Addiction, Depression and Treatment
The Disease of Alcoholism
In General - The Three Stages of Alcoholism (Early, Middle and Late)
There are many attitudes in our society about alcoholism which have proven to be ineffective when applied to the treatment of this illness. They generally assume that alcohol has the same effect on everyone who uses it, leading most people to erroneously believe that alcoholism is caused by the excessive use of alcohol by people lacking sufficient personal willpower or moral convictions to control their drinking.
Our society has a universal preoccupation with the amount and frequency of drinking however, there is no one "alcoholic profile". There are daily drinkers, periodic drinkers and binge drinkers. It is neither how much nor how often one drinks that determines alcoholism - rather, it is the abnormal physiological effect which alcohol has on the drinker which is indicative of the disease.
Nor is alcoholism a secondary symptom arising out of mental illness as many psychiatrists still believe. The prolonged use of large amounts of alcohol on the brain may create psychological problems which generally disappear when the alcoholic stops drinking. Alcoholics suffer from mental illness in the same proportion as the rest of our society; however, any psychotherapy which does not stress abstinence from alcohol and all mood altering drugs (prescription or illicit) will fail.
Several studies have proven that alcoholism runs in families. Alcoholics appear to be genetically susceptible to this disease as a result of a liver enzyme malfunction creating a buildup of acetaldehyde throughout the body. Acetaldehyde interacts with the brain's neurotransmitters to create isoquinolines which act on the opiate receptors of the brain.
The early stage of alcoholism is characterized by cellular adaptations in the liver and central nervous system, increased tolerance to alcohol, and improved performance when drinking. These reactions are hidden but over a period of months or years the cells will have been so altered by alcohol that the alcoholic's behavior and thought processes will be affected.
The middle stage of alcoholism is characterized by physical dependence, craving, and loss of control. As the body adapts to accommodate alcohol (in response to the malfunctioning metabolic pathways of the liver and brain), tolerance increases. Cellular adaptation allows the alcoholic to drink more without becoming drunk (increased tolerance). The increased presence of alcohol causes further adaptations and eventually the cells are no longer able to function normally without the presence of alcohol (withdrawal). The physiological disruption in the body and brain triggers both a physical and psychological overwhelming need for alcohol. Alcohol becomes the only release from this intense physical and mental pain. As the disease progresses, the alcoholic is no longer able to restrict his or her drinking to socially and culturally accepted times and places. This gradual loss of control is the result of a decrease in tolerance and an increase in withdrawal symptoms. At some point, the episodes of uncontrolled drinking become more frequent and severe.
Late stage alcoholism is when the symptoms associated with adaptation to alcohol are gradually overcome by symptoms that reflect increasing toxicity and damage to the body organs and systems. The alcoholic's mental and physical health are seriously deteriorated and he or she spends most of his or her time drinking to avoid the agony of withdrawals. Continued drinking, however, is eventually fatal.
How Denial and Enabling Prevent the Alcoholic From Facing Reality
The first drink an alcoholic ever takes sets in motion a complex bioneurological reaction that results in a chemical effect on the opiate receptors of the brain. How they feel and how they perform are improved after a few drinks a reaction contrary to the nonalcoholic. This sets in motion an unshakable belief that alcohol solves their problems. The alcoholic clings to this way of thinking long after it becomes obvious to others that alcohol is interfering with their health, personal relationships, and career. This is called denial. Denial allows the alcoholic to continue drinking by blaming their problems on others, rationalizing or justifying their inappropriate behavior, and minimizing their responsibility.
Enabling is the system of support provided to an alcoholic by his or her friends, family members, colleagues and coworkers that keep the alcoholic from facing the consequences of their drinking. Misplaced loyalty, friendship or concern leads the enabler to protect the alcoholic by covering up mistakes, making excuses, doing their work, and accommodating them at every turn. Eventually the enabler grows weary of the situation. Their concern turns to despair, frustration and anger when the alcoholic breaks promises to change and quit drinking.
Intervention can put an end to both the enabling and the denial.
Treatment, Recovery and Relapse
Treatment assists the alcoholic or addict to accept that they have a disease and, also, accept responsibility for their recovery. They must come to understand that there is no cure for addiction and that successful recovery is based upon total abstinence from alcohol and all other mood altering drugs. They must believe this or face relapse.
Recovery is a life long process of personal growth and change with the addict having to take personal responsibility for their own recovery. Their recovery is most likely to succeed if they are willing to get involved with a 12 Step program such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA).
In today's climate of managed health care and shorter inpatient treatment stays, it is increasingly more difficult for attorneys to accept these basic tenants of recovery before they leave treatment. Thus, LAP holds several confidential lawyers meetings throughout the State to encourage newly recovering attorneys to get involved with AA or NA.
These 12 Step programs are designed to create awareness of and change the addict's way of thinking and behaving; thereby, allowing him or her to live a life free of alcohol or other mood altering drugs. Without this change, the addict will eventually feel overwhelmed by their problems or, alternatively, feel empowered by their successes either of which brings forth the return of their denial and a resumption of their drinking or drug use. The disease and its destructive progression is reactivated.
A 12 Step Program helps an addict to admit the need for help, accept that help by attending and participating in 12 Step meetings, complete a process of self-examination, admit their wrongdoings and make appropriate restitution, and help others to recover from their addiction.
This new system of thought and action counters the addict's denial system and allows the addict to live alcohol and drug free.
Nevertheless, years of alcoholic drinking and drug usage causes serious and widespread destruction throughout the body (malnutrition, hypoglycemia, autonomic nervous system dysfunctions, cortical atrophy, and brain amine depletion). The healing process can take years to complete.
Meanwhile the clean and sober attorney may feel anxious, nervous depressed, moody and wanting to get high. These feelings can be expressed and responded to in the 12 Step meetings. However, this only works if the attorney attends and speaks up, asking for help.
For the attorney who is willing to embrace the 12 Step Program, a new life of usefulness and happiness can be found. Even those who only halfheartedly get involved with these programs may, in time, find the rewards such that they increase their involvement.
It should be noted that there are some attorneys who suffer from both an addiction and a psychological illness, such as clinical depression or bipolar disorder. A proper diagnosis followed by appropriate medication and professional counseling will complement their 12 Step Program. Caution is called for as many medical professionals are not properly trained in this area. LAP can provide guidance on which professionals have the requisite knowledge and expedience to properly diagnose and treat these dual illnesses.
Understanding Relapse - The Protracted Withdrawal Syndrome
It takes a long time to recover from the damage caused by alcohol and other drugs. All major organs, the central nervous system and the body's cells in general are all damaged and their functions disrupted first by having too much alcohol and then by its removal. This physiological dysfunction affects how the recovering addict "feels" which, if not understood, can lead to relapse. Continuing depression and anxiety are not uncommon. Compounding these feelings are emotional swings and confusion as to why life's problems are not going away now that the drinking and drug use has stopped. These problems came about through many years of addiction and will require many years to resolve. Once the initial relief of getting into recovery wears off, these problems can appear insurmountable and trigger a desire to escape through a return to drinking. A proper diet, exercise and a weekly visit to a treatment counselor or therapist is not enough. Active participation in a 12 Step Program is necessary to help the recovering attorney to understand what is going on and how to appropriately handle their emotional swings and problems on a day to day basis. A judge who is concerned that an attorney may be struggling with their recovery or has relapsed should contact the local LAP volunteer immediately.
