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Newsletter Volume 1, Number 5
I developed a chart on the progression of addiction that was helpful for educating interns, used in patient lectures and addiction assessment. The chart changed over the years as new studies and medical information emerged. Much of the information came from James Milam, Katherine Ketchum, George E. Vaillant and Sidney Cohen. M.D.; however, there were many others that helped give clarity to the issue.
Ernest Hooker, NCAC II
Details on the Addiction Chart
In this fifth newsletter I plan on giving additional information on the chart details.
Dr. Jellinek is the author of many scientific articles and books, of which, perhaps the most important is Disease Concept of Alcoholism (Hillhouse Press, New Haven, Conn., 1960). Every program in the field of alcoholism in the world today has been influenced - some very profoundly - by Dr. Jellinek's scholarly contributions. Starting to understand the progressive symptoms of addiction and recovery was due to Jellinek’s work.
Here is the chart I developed. A copy can be downloaded by going to: http://alcoholismanswers.net/Forms.aspx
The Early Stage
In the early stage it often doesn’t look like a disease at all. Many appear to start with a high tolerance or the ability to drink large amounts of alcohol with minimal effects. Clearly, many have a genetic predisposition to alcoholism. The upside of the early stage is he or she may be the best behaved in the group. The only downside that frequently shows up is that tolerance will likely be present with pain medication and anesthetics. With dental work or surgery, pain relief is often a problem for early stage alcoholics. Many early stage people suffer little or no hangover and appear to process the toxins with amazing efficiency.
What is a high tolerance? .15 BAL (blood alcohol level) or above has been used in the criminal justice system and medically. Anyone that can function with a .15 BAL is demonstrating a high tolerance. Typically a normal drinker would be showing marked effects of their alcohol use at .065 BAL or .07BAL. At around .10 BAL a normal drinker often cannot function at all.
During the early stage of addiction the person loses the ability to mature or heal emotionally. The physical changes associated with addiction have just started and soon the dysfunction will start to be evident for those who know the signs. The physical change has started and soon psychological damage will also follow.
Middle Stage
Two changes mark the start of the middle stage loss of control and denial. Loss of control means that the drinking is no longer predictable. As an example, a man stops at the bar on Friday night for a couple of drinks and then goes home to eat dinner about 6 PM. He has done this for at least several months. This time he stays an additional hour or more and when his wife asks him why he didn’t get home on time he doesn’t really know why. Eventually he makes up an excuse but he realizes it isn’t true; he just isn’t sure what is true. He may stop for the next few weeks on Friday night and come home on time and then once again he is quite late. So, every time he drinks now he cannot predict when he will stop. Soon the excuses become automatic or subconscious. When he is late his denial system starts to take over.
The denial system has three general areas: repression, blackouts and euphoric recall. Repression is the subconscious act of shielding us from shame, so consequently the information is kept from the conscious. Blackouts are periods of amnesia caused by a high level of the toxic effects of alcohol or other drugs. Euphoric recall is the result of brain changes that feed the person false information. One person stated it simply by saying “I remembered good times I know I never had”. The overall effect of denial is that it deletes or keeps information from the person, leaving them in an increasingly confusing situation. It certainly ultimately results in sincere delusion. In the first part of the middle stage repression is the primary issue. More details about the denial system in another newsletter.
As the middle stage progresses damage due to the toxic effects of alcohol cause more brain and body dysfunction. Often the person describes the advanced experience of the middle stage as flu like symptoms. This is a fairly accurate description of what is going on physically.
Depression starts to become a problem due to damage to the brain and chemical changes. Often suspiciousness becomes a problem. The person is starting to lose some of their cognitive abilities. Euphoric recall is almost certain to periodically be a problem. To those around the alcoholic this looks like lying but it isn’t, it is delusion.
Physically the person is starting to have mild to moderate withdrawal symptoms. Often this is called a hangover, however, it is quite different because more alcohol or a drug will relieve the symptoms of withdrawal and this isn’t true of a normal drinker with a hangover. They are finding that it takes more alcohol to produce relief but it takes less alcohol or other drugs to make them toxic (flu like symptoms). This is increasingly becoming a damned if you do and damned if you don’t situation. The alcoholic will tend to alter their use and may become periodic. They have to adjust in some way to the advanced symptoms of their illness. At this point they no longer have the high energy like they did in the beginning. Some add street drugs, particularly uppers, at this point and because they have chronic flu like symptoms others add prescription drugs to their intake. Because their pattern has changed and may become periodic this stage of the illness often is not seen as a progression but is believed to be an improvement.
Late Stage
This is the stage of the illness when most people only start suspecting possible alcoholism. Rarely is it recognized in the earlier stages. They have periods of significant depression which may alternate with grandiose ideas. The alcoholism started causing mental illness in the last part of the middle stage and now there are very definitely more serious issues with their mental health. Periods of dementia are not uncommon; one of the possible reasons is that changes in the liver have resulted in a high ammonia level. Hallucinations and delirium tremens may be experienced.
