders, and disabilities.  Hardly anyone took psychotropic medications.  Life was slower, different, more thoughtful—or am I just becoming old and nostalgic?  “Back in the good old days…”  We had less communication but perhaps better communication. We dressed with more care, eating habits had not deteriorated as much as they have now.   People wrote letters to each other, and letters were more thoughtful than e-mails.

But I do sound like an aging complainer….or do I?  I worry about that often because there is so much in the growing-up world that frightens me, disturbs me.  Sometimes I think the main value of residential treatment for kids is taking them out of their modern, highly-stimulated world.  What do you think?  Am I being simplistic?  Are we, as individuals, parents, Americans better off now than in 1986?

Well, obviously there is no one and certain answer (or maybe there is—that’s even scarier…).  More importantly, there is no going back.   So what can we learn?  How to move forward?

I think the main point is that more is not better.  More is simply more which doesn’t make it better. I think that pivoting around that millennial moment (remember Y2K? and all the horror that was to ensue that didn’t happen?) provides a window to observe where we are and where we want to be.  I’m not suggesting that we engage in Soviet-style five-year plans, but I am wondering about thinking more about how we want the world to be for our children.

And yes, I know the politicians accuse each other of stealing our children’s future (usually referring either to the National Debt or to Climate Change), but I don’t mean that.  I mean do we wish to provide our children with so electronic a world that they are using iPads before they can talk?  What about constant music everywhere providing emotional indications of how to feel just in case you don’t know yourself?  What about diagnosis of purported disorders?  Do we prefer a world of medication or a world of understanding the wealth of human emotions? 

I think the 28 years around the fulcrum 2000 have been years where we became more quickly reactive but not more helpfully reactive, or proactive.  Public figures apologize ad infinitum, So that the whole concept of apology no longer has any meaning (and I do remember beginning to notice that in the ‘80s).  Accountability is a word and one we don’t really even expect to have meaning.  There are so many words like that.  Depression is another one.

We have the opportunity to become more thoughtful, more deliberate, more reflective as we re-think the growing up world we present to our children.  Or not. 

It’s Not A Competition

By: Carol Maxym Ph.D.

When I was a kid, I remember noticing that my parents used my brother’s many successes as what I then called to myself “Parent Badges”.  He was very smart, so that meant they were smart also.  He won all sorts of competitions, so, in effect, they did, too.  They bragged about him whenever they could (particularly when they could seem not to be bragging).   For any of you who know I Love Lucy (and if you don’t know that TV comedy series, I urge you to have a look at it.  If you can watch one episode and not laugh gleefully, please do let me know), you may remember the episodes where Lucy and Ricky get into (or try to avoid) bragging competitions with their best friends about which son is cuter and smarter and learning more things earlier.

I didn’t have so many overt successes as my brother, so I didn’t provide much in the Parent Badge department.  However when I did, I kept my triumphs to myself because I couldn’t bear the thought of my parents using my successes as their Parent Badges.  Somehow it seemed to me to take away from my hard work if they took it as their own.  Was I too sensitive?  What do you think?

As a mom, I shied away from talking about my kids very much or carrying their photos because I couldn’t bear the idea that someone might think I was bragging.  I never even kept photos in my office because I didn’t want to be asked questions that would lead me to have to talk about my daughters who accomplished much.  Perhaps I carried it all a bit too far.

Being a mom or a dad is about guiding and teaching and loving and connecting, not getting or seeking validation for yourself.  Perhaps ‘parenting’ has become something of a competition—thinking back to I Love Lucy, I guess it always was.  Perhaps that is a part of the reason I have never liked the verb “to parent.’  Your child desires your good opinion, your praise—even if he/she doesn’t want to show it.  If you use your child’s success as your Parent Badge, you take away from the connection, the relationship becomes it takes on a hint of contingency.

And then there is yet another aspect to the competition: things, buying things.  What happens to a child’s self-respect, to his/her soul when your ability to provide more and more things for status becomes a part of your child’s actual belief in his/her self worth?  Is any child better or better off for having more things than other kids—or even for being able to keep up with what other kids have or can get.  And, yes, I acknowledge that I am writing this in the midst of the Christmas/Channukah buying season/frenzy. 

When I talk to parents whose child is not doing well, they often want to know if they are to blame for the problems.  That is such a complex and complicated question.  Parents always make mistakes—that’s jus a part of the deal.  Making mistakes is not the same as “causing” your child’s problems.  And the opposite is also true.  When your child succeeds at school or sports or in the school play or the marching band, you’ve certainly helped but you haven’t done it. 

Being a parent is never about the parent.  It’s always about the child.  However that very specifically does not mean that your child should become the center of your world or that you should teach your child the false and dangerous belief that he/she is the center of the world.

So, what’s the point here?  Perspective mainly,  and the same old thing I’ve written about so many times.  Being a mother or a father is about teaching, guiding, loving, connecting.  Being a parent isn’t about the bragging rights but about helping your child learn to be a productive, caring, generous, honest citizen (which is the best recipe for happiness I know).  However much you can help your child to become that person, you gain [silent] bragging rights—and a little peace and quiet in your later years.