Judicial Intervention....How Judges Can Help Lawyers In Trouble
A judge concerned about an attorney should call the LAP Confidential Lawyers' Helpline (866-354-9334) or contact their local LAP Volunteer. The LAP Volunteer will assist in scheduling a confidential meeting with an addictions professional to discuss your concerns. The professional will assess the situation and make recommendations which may include conducting an intervention if a problem with alcohol, other drugs or gambling is thought to be involved.
Intervention seeks to interrupt the harmful, progressive and destructive effects of chemical dependency or problem gambling on both the suffering attorney and those participating in the intervention. It is a method of "presenting reality to a person out of touch with it in a receivable way.”
Interventions require the careful and loving exertion of leverage, with controlled strength, limited and defined objectives, and professional guidance and participation.
District Court judges are in a unique position to see practitioners in their community on a regular basis. They interact with members of the bar on a social basis and see local attorneys in their courts as a daily routine. Many times it is a District Court judge who will first notice that an attorney may be suffering from a debility related to alcohol or drugs. When that happens, the judge can initiate a process designed to address the lawyer's problem and can participate in that process. Many judges across the state have done this and have thus helped save and reclaim lives. The following sections detail how the process works.
Components of the Intervention Process
The professional intervenor is in charge of all planning and coordination, education, rehearsals and conducting the intervention.
The components of the intervention process include:
Assembling the Intervention Team
- Assembling, educating and evaluating team members on the dynamics of addiction, denial, enabling and the need to intervene.
- Preparing for and rehearsing the intervention.
- Arranging the medical assessment and admittance into treatment (including insurance and payment issues).
- Planning for the proper handling of the attorney's professional responsibilities while in treatment.
- Considering post-treatment back to work issues.
The intervention team may vary in size depending upon the circumstances. Team members may include:
The professional assembles the team by asking two basic questions:
- A professional intervener;
- A local judge who understands addiction
- A law firm managing partner;
- A colleague;
- A family member (including children);
- A respected friend, clergy, community leader, etc.;
- A LAP Volunteer
- Who are the most meaningful persons that surround the attorney?
- Can you arrange for them to meet with the intervenor?
The responsibility for assembling the team may be shared by several people including the judge, the LAP Volunteer and any other concerned party who can discreetly assist.
: Everyone should be briefed on the need for caution and discretion so as not to alert the attorney, alarm anyone, or create a basis for a lawsuit.
: Consider carefully before involving an active drinking/drugging/gambling buddy or girl/boyfriend or spouse. They may alert the attorney to your intentions.
Final team members are chosen for their close relationship with respect to the attorney; their genuine concern and willingness to take part; and their understanding of the nature and dynamics of the illness, including how denial prevents the attorney from asking for help.
- These should be people recognized by the attorney to be interested in his or her welfare and upon whom his or her own self-esteem depends.
- Anyone who insists that addiction is a matter of morality or personal will power should not be involved in the intervention as they may appear judgmental or condemning.
- Anyone with serious personal, professional or political conflicts should not participate as these conflicts will distract from the purpose of the intervention and negate the attorney's perception of being in a safe environment.
Consider using letters, videotapes or conference calls if a concerned party cannot attend.
Evaluating and Educating the Team Members
The professional evaluates each team member's knowledge and understanding about the nature of the disease especially as to the attorney's denial and inability to voluntarily seek help.
Team members are thoroughly educated about the dynamics of the disease so that they understand that they must intervene if the alcoholic/addict/gambler is to be helped. The intervention process is described. The choice of asking a ruptured or impaired relationship by intervening versus doing nothing and watching the addict slowly die is put forth and discussed.
The professional evaluates each team member to determine if they are qualified to participate in the intervention.
Should the LAP Volunteer participate in the intervention?
- Is a team member too fearful, judgmental or angry?
- If so, assist them in recognizing and accepting that they are dealing with a progressive condition which, if they do nothing, will lead to divorce, malpractice claims, disciplinary actions, loss of career and license, health problems and eventually a preventable, premature death.
- Is a team member in denial of their own chemical dependency problem? Remove him or her from the team
- Does a team member need to attend AlAnon, NarAnon, Gam-Anon, counseling, etc. to understand and appropriately deal with their own recovery issues (codependency, enabling)?
- Is there a personal, professional or political conflict, real or perceived? Is there any other concern as to why a Volunteer should not be involved?
- Will the Volunteer's sharing of his or her experience be of value in the intervention (i.e., will attorney identify with Volunteer's story)?
The professional should hold final say as to who is to be on the team.
Preparing for the Intervention
Each team member prepares a written list of specific incidents (preferably first hand knowledge) which legitimatize their concern for the gravity of the situation.
Identify available treatment options and agree on what action the team members will insist be taken by the attorney.
- Avoid opinions and generalizations. Describe first person experiences with dates, times, places and personal reactions.
- Focus on inappropriate behavior or job performance problems they have encountered, especially those related to the use of alcohol, other drugs (prescription or illicit), or gambling.
- Statements should be nonjudgmental; avoid derogatory terms; no putdowns; and no moralizing.
- Keep the focus on the attorney, but be prepared to identify and state relevant plans to change your own behavior.
- Each team member must be able to express real concern and caring. For example, "I care about your welfare and I am willing to assist you in getting help."
- The professional must educate the team on alternative ranges of care and advise them of what appears to be in the best interest of the attorney, subject to a full and proper medical assessment.
- Generally, the first goal is to insist that the attorney be assessed by qualified personnel already selected and arranged by the team. This leaves no room for delay or the selection of an unqualified assessor by the attorney.
- Be careful about using a "family physician" who is not qualified to do an assessment (i.e., has no training or experience in addictions).
- The second goal is that the attorney must immediately abide by the recommendations of the assessor. Leave no room for delay. Arrangements for admission must be made in advance.
Each team member must write down the action they will take if the attorney refuses to cooperate (e.g., no more "covering" or "protecting"; willing to file disciplinary complaint, legal separation or divorce action; willing to terminate employment or dissolve the partnership.).
The intervention chairperson:
Further preparation and rehearsing of the intervention:
- As a general rule, the professional intervenor is the "chairperson" who will direct both the rehearsals and the actual intervention.
- If a professional is not going to conduct the intervention, then the team must choose a chairperson. The best choice is a nonfamily team member who will command the most respect and has management ability. This will probably be the judge.
- One role of the chairperson is to keep the intervention from turning into an inappropriate and angry confrontation. All team members must agree to follow the chairperson's direction.
- During the intervention the chairperson is responsible for:
- Stating the purpose of the meeting.
- Setting the ground rules; i.e., the attorney is asked to agree to listen to each person without interruption.
- Calling upon each member in proper order for their presentation.
- Maintaining control over the intervention process.
- Summarizing the concerns of the group and offering the agreed upon course of action (i.e., an immediate assessment followed by appropriate treatment).
- If the attorney rejects assessment and treatment, the chairperson calls upon each person to present the action they will take if the attorney does not cooperate.
- If the assessment and treatment are agreed to, the chairperson makes sure that it is immediately received. Delays can be catastrophic.