Wernicke-Korsakoff Syndrome may be present at this point. You can find more out about this condition at: http://www.alz.org/professionals_and_researchers_13509.asp
The alcoholic’s physical condition has deteriorated to a dangerous level. They do not have to be elderly to experience this condition. The alcohol has become extremely toxic to them in very small does. If they use a small amount of alcohol and a small amount of valium it can add up to a fatal dose. Small amounts of alcohol give them severe flu like symptoms and yet it takes large amounts of alcohol to give them any relief. At this point they are in a very difficult situation. Because at this stage of the illness they may drink only relatively small amounts it might be assumed the alcohol isn’t why their physical condition is in such a serious decline. They now need medical attention in a hospital that is familiar with alcoholism detoxification and recovery.
The ability to heal has slowed almost to a stop.
During the eighties I worked with a psychologist that tested the patients for any psychological pathology and also for intelligence. He mentioned that those who relapsed and were administered a particular test that took ten minutes on vocabulary and ten minutes on abstract problems dropped significantly on the abstract problems side but changed very little on the vocabulary. Many of those that returned for treatment had only relapsed for a very short period of time. It tended to indicate that when they returned to alcohol use the stage of the illness they were in had advanced. It also demonstrated that if you only considered their vocabulary there had been little change; however, if you considered abstract thought a dramatic change had taken place.
One patient who went to treatment the first time at about age 30 was at 115 on the intelligence test. Her problem was periodic crack cocaine use. She also lost weight very fast when she started using. After a few years she was retested and her intelligence test rated her at 85. She was well aware of the change in her cognitive abilities and described it as terribly frustrating.
This is the stage of the illness where they are likely to be charged with a DUI. At this point parts of the brain are shrinking, the cognitive ability is significantly decreased, thinking is slowed and the ability of the body to respond has slowed severely. Some studies have indicated approximately 90% of the DUI charges happen as a result of these physical and mental changes.
If you understand that it takes less alcohol or other drugs to cause the person to be toxic as they move to the later stages and it takes more of the alcohol to provide any relief the rest of the symptoms will make sense.
Ernie
| | Newsletter Volume 1, Number 6
In addiction treatment the family and friends of alcoholics have been subjected to a wide range of information, all the way from being told they caused the alcoholic to drink to they are innocent victims of alcoholism and a few other beliefs, some of which bordered on the bizarre. Let us sort through some of the last sixty years clutter about the family role in alcoholism.
Ernest Hooker, NCAC II
Codependency, what is it?
In this sixth newsletter I hope to simplify codependency and sort out a few facts from myth. Due to space limitations of a newsletter I am not attempting to describe all areas of codependency and will only cover a few points of interest.
Psychiatrist Timmen Ceremak gives us some insight into codependency with information from the books he has authored on the subject. I will encourage anyone seriously interested in the subject to read his books, which are excellent.
• Under-learning is one of the causes of codependency.
• Immaturity is present in codependency.
• If a person stays with a partner who is an active addict or has a serious personality disorder for two years or more without taking action the person has a codependency issue.
First let us consider some possible examples of under-learning. This results from growing up without adequate role models. I often think about people who have not learned what reasonable physical boundaries are. Most of us have encountered a person who attempts to stand almost on top of you - you move back and they move towards you again. It doesn’t encourage you to make them your friend and it is really annoying. This doesn’t mean they are not intelligent or well educated; it just means that they did not learn about physical boundaries as a child. Typically, codependents have inadequate emotional boundaries and this seriously impairs their social life, probably more than lacking skills with physical boundaries.
I remember a social worker who had many years of experience with family problems associated with addiction. Her understanding of codependency was excellent. She said it is about learning to mind your own business. A codependent person has no way of determining the difference.
Immaturity is present when an adult has not acquired adult skills and attitudes that are needed to function in everyday life. A child needs parents who can demonstrate how to behave as an adult or they have no way to become a mature adult. Having a parent with active addiction or an untreated mental health problem often will result in an adult who doesn’t know how to behave. It isn’t always true that growing up in this situation results in immaturity. Sometimes, fortunately, they have another relative or a neighbor who teaches them the skills they need.
If an individual grew up in a home with untreated addiction or mental illness it may seem normal for them to be with a partner with a similar pathology. So it may not even occur to them to attempt to demand change.
After many years of working with families of alcoholics I understand codependency as behavior that supports pathology in other people. It helps the addicted stay using without facing the consequences of their own behavior. It supports the immature in continuing in their immaturity, it penalizes and ignores the healthy, and rewards the lowest common denominator.
I remember a patient who came in for detox. He had been very ill and confined to a bed for several weeks. He was in a bed with tubes running in and tubes running out and his wife sitting by his bed. He still smelled of alcohol. She said he just won’t stop drinking. I asked her how he gets the alcohol; she told me he makes me get it!