Finalizing the Details Preparation checklist:
- The chairperson makes the opening statement and obtains an agreement from the attorney to listen.
- Each team member reads aloud each item on their list. The group listens and recommends helpful changes.
- Start off with a positive statement which reassures the attorney of the speaker's concern and support.
- Be honest and detailed; devoid of value judgments, generalizations and subjective opinions.
- No hostility or self-pity. Express genuine concern.
- Make a final written determination of the order in which the members will read their list during the intervention.
- Start with the team member who has the closest and most influential relationship with the attorney.
- End with the second closest and influential member.
- Prepare for denials, excuses, objections and emotional outbursts.
- Consider having someone play the role of the attorney using denials, excuses, objections and outbursts.
- Responses must be firm and realistic.
- Each person must be prepared to calmly continue on with their presentation despite angry outbursts, verbal attacks or denial.
- Work related objections:
- "Too busy for treatment": trials, hearings or other proceedings; deadlines, appointments, etc.; (Discreet approaches need to be made to judges and hearing officers regarding continuances. Also, members of the firm or, if solo practitioner, understanding colleagues need to be asked to cover deadlines, appointments, etc.)
Caution: Such approaches must be done carefully and selectively to protect the reputation of the attorney. Confidentiality and discretion must be stressed to the party being approached.
- What members of the firm will be told;
- Disclosure to firm members and staff should be made strictly on a “need-to-know” basis. Discretion and confidentiality must be stressed. The general statement of taking leave for personal reasons or illness can be used. Further explanation is not necessary.
- Loss of income, especially for the solo practitioner.
- Will the firm agree to continue payment of salary, salary advance or draws?
- A solo practitioner, whether or not indigent, must be made to understand that their future livelihood depends on treating their illness.
- Selection of an assessor, treatment center, packing, transportation, admissions, etc. should all be arranged in advance. Allow no opportunity for delay. Delay leads to inaction and failure to follow through by the attorney.
- Cost of treatment and insurance issues.
- Insurance issues should be dealt with in advance. If no insurance or other funds are available, arrangements should be made for either a loan or scholarship from the treatment center.
- “You’re right, I need to quit drinking, but I don’t need treatment. I’ll just quit drinking. I’ll even go to AA or therapy.” In these instances, kindly but firmly remind the attorney of any past promises and failed attempts to stop drinking, drugging or gambling on his or her own. Explain the need for proper assessment and to follow the recommended plan of treatment. Emphasize your own efforts to support his or her recovery.
Set a time and place for the intervention:
- Chairperson agreed to.
- Team members qualified and educated.
- List of specifics written out.
- Order of presentation agreed to and written out.
- Ultimatum written out.
- Immediate assessment and admission into treatment arranged.
- Insurance and treatment cost issues taken care of.
- Professional responsibilities covered.
- Prepared to deal with financial or personal issues.
- Bags packed and transportation ready.
- Schedule it for a time when the attorney is likely to be sober. A time soon after a drinking or drug using episode can be helpful, if they are not still high.
- Most leverage is in judge's chambers. Otherwise choose a discreet, neutral place where you won't be interrupted. Avoid large rooms.
- Use circular seating. Don't use tables. Seat those team members who will provide the most emotional support closest to the attorney. Do not seat team members with the most difficult material next to the attorney. Separate spouses.
Try to use only those who have prepared; avoid last minute walk-ins.
Choose the person who commands the most influence to make the call inviting the attorney to the intervention. A judge is best. Say only what is necessary to make the person attend.
Caution: Denial often makes it necessary to surprise the attorney. Although we don't want to mislead or misinform them as to the purpose of the meeting, it is often necessary.
Conducting the Intervention Recap
No deals or compromises.
- Chairperson's opening statement and obtaining attorney's agreement to listen.
- Presentations begin (concerned, supportive, firm).
- Chairperson's summary and request that attorney accept immediate assessment and recommended treatment.
- Ultimatums issued, if necessary, with repeated request for attorney's cooperation.
- Take attorney to assessment and treatment facility.
- If the attorney refuses to cooperate
- Each team member must follow through on their promised action.
- The team members should be open to a second intervention at a later date.
- The team members should understand that the intervention has been successful in that: they better understand the illness, how it affects them and what to do about it; they have ceased enabling the alcoholic, addict; or gambler; they have made a sincere effort to help which may have planted a seed for future recovery.
What Lawyers Can Do About Stress
(The following materials are taken from an article appearing in THE PROFESSIONAL LAWYER, MAY 1994 Edition, written by Barbara Harper and Donna L. Spilis. The magazine materials were excerpted from an article from a book to be published by the ABA Law Practice Management Section entitled “Stress Management and the Legal Profession.”)
What Lawyers Can Do About Stress by Barbara Harper and Donna L. Spilis.
Stress Often Goes Unrecognized Until it Causes Negative Physical, Professional or Interpersonal Consequences
Stress is so prevalent in the life of legal professionals that – unfortunately – it seems to go unrecognized until the serious and negative consequences of that stress is made manifest within the life of the attorney. Put another way – and to use terminology which will be understood by most Louisianans – the attorney-in-trouble does not realize he has a problem until the water around him has reached a full, rolling boil.
Stress is usually defined as a physiological and psychological response to negative or positive environmental changes. How an individual may respond to this stress depends on how the event is perceived.
Stress that elicits a negative response in one practitioner may have no ill effect on another.
Problems often arise when a practitioner attempts to medicate the inappropriate levels of stress existing within him through either chemicals or other releases, such as gambling.
Stressors Reported By Lawyers
1. Inadequate time to complete jobs satisfactorily;
2. Competition – turning every encounter into a win-lose situation;
3. Self-criticism – focusing on weaknesses, rather than strengths;
4. The absence of recognition or reward for good job performance;
5. Powerlessness – the failure to see available choices;
6. Hurrying – constant pressure to perform better and faster;
7. The comparison of achievements, or lack of them, to these of peers;
9. The unrealistic expectation that life should be problem-free;
10. Lots of responsibilities but little authority or decision-making capability;
11. The inability to work with others because of basic differences in goals or values;
12. Job insecurity due to pressures from within or to the possibility of a takeover or merger;
13. Prejudice and bigotry expressed by colleagues of a different age, race, sex or religion;
14. Concerns related to being responsible for employees;
15. Not being able to use personal talents or abilities effectively or to full potential;
16. The FUD factor – Fear, Uncertainty and Doubt.
Signs and Symptoms of Stress - Some physical symptoms are:
1. pounding heart;
2. tightened stomach;
3. neck and lower back pain;
5. dryness of mouth/throat;
8. disruption of digestion.
Some behavioral symptoms are:
1. the inability to sit still/concentrate;
2. increased smoking and/or drinking;
3. loss/increase in appetite;
4. proneness to accidents.
Some personality changes are:
1. emotional tension or alertness;
2. general irritability;
The impact on professional performance may be:
2. file stagnation;
3. failure to respond to messages;
5. lowered productivity;
6. fewer billable hours.
The lawyer may experience:
2. a deterioration of communication;
3. lowered self-esteem.
Mechanisms to Increase the Capacity to Tolerate Stress Physical
1. eat a proper diet;
2. get enough rest;
3. take regular exercise;
4. eliminate high-risk behaviors (smoking, excess alcohol, missed meals, tranquilizers, etc.);
5. use systematic relaxation techniques;
1. seek out those who support you unconditionally;
2. share your pain with another.
1. take time to assimilate what is going on with you;
2. make what you enjoy a priority in your life;
3. get clear about your goals, values and priorities.
If a practitioner believes that he is negatively burdened with inappropriate stress levels, then he should seek a stress assessment, which gives a clear picture of what needs changing and helps to direct these attorneys to the appropriate resources. However, the provision of available resources can only be initiated once the practitioner is willing to admit that he feels “stressed out.” Until this admission is made, no assistance can be provided UNTIL the inappropriate stress levels begin to result in inappropriate behavioral or chemical intake changes which are obvious for all to see.
So, the simple secret to appropriately facing increasing stress levels is to ADMIT the feelings of being “stressed out.”
Alcoholism, Drug Addiction and Chemical Dependency is a TREATABLE ILLNESS
(The information contained in this section was taken from an article entitled “What the Lawyers Assistance Program Can Do for Your Firm,” written by the Executive Director Emeritus-Mr. Bill Leary for the Louisiana Lawyers Assistance Program and published in the Louisiana Disciplinary Review in the Winter, 1998 edition. The information excerpted here is quoted with permission from Mr. Leary.)
Alcoholism/drug addiction is not a moral issue, but rather it is a treatable illness. The stigma is not in having this illness; the stigma is failing to seek treatment.
Medical authorities have established that alcoholism/drug addiction is a disease in which there is a preoccupation with alcohol/drugs coupled with a loss of control over its consumption.
Addiction may be arrested (not cured) by treatment. It is perfectly acceptable social behavior to seek treatment; it is antisocial to continue the denial.
Some symptoms of addiction are:
1. The inability to guarantee one's actions after starting to drink or use drugs.
2. Deteriorating health accompanying a pattern of heavy drinking or drugging, impaired ability to work and concentrate.
3. Disrupted personal relationships, denial that drinking or drugs is a problem when it is obvious to others.
4. Defiance, impatience, intolerance, impulsiveness.
5. Addiction is a progressive disease; it only gets worse, never better.
Top Ten Tips for Surviving Depression
I am the same person you are. A life long resident of the state, an honors graduate of my law school here in Mississippi, a good life with three wonderful children, brilliant and witty friends, active in the Bar and in the community, managing attorney of a medium sized law office, all of the things one imagines oneself achieving after graduation from law school. Yet none of these things protected me from depression.
In retrospect, my illness began rather slowly, six months before I became dangerously ill in December. I had begun to have nightmares and suffer from rampant anxiety around the middle of July. I also had begun to wish on some level that everything would just cease to be. The majority of these (to me, seemingly normal) symptoms were connected to a case I was handling. Nothing at the time seemed unusual, and to this day, that absurd sense of “normality” is one of the memories that haunts me the most.
In the brief period immediately preceding the severe phase of my illness, one or two friends had suggested to me that I see a therapist. I made every excuse in the book why I could not possibly do this: I didn’t want to spend the money, I didn’t have the time, I could control whatever was happening. On a subconscious level, I knew that if I looked below the surface of what was taking place, huge, possibly unwelcome changes would occur in my life. Even today, over seven years later, I can instantly recall the intensity of the dread that accompanied this breakdown period.
In the hours after the trial of the matter of which I wrote above, I dropped off my client’s file at the office and went home. For the remainder of that afternoon, I walked around my house looking at and touching things that were dear to me, mostly pictures of my children and my books. By nighttime, I was in critical condition. I cried for hours, not knowing what was wrong, but pleading with God over and over to help me. The next morning, I awoke seemingly in a much better mood. I got up that Thursday and thought to myself, “Today I will either kill myself, go to the hospital or find a psychologist.” Finally, even I realized something was seriously awry. By two o’clock that afternoon, I was in a psychologist’s office. I continued to go to that office at least twice a week for five years, a period during which I was totally unable to work.
I spent untold hours, days and months trying not to commit suicide when I was intensely suicidal. Everything in my life had ground to a halt. I became what I can only describe as a “corpse with a pulse.” I could no longer do things with my children, cook, read, go to the post office, to church, or to a store. I had no sense of taste, zero libido, and I literally saw things in black and white. Sleep was either non-attainable or all consuming. An overwhelming sense of horror suffused my every waking moment and many of my dreams. My life was held together only by Monday and Thursday visits to my psychologist because that office was the one place I felt safe. This descent into paralyzing terror and severe depression came hard and fast, and was perhaps particularly shocking to a lawyer accustomed to controlling almost everything.
My survival of this illness I attribute to a combination of grace, good treatment on the medical front, and strong support from friends, children and therapists. I now have a tremendous respect for people who fight and prevail over life’s challenges. I still take antidepressant medication everyday and will probably continue to take it for the rest of my life. I am very cautious about not exceeding my limits. (Funny thing about limits – you never know what they are until you exceed them.) I go to a psychologist whenever the need arises, which is seldom these days. I look at my children everyday and thank God I am still alive. I recently opened my own law office, which has been a dream of mine for years.
Below is a short list of what I feel are important touchstones for surviving depression.
- 1. If you think you are suffering from depression, you most likely are. Ask questions, find a book on the subject, go on the Internet and research depression. You will find that depression is a medical illness, and major depression is a medical emergency. (Yes, just like a heart attack.) Don’t ignore the symptoms because major depression, left untreated, can quickly escalate to become a life threatening illness. It doesn’t need to be.
- Find yourself a good doctor. This can be your family physician if you don’t know anyone else. Ask friends for references. I have found through reading, conversations with fellow sufferers and medical professionals, and long personal experience that a combination of a good psychologist and a good psychiatrist (or psychopharmacologist) is the gold standard here. Family physicians may not be sophisticated enough to fine tune your medication needs in the long run.
- Force yourself to ask a responsible adult to help you. If you are unable to work for any length of time, you will need assistance with your financial affairs, disability filings, etc. You know hundreds of excellent lawyers – put one of them to work for you. The ideal time to discuss this with someone is early in your illness. In moderate or severe depression, higher cognitive functioning may be one of the first things to go. My current law practice is a testament to the fact that it can and does return.
- If you’ve put all your eggs in one basket and don’t have interests other than practicing law, you should consider placing this issue at the head of your list of topics to discuss with your therapist.
- Be honest with your family. You will need them, and they need you. They will not understand a lot of what is happening to you, but a competent therapist, in my opinion, should sit down with everyone in the family and discuss what is going on and what to expect.
- Don’t become agitated if someone doesn’t understand the things you are going through. The more reasonable expectation is that other people will not understand. Depression is a serious illness, and unless the people around you have experienced it firsthand, they simply will not comprehend what you are feeling because the feelings and emotions that depression engenders are so far removed from the range of “normal” human experience.
- Sometimes you have to surrender to the illness and not fight it. If you can’t function, go to bed. I guarantee you this fact will not be reported on the six o’clock news. (One of my biggest fears – “everyone will know.”) Can’t sleep? My solution was to rent four movies a night and watch them from 8:00 P.M. until 4:00 A.M. If you choose this solution, you might run out of good movies in a few weeks, but there is a bright side. You will make friends with the people at the video store and possibly get a free movie every few nights. Flexibility is the key here.