When I am confronted with attempting to explain codependency to a codependent person I often think about an example a former colleague used. This describes the dilemma of codependency “It is hard to see the picture when you are the frame”.
Codependency is a very common problem among sober alcoholics and after being sober a short time it is not unusual for the recovering alcoholic to undermine their own recovery by exhibiting codependent behavior. I believe a reasonable estimate would be thirty percent of those who have a chronic relapse history, or a very difficult recovery, avoid recovery work by indulging in codependent behavior. There is a lot of misunderstanding about codependency characteristics. The term has been used so much in so many different ways that it has lost some of its usefulness.
Codependents are attracted to employment in the helping professions such as physician, social worker, nurse or therapist. Their burnout rate is very high, so their rate of ending up on a disability is much higher than average. Their use of sick leave is higher than average. There is often a pattern here: they initially work more hours than other employees, they keep secrets, and they soon believe they are the only ones who really understand how things should be run. They often complain a lot and secretly feel superior. They find it difficult or impossible to be a team player. After some months (or even years) they burn out and end up taking a lot of sick leave, quit or go on a disability.
Codependents are attracted to jobs that only have vague and general descriptions with low authority and high responsibility. Then they can only perform their job duties by covert action. This is a familiar situation for them and a repeat of their childhood condition.
Codependents, like alcoholics, have a remarkable ability to assign themselves good motives for bad behavior and then believe it themselves. However, most of the time they don’t fool others. An example would be advising an alcoholic in early recovery to go slowly in working the twelve steps because it might upset them and make them relapse. Unfortunately, they really believe they are just being helpful. That is like telling a diabetic to wait until their glucose is normal before taking their medication. In over thirty years in the treatment business I have never had an alcoholic patient come back after a disastrous relapse and complain that they completed a fourth and fifth step too soon. Many have said if only I had followed my sponsor’s advice and completed the work he or she suggested. Yet many codependents continue to see the healing process as dangerous. They don’t know that they don’t know.
Another area that really baffles codependents is that regardless of a lack of any evidence to prove it, they are sure they are an excellent judge of character. A man meets a woman and everyone else knows she has terrible financial problems and shops until she is in deep debt with her credit cards or, for that matter, anyone else’s. He believes it bad luck or just plan untrue gossip. When she helps wreck his credit his response is “But she said ….”.
A man has a history of being late most of the time. His friend is furious when he is late again, he’d somehow expected him to be on time this time. Regardless of his past behavior he expects him to be different this time. It appears that the person is chronically naïve.
A man’s wife’s has a history of alcoholic drinking for over twenty years; she has drunk in good times and bad times alike. After her last drinking bout he brings her to treatment and says “I just don’t know what set her off”. The nursing staff is baffled - not with her but with him that after all these years he thinks she needs something to set her off, is he an idiot? No, he is a codependent and had years of training as a child to think that way. The world is a confusing place for him and he attempts to control the uncontrollable.
For about three decades I trained interns to work in the addiction field. All had training, education and experience at group therapy, many had several years of experience. The most common problems I had in the early months of their training were their habit of focusing their time and energy on the patient most resistant to recovery. This left the motivated patients out of the picture; soon the groups would be negative and near rebellion. By focusing on the motivated patients at least as much or more than the resistant patients, soon the positive group attitude would even be hard for the most resistant ones not to change their attitude. Getting certain interns to see their own codependency is not an easy task. Codependency keeps narrowing the person’s vision down to seeing only the one very resistant patient and no one else exists to them.
Here are a few ideas that have been helpful in producing long term results for codependents.
Attend Alanon, family programs associated with addiction treatment programs, and education on codependency.
Books that have been helpful: Facing Codependence: What It Is, Where It Comes from, How It Sabotages Our Lives By Pia Mellody, Andrea Wells Miller, J. Keith Miller and Diagnosing and Treating Co-Dependence: A Guide for Professionals Who Work with Chemical Dependents, Their Spouses, and Children (Professional Series) By Timmen L. Cermak. For an interesting overview of codependency there are several books by Anne Wilson Schaef that describe how codependency has undermined politics, mental health therapy and business.
Although The 7 Habits of Highly Effective People by Stephen R. Covey does not even mention codependency I know of cases where his information has been of great benefit to codependents.
A book on therapy that can be helpful to both alcoholics and codependents is The Feeling Good Handbook by David D. Burns. The Grief Recovery Institute is a powerful resource, go to the helpful articles.
The central issue with codependency is a subconscious belief system that goes unchallenged. It can be described in many ways and is the result of family rules that have been taught as a child. Some of these unconscious rules work for the person and some don’t. The way people experience this unconscious thought process has often been described by patients. The patient experiences this when they say I am educated about codependency and I know how I should behave to feel better but it always takes so much effort and as soon as I relax the old behavior is back, it is like a rubber band pulling me back. When that is going on it is the old unconscious thought pattern that is running the show and it won’t change until that is challenged at the conscious level.
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