- Do not waste precious emotional energy by being embarrassed or shamed by your illness. Forget about suppose stigma; your only job is to get well. I found through trial and error that letting as many caring people as possible know about my illness was a safety net for me. Your friends can be the most supportive people on earth.
- Try to do something everyday, no matter how small the task. You need to maintain some connection with the normal rhythms of everyday life. Start small with one or two things a day. Do not, under any circumstances, put more than three things a day on a “to-do” list. You may not be able to complete them, and you have no business setting yourself up for failure. (This was one of the wisest things my very wise therapist ever told me.)
- Locate that one critical thing that triggers your self-preservation instinct. For me, it was my three children. More than my actually committing suicide, I could not abide the thought that any one of them would ever be known as the child “whose parent committed suicide.” In all honesty, I was not always happy to oblige, but in the end, I could not let them down.
These are necessarily general guidelines. Each person who suffers will experience depression in a way that is unique to him or her. The above suggestions are the things that helped me through a lengthy illness. I strongly believe that each person can find something that will serve as a beacon guiding him or her through depression. For instance, I kept a dog eared copy of William Styron’s Darkness Visible on my bedside table long after it had been read, and would look at it every night and think, “Styron is someone who was at least as sick as I am, if not more so, but lived to write about it.” The mere fact that someone had survived a severe case of depression made me know it was survivable. This may seem idiotically simple to a person who has not suffered with depression, but anyone who has been a sufferer will tell you that it is the little things that count.
All of us are vulnerable. I have known too many lawyers in the last few years who have suffered from depression and more than a handful who have committed suicide. Every one of those suicides was an irreparable loss, to friends, to families, to communities and to our profession. We owe it to ourselves to become educated about all facets of mental illness so that we cannot only help ourselves, but also help other lawyers when they need us. Do not be afraid to take action or become involved. Your life or a colleague’s life may depend upon it.
Symptoms of Depression
There is a growing acceptance in the medical community that long hours and stressful work can contribute to professional burnout and clinical depression. The legal profession often provides ample opportunities for just such conditions. If you see yourself in this list, you may need help.
- Persistent feelings of sadness or irritability
- Loss of interest in activities once enjoyed
- Changes in weight or appetite
- Changes in sleep patterns (e.g., insomnia, excessive sleeping, oversleeping in the morning)
- Feelings of guilt or hopelessness
- Inability to concentrate or make decisions
- Restlessness or lethargy that is noticed by others
- Thoughts about suicide or death
- Isolating or avoiding friends and family
Any individual experiencing four or more of these symptoms for a period of two weeks or more should be evaluated by a psychiatrist.
(This article was originally published in The Mississippi Lawyer, Volume XLIX, Number 4, March-April-May, 2003)
Partners in Alcoholism
If He’s the Drunk, Why Do I Feel Crazy?
When we got married, my husband knew I did not drink, and that I did not like to be around drinking. In fact, I thought it was agreed that we would not have alcohol in our home. It soon became obvious that he did not understand our agreement the same way I did.
When we met in college, I knew he drank, but I thought that graduation, a tour of duty in the Navy, and law school, would end all that. It was not until a few years into the practice of law that he began to drink again. Maybe I was naïve, but I was surprised.
My husband and I were active in our children’s lives. Our children made good grades and were leaders. We were active in our church and community. From the outside we were an upwardly moving successful family.
My husband and I had been married about 17 years when our relationship started to flounder and we discussed divorce. I thought he drank too much – that he had a drinking problem. He thought that to me, any drinking would be too much and that I had a thinking problem. He also pointed out that anyone who had to live with a nag like me would drink in self-defense. In a way, he was right. I was as much of the problem as he was. In fact, as I was to learn later, our children were reacting more to my feelings than to his. They could see he had a drinking problem – but what was my excuse?
Then this “thing” started happening to all of us. When “it” happened we were confused and baffled. In the beginning it did not happen often. But it was a progressive, creeping happening. As the tension in the family increased, the children and I started feeling “gun-shy,” like waiting for the other shoe to drop. We could no longer trust that a more or less innocent remark would not be taken in the opposite way from which we had meant it. We could not predict my husband’s or my reactions to any situation. We did know when my husband would drink too much, or for that matter, how much would be “too much.” It was like walking on egg shells, trying our best not to break any, without knowing how.
I felt like a victim and I often acted that out. I had set up a pattern of “flight” from unpleasant situations, and my husband had set up a pattern of aggressiveness and “fight.” I ran away from unpleasantness and he ran aggressively toward it.
My parents had divorced, and I was willing to go to any lengths not to reproduce that situation for my children. When my husband said “shape up or ship out,” it terrified me and I would try to please him. I became ill physically and emotionally. I had debilitating headaches and could not sleep. I became depressed and lost weight. Finally, my husband sent me for therapy. So, then it was acknowledged openly – I was the fragile one, the sick one. That was a low point.
The final bottom for me came when one night he said the “shape up or ship out” thing, and I said okay – that I had done everything I could. He then said, “Well, let’s not be too hasty – let’s give ourselves six more months to work on our marriage and see if we can make it better.” I believe that only the love is real, and we still had our love. The disease of alcoholism can take away many things, but it cannot kill love – it can only force it underground.
I only confided in one friend. (I had my pride – I was the wife of a professional man that I felt I needed to protect.) One day this friend came over with a “Dear Abby” column that mentioned Al-Anon. I had never heard of it. She said, “maybe you ought to look into this thing called Al-Anon.” I was insulted – I did have my pride – but soon went to me first meeting. At that meeting I was pleasantly surprised that some of the women there were just like me. I was committed to my church, but Al-Anon gave me two things that my church could not: knowledge and understanding. I was so confused about reality that I had a confused understanding of the problem. I was reluctant to talk in the meetings even though the emphasis was on principles not personalities. But I listened, and little-by-little, I learned. I learned that we had a family disease called alcoholism – all of us were affected by it – that it did not matter who drank. I learned that one of the greatest symptoms of the disease is denial. The emotional trauma is a big part of it. It was a relief to learn that I did not cause it – I could not control it – I could not cure it.
I was exposed to the 12 steps of Alcoholics Anonymous which are used in Al-Anon with the exception that in step 12: “[h]aving had a spiritual awakening as a result of these steps, we tried to carry this message to other alcoholics…,” Al-Anon simply uses the term “others.” (i.e., “…we tried to carry this message to others.”)
I was eager to learn everything I could and put the 12 steps to use. By using the program’s slogans and trying to “work the steps” and live the principles, I began to live the solution instead of the problem. Little-by-little I was able to control my emotional life. Our home became a more pleasant place for the children to bring their friends. Our meals became more nourishing and the mealtimes more conducive to good digestion. I used the Al-Anon slogan of “Live and let live,” and quit trying to control the uncontrollable. I quit feeling guilty over other people’s words and actions. I began to realize the wisdom in the short slogans that we studied in the meetings. Each slogan is a life lesson in a word or phrase. My sponsor told me to use, “Keep thy mouth shut,” and to use it appropriately instead of in sullen silence. I came to believe that it was imperative for me to take the power away from the people, things, conditions, and situations that I had made my Higher Power, and give that power to God as I understood God. I was told that whatever got my attention “got me” and became my Higher Power. I wanted God to be my Higher Power, so I tried to put my attention there the first thing each day, and to keep it there as it seemed appropriate. I learned to “pause and ask for guidance.” I took the first three steps every morning; I admitted I was powerless over alcohol and alcoholism and that my life had become unmanageable; acknowledged my belief that a power greater than myself could restore me to sanity; and made a decision to turn my will and my life over to God as I understood God. I began to believe that God’s will for us is for our highest and best, and to ask for God’s will in my day with more confidence. With this understanding, I became a calmer, more serene wife, mother, friend … a more attractive person to be around. I started being interested in others and looking for ways to make their lives better.
While all these changes were occurring in me, my husband continued to drink excessively. He seemed not to notice these changes, although some of them made him very uncomfortable. For a time, things got worse, not better. I was told to persevere, and thankfully, with the help of my living sponsor and Al-Anon friends, I did. Eventually, he saw the need to seek help for himself.
That was many years ago, and there have been many life happenings as we have gone along this “road of happy destiny.” Life goes on and so do life’s lessons. The difference now is that our Higher Power – whom we choose to call God – is in charge of our day, one day at a time. We have learned that (as some of Al-Anon’s literature states) “…love cannot exist without compassion, discipline, and justice; and to accept love or give it without these qualities is to destroy it eventually.”
Our God is a God of love, and my husband and I believe that God’s love is the only enduring reality, and is the healing power. We are active in our respective programs. We are fulfilling a program goal of becoming the best “us” we can be. We know a new freedom and happiness most of the time, individually and together. We have much to be grateful for in our lives. Underneath it all, “Only the love is real.”
Is Your Spouse Impaired?
Except in the worst cases, chemically dependent lawyers usually do most of their drinking and drugging at home where it is “safe.” If you know or think your lawyer-spouse has a drug or alcohol problem and you want free and confidential help, call the LAWYERS ASSISTANCE PROGRAM, INC. 1-866-354-9334.
(This article was originally published in the Texas Bar Journal, Volume 58, Number 3, March 1995)
Dealing With Depression
How I Got Out of the Black Hole
I have been diagnosed with a major depressive disorder, recurrent and moderate, but I do not presently suffer from depression. For me, it is easily medicated with no side effects. However, getting to the point where I was able to help myself was not quite so simple.
For a long time, I did not know I suffered from depression. I had no explanation for why I did not want to get out of bed. If I did get up and go to the office, I often felt useless. I did not want to take phone calls, I could not read anything substantial, and I found great comfort in staring at the wall. A new client was a burden, not a challenge. In fact, everything was a burden – nothing was fun. I was convinced I had chosen the wrong profession.
I first visited a psychiatrist eight years ago at the suggestion of my psychotherapist who was frustrated with me for being “stuck.” I was astounded at some of the questions he asked. Did I have mood swings? (Well, yes, but I thought that was just part of my bohemian, beatnik, creative side expressing itself at the expense of all those around me.) Had I always had mood swings, even as a child? (Well, yes, “that’s our moody child…”) Thoughts of suicide? (Absolutely.) I knew all the answers to his questions and was relieved that someone was finally asking them.
He explained that I was probably biologically depressed which meant I had a chemical imbalance. He added that the only way to diagnose it was to see if the imbalance responded to medication. I was reluctant, having been in recovery for drug and alcohol abuse for less than two years. But I was also tired of being tired so I agreed.
The first drug I tried made be feel woozy. To my surprise, I did not like that feeling anymore, so he switched me to a different antidepressant. It took a couple of weeks for me to feel any difference, but within a short time I had more energy, felt more positive about like, and most important, suicide dropped off my list of ways to deal with myself.
What was the black hole that I barely escaped? It was not just the occasional “blues.” For me, it was years of periodic hopelessness, loneliness, frustration, and a deep desire to escape, sometimes in the most final of ways. I escaped and medicated the depression for years with drugs and alcohol.
Sobering up had made a big difference in my outlook on life, but at times I still felt self-destructive, apathetic, and hopeless. When I felt depressed, even the most menial of tasks looked impossible. As a relatively new lawyer I struggled with low self-esteem anyway, but when I was depressed, I was sure I was going to be “found out” as the big fake that I believed I was. Procrastination became my haven as I kept waiting for the day when I would feel better. Sometimes it was all I could do to get dressed, go to the office, prop myself up in my chair, and try to look busy for a few hours until I could contrive a really good and new reason to leave early. This worked for me for a while because when I felt good, I was a work horse.
The longer I was sober, the more I wanted out of life. I wanted more balance, stability, self-confidence, and some way to deal with that shift in my horizon. I was my worst enemy, but I could not seem to do anything about it. I was full of fear. I was scared of other people, scared of myself, and scared that at some point I just might get the courage to turn my car in the path of that speeding 18-wheeler instead of showing up for the deposition.
When you feel hopeless, where does hope come from? I prayed that the hopelessness and depression would go away. I wondered if I were crazy, lazy, or just not fully evolved; and I faked normalcy a whole lot.
You might think that when I found a medication that helped, I would feel like all my prayers had been answered and that my problems were behind me. But I have not always been comfortable with the stigma I felt from taking antidepressants. As a result, several times in the past few years I have stopped the medication in the hope that I was cured. Unfortunately, within six to eight weeks I would start the slide down, wondering why I felt so bad.
I now believe my depression is not a character weakness or a failing of my spiritual life, but simply a biological, chemical imbalance. At this point in my life, and perhaps forever, I will take medication for depression, much like a diabetic who needs insulin. I did not ask to be depressed, but I can do something about it. Doctors tell me that depression is one of the easiest things to treat – if people seek help.
Our profession demands that we be our best every day, and most of us want to be able to rise to the occasion. Even without depression, some days I just do not feel like expending the energy, and that is normal. But most days, I am an alert, productive, happy-to-be-alive lawyer. I still get stressed, but I am not depressed. I can separate the healthy and motivating stress from the excessive and unnecessary stress, and still have the necessary energy to deal with the day.
If you suspect that you are depressed, I encourage you to be courageous, face your demons, and seek medical help. You do not have to live in the black hole.
Common Symptoms of Depression
10 Most Depressed
- Feelings of sadness, hopelessness
- Insomnia, early wakening, difficulty getting up
- Thoughts of suicide and death
- Restlessness, irritability
- Low self-esteem or guilt
- Eating disturbance – usually loss of appetite and weight
- Fatigue, weakness, decreased energy
- Diminished ability to think or concentrate
- Loss of interest and pleasure in activities once enjoyed, such as sex
- Chronic pains that fail to respond to typical treatment
- Jobs and Depression
- John Hopkins University researchers interviewed 12,000 workers in a study on depression. Below are professions reporting symptoms of depression.
10 Least Depressed
- Clothing salespeople
- School counselors, special education teachers
- Sales staff supervisors
- Computer operators
- Waiters and waitresses
- Data entry keyers
- Miscellaneous food preparers
(This article was originally published in the Texas Bar Journal, Volume 58, Number 3, March 1995)
- Secondary schoolteachers
- Physicians and other health diagnosing professionals
- Production inspectors
- Dressmakers, tailors
- Electrical, electronic repairers
- Computer programmers
- Other sales occupations
- Shipping and receiving clerks
- Miscellaneous mechanics
Is Addiction Really a Disease?
By Kevin T. McCauley, M.D.
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This year the American Society of Addiction Medicine celebrates its 50th anniversary. Yet even after a half-century of accomplishments, the field of addiction medicine struggles for legitimacy. And while a recent study by Harvard University and the Robert Wood Johnson Foundation demonstrated that most Americans believe that addiction is a medical problem, the debate over whether or not addiction can truly be considered a disease continues.
The argument against calling addiction a disease centers on the nature of free will. This argument, which I will refer to as the "choice argument," considers addiction to be a choice: the addict had the choice to start using drugs. Real diseases, on the other hand, are not choices: the diabetic did not have the choice to get diabetes. The choice argument posits that the addict can stop using drugs at any time if properly coerced.
In making the argument in favor of calling addiction a disease, it is important to tacitly admit that the behavior of addicts is unpleasant. To be sure, the behavior of addicts can be frustrating, revolting - even criminal. But in medicine, the character of the patient is separated from his or her symptoms, however unpleasant or harmful. Patients are not judged based on the palatability of their symptoms. If that were the case, patients with cholera would receive the harshest sentences.
I would like to think that physicians do this out of a sense of clinical humility for medicine's past mistakes. Many times, we have thought we were looking at badness when, in fact, we were looking at a disease process. Just because we observe bad behavior in a patient, we cannot always be certain that what is driving that behavior is some kind of intrinsic badness.
The law makes a similar distinction. Except in cases of strict liability, a truly just conviction requires more than the commission of a harmful act. The prosecution must show intent, a state of mind bent on doing harm.
So when we ask the question, "Is addiction really a disease?" we are asking a question about causality: I'm seeing bad behavior, what's the cause? Are addicts sociopaths? Are they inherently liars, cheats, and thieves? Do they have an addictive personality disorder? Did their parents raise them improperly? Did they learn addictive behavior from a bad crowd? We have bad acts, but do we have bad actors? Or are these symptoms of a disease?
To answer the disease question, we must have a standard. What is disease? What does it take to get into the "disease club" and earn the rights and privileges that accompany that distinction? In medicine, the causal model we use to explain illness is the disease model. This model, which is only 100 years old, emerged from the germ theory described by early "microbiologists such as Louis Pasteur and Robert Koch.
Simply put, the disease model says that you have an organ (bone, liver) that gets a physical, cellular defect (cells die, cancer develops, an infection sets in, a bullet whizzes through the organ), and as a result you see symptoms. You see the same symptoms in all patients with that defect in that organ, differing only by severity or stage of illness.
It is easy to see how the disease model works. Let's take a broken leg. The organ is the femur, the defect is a fracture, and the symptoms are screaming, bleeding, bone deformity, and disability. The beauty of the disease model is that it strips away the nonsense about personality and social environment. There is no "femoral personality disorder." We don't have a problem with "femur gangs." The disease model gets us to the real cause of the problem: the fracture. It tells us how to treat this patient. We do not go after the symptoms, we go after the defect - fix that, and the symptoms go away. In the case of diabetes, the organ is the pancreas, the defect is islet cell death leading to a lack of insulin, and the symptoms are the seemingly unrelated symptoms that go along with diabetes. We can't cure diabetes, but the model reveals how to treat it - we replace the insulin and the symptoms get better. It may not look like much, but the disease model is so powerful a causal model that it has doubled the human lifespan in less than a century.
One hundred years ago, doctors knew they had a winner. Doctors knew the disease model would boost medicine's reputation; for the credibility of medicine, they had to decide what was and was not a disease. It was easy to see how a broken leg fit the disease model. They could even fit diabetes to the model. But addiction? What was the organ? The brain? Some doctors thought it might be the liver. What was the defect in addiction? And what about the symptoms? At first glance, the symptoms of addiction don't look like symptoms at all. They look like badness. And so doctors made a decision that affects every day of every addict's life: they decided that addiction was no longer a disease.
Almost overnight, treatment innovation for addiction ended, research into the problem of addiction stopped, and advocacy on the part of physicians for their addicted patients ceased. When doctors could not fit addiction to the new disease model, they walked away. That didn't mean that addiction disappeared. It meant that another group of professionals had to come in and handle the problem. That group is the criminal justice system.
And so today there are more than two million people in prison - many of them nonviolent drug offenders, many more convicted for offenses committed under the influence of drugs or alcohol. Because doctors abdicated their responsibility to addicted patients, the United States deals with addiction punitively. But with numbers like two million, the problem looks less like a criminal justice problem and more like a public health problem. The problem falls back into medicine's lap.
If we could fit addiction to the disease model - if we could show what part of the brain was involved in addiction, what the nature of the defect was, and link that defect in that organ to the symptoms of addiction, then addiction would be a disease. Everything would change. And for 100 years we've been unable to do that.
In the last few years we have finally learned enough about the brain - we have finally gotten enough pieces of the puzzle - that we know exactly what part of the brain is involved in addiction. We know the nature of the defect. And we can link that defect in the brain to the frustrating, revolting, and criminal symptoms of addiction. For the first time in the history of medicine we have some hard and fast knowledge about what happens in the human brain when it becomes addicted to drugs. There are very good brain chemistry reasons for the things addicts do. We can explain everything about addiction without having to resort to causal variables like "bad choices" or "addict personality."
That information is very powerful. I believe that in our lifetimes, we will see everything that we do for addiction change. I believe that the people in treatment centers today are among the last generation of Americans who will be faced with the threat of a jail cell if they don't sober up on somebody else's timeframe.
Here is a brief summary of what we know in neuroscience about addiction:
1. Drugs work in the midbrain. This is not the part of the brain that handles morality, personality, parental input, sociality, or conscious choice. That processing takes place in the cerebral cortex. The midbrain is the amoral, limbic, reflexive, unconscious survival brain. As humans, we have a bias in favor of the cortex. We believe that the cortex should be able to overcome the libidinal impulses of the midbrain. Normally that's exactly what happens. But in addiction, a defect occurs at a level of brain processing far earlier than cortical processing. The mid-brain becomes stronger than the cortex.
2. While predisposing factors are important (especially genetic burden), the primary cause of addiction is stress. We all face stress, but not all of us experience it in the same way. The stress that changes the mid-brain is chronic, severe, and unmanaged. When the cortex does not resolve the stress, the mid-brain begins to interpret it as a threat to survival.
3. Persistent severe stress releases hormones such as Corticotripin Releasing Factor (CRF). CRF acts on genes for novelty-seeking and dopamine neurotransmission. People under severe stress increase their risk-taking behavior in the search for relief. At the same time, the brain's ability to perceive pleasure and reward - mediated through dopamine - becomes deranged. The patient becomes anhedonic. He or she is unable to derive normal pleasure from things that used to be pleasurable. Addiction is a stress-induced defect in the mid-brain's ability to properly perceive pleasure.
4. Drugs of abuse, whether uppers or downers, strong or weak, legal or illegal, have a common property: they cause the rapid release of dopamine in the mid-brain. If the stressed and anhedonic patient is exposed to this drug-induced surge of dopamine, the mid-brain will recognize a dramatic relief in the stress and tag the drug as a survival coping mechanism. At this point the line is crossed - from the normal, drug using, or drug-abusing brain to the drug-addicted brain. The drug is no longer just a drug. As far as the mid-brain is concerned, it is life itself. This process tagging of the drug is unconscious and reflexive. Conscious cortical processing is not involved.
5. Increases in stress (and CRF) trigger craving - a tool the midbrain uses to motivate the individual to seek the drug. For non-addicts, craving is simply an unusually strong desire. Even though the word is the same, it is critical to remember that craving for the addict is a constant, intrusive, involuntary obsession that will persist until the drug is ingested and the survival threat is relieved. Craving is true suffering. The tendency to underestimate the misery of craving is a major reason for the failure by healthcare professionals to effectively intervene in addictive behavior. Brain imaging is able to demonstrate a difference in the midbrain activity of the addict and non-addict during craving. (These scans also demonstrate a relative inactivity in the cortex.)
In light of this new understanding of addiction in neuroscience, the choice argument takes several hits:
Punishment will not work to coerce addicts into making the right choice because the drug is tagged at the level of survival. Nothing is higher than survival. And so nothing used as leverage - threat of loss of job, prison, loss of child custody - can compete with an existential threat. The midbrain give the addict the message that the way to take care of the children, keep the job, calm the probation officer is to first secure survival (by using the drug). When the craving really kicks in, punishment has no effect and coercion is useless.
Addiction is a disorder of pleasure. I believe all the moral loading of addiction stems from the fact that the patient with a disorder in his or her ability to correctly perceive pleasure is much more likely to be interpreted as being immoral before he or she is seen as being blind or deaf.
Under stress, the addict craves drugs. As far as the midbrain is concerned, the addict's moral sense is now a hindrance to securing survival. It is not that addicts don't have values; in the heat of that survival panic, the addict cannot draw upon his or her values to guide behavior. Values and behavior become progressively out of congruence, increasing stress. In order to consummate the craving, the addict's cortex will shut down. But that's not the same as badness. The absence of one thing (cortical function) cannot stand for the presence of another (criminal intent).
While it is true that a gun to the head can convince the addict to choose not to use drugs, the addict is still craving. The addict does not have the choice not to crave. If all you do is measure addiction by the behavior of the addict - using, not using - you miss the most important part of addiction: the patient's suffering. The choice argument falls into the trap of behavioral solipsism.
Just as a defect in the bone can be a fracture and a defect in the pancreas can lead to diabetes, a defect in the brain leads to changes in behavior. In attempting to separate behaviors (which are always choices) from symptoms (the result of a disease process), the choice argument ignores the findings of neurology. Defects in the brain can cause brain processes to falter. Free will is not all-or-nothing; it fluctuates under survival stress.
This information allows us to fit addiction to the disease model: the organ is the midbrain, the defect is a stress-induced hedonic (pleasure) dysregulation, and the symptoms are loss-of-control of drug use, craving, and persistent use of the drug despite negative consequences.
But something very important happened when I filled in the disease model for addiction: addicts became patients! And that means addicts earn the same rights as the patient with diabetes or a broken leg. If I cannot ethically punish the diabetic, I cannot ethically punish the addict. If I cannot effectively treat broken legs with incarceration, I cannot treat addiction with jail time.
Blurb - The clinically depressed lawyer:
Blurb - The two faces of depression
- Has little or no energy – getting out of bed and making it to the office is exhausting.
- Firmly resolves every morning to get to those cases and projects having deadlines but doesn’t.
- Knows phone calls have to be returned, but feels too enervated to do so.
- Sometimes spends hours at the office behind a closed door staring out the window or playing mindless computer games.
- Becomes angry or irritated easily and can’t seem to let it go.
- Experiences a pervasive sense of sadness; feels overwhelmed and immobilized by indecisiveness.
- Has diminished ability to concentrate, analyze, and synthesize information.
- Isolates socially and professionally – pulls away from close relationships.
- Is confused by inability to “snap out of it”; feels “weak” and berates self.
- Feels extremely or inappropriately guilty about not meeting occupational or personal responsibilities.
- Tries to feel better by using alcohol, sedatives, stimulants, or other substances (including food).
- Fantasizes about some kind of escape; has fleeting thoughts of suicide.
- Thinks about ways to end the pain – may begin a plan for suicide; sometimes acts on this plan.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) recognizes two main types of depression: major depressive disorder and dysthymia. Common to both forms of depression are the following:
- Depressed mood or irritability;
- Loss of pleasure in things that were once pleasurable;
- Insomnia or sleeping too much;
- Feeling sluggish or chronically fatigued;
- Changes in weight or appetite;
- Difficulties with memory, concentration, and decision-making;
- Feelings of worthlessness, inappropriate guilt, or hopelessness;
- Thinking of death, suicide, or making a suicide attempt.
- Although major depressive disorder is the more severe of the two in terms of debilitating symptoms, a disorder called dysthymia, characterized by similar but less severe symptoms, can cause significant distress or impairment in functioning because of its chronicity.
Episodes of major depressive disorder result in symptoms felt most of the day, nearly everyday, which can last anywhere from two weeks to many months. With dysthymia, the symptoms occur most of the day, more days than not, for a period of at least two years. Fortunately, both forms of depression are treatable. The two most common forms of treatment are antidepressant medications and psychological therapy. Numerous studies have shown that the most effective treatment for depression both in terms of relief from symptoms and in terms of long-term recovery is a combination of both forms of treatment.
All of us have difficult days and, sometimes, difficult weeks. Coping with life’s challenges is an unavoidable aspect of the human condition. However, if you find yourself experiencing several of the above symptoms for a prolonged period of time and find you don’t return to your previous level of functioning, don’t just hope things will get better. Call the Lawyers Assistance Program at 866.354.9334.
Blurb - Mania:
True mania is rare. As with depression, symptoms can range from mild (hypomania) to severe. A manic episode is characterized by a distinct period (noticeable to others) of at least one week of abnormal and persistently elevated, expansive, or irritable mood. In addition, the individual experiences several of the following:
- Inflated self-esteem or grandiosity, sometimes rising to the level of delusions (firmly held false beliefs);
- Restlessness, increased energy, and decreased need for sleep;
- Increased sociability;
- Racing thoughts or abrupt changes from one topic to another;
- High level of distractibility evidenced by the inability to screen out irrelevant stimuli;
- Marked increase in productivity and goal-directed activity;
- Use of poor judgment and excessive involvement in activities that have a high potential for painful consequences.
Bipolar disorder is diagnosed when an individual experiences at least one episode of mania. Often these episodes are followed by a return to normal functioning, but sometimes by a depressive episode.
Because individuals in the midst of a serious manic episode often lack insight into their behavior, friends and family often have to assist the person in getting properly assessed and treated, which may include hospitalization. The great majority of people with bipolar disorder can stabilize their mood swings by taking lithium or one of the mod-stabilizing anticonvulsants.
Dr. Kevin McCauley is a nationally recognized author and speaker on the subject of addiction medicine. He is a graduate of the Medical College of Pennsylvania and a former Naval Flight Surgeon. He is the Director of Medical Education at Sober living By The Sea Treatment Centers, a family of treatment centers in Southern California.
(This article was originally published in the Texas Bar Journal, Volume 67, Number 7, July, 2004)