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blwood

blwood

Barbara Wood is a licensed psychologist who practices in Bethesda, Maryland and specializes in the treatment of addictions and trauma. She is the author of two books that explain the impact of alcoholism on families and describe a path toward recovery for family members. Her first book, Children of Alcoholism: The Struggle for Self and Intimacy in Adult Life wa an alternate selection of the Psychotherapy and Social Sciences Review in 1987, and is identified in the current New York Review of Books Reader’s Catalog as one of the best books in print. The Journal of Contemporary Psychology described it as "compelling from intellectual and emotional standpoints" and said that it was "highly recommended to a general clinical readership.” Dr. Wood's second book, Raising Healthy Children in an Alcoholic Home" is a book written for parents in recovery from alcoholism, co-dependence, and other addictive problems. It helps them to become “therapeutic ” parents—active and compassionate listeners and sensitive guides to children in crisis. A reviewer from the Harvard Medical School described it as" an impressive contribution for everyone who grapples with this issue in their own lives as well as for practitioners helping their clients to become therapeutic parents.”

Dr. Wood also performs forensic evaluations and provides expert testimony in cases where plaintiffs or defendants have been affected by traumatic events and/or substance abuse disorders. Washingtonian Magazine has identified her as one of the top 123 psychotherapists in the Washington D.C. Metropolitan area. She lectures widely on her work.

Posted by on in Alcoholism

Where’s That Pink Cloud When You Need It? Understanding and Managing Post-Acute Withdrawal

pink cloud

When I was in training, more years ago than I care to count, my mentors warned me not to float away on the “pink cloud” likely to envelop patients in the early stages of  recovery from substance use disorders.  I was told  that   the initial rockiness of stopping alcohol and/or other psychoactive drugs is often followed by feelings of elation and  great expectations for the future.  In this irrationally exuberant state, recovery can feel essentially effortless and treatment activities may seem like an unnecessary  waste of  precious time.  The danger, of course, is that  abandoning these activities leaves one  defenseless when the pink cloud vaporizes.  At some point,  the hard work of sustaining sobriety in the face of the wreckage wrought by addiction  seems daunting if not overwhelming,  and those who are going it alone and who  fail to  anticipate the transience and fragility of the pink cloud experience often take it hard when their mood darkens,  and  are vulnerable to relapse.

Clinical experience has taught me that some people do pass through a pink cloud after negotiating the acute withdrawal phase of recovery,  but I’ve also learned that the  first year(s) of recovery  are a jarring and complex mix of  emotional highs and lows for most people.  And I’ve found that  some people never catch a  glimpse of the pink cloud in the early going.  They  just feel chronically down,  out, scared and  hopeless for months on end.

Today, the treatment and recovery communities offer  more detailed guidance to practitioners, recovering individuals and family members about the array of difficult and highly individual challenges people face during the first months and years of abstinence from alcohol and drugs. And they caution that it can take a good deal of time  for mood, thinking and behavior to improve and stabilize. Terms likes “Protracted Withdrawal” and  “Post-acute Withdrawal Syndrome (PAWS) are used to describe the psychological and physiological phenomena that can destabilize and derail people in recovery  for an extended period after drug and alcohol use end.

For example,  The Substance Abuse and Mental Health Service Administration (SAMSHA) warns thatlow feelings are to be expected for most people in early recovery and that protracted withdrawal may persist for “weeks, months, and sometimes years”.  In a 2010 Advisory SAMSHA explained that:

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Posted by on in Drug Addiction

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“The perception that mental illness and psychiatric symptomatology uniformly lead to aggression and violence is a

major source of stigma for the severely mentally ill.”

(Zhuo, Bradizza and Maisto, 2014)

PsychCentral reports that a study conducted under the auspices of the University of Buffalo found that substance abuse is a stronger predictor of violence than severe mental illness and that  treating the substance abuse disorders in  dually diagnosed patients illness can reduce their risk of future violence. The study appears in the current issue of the Journal of Substance Abuse Treatment (47 (2014) 353–361).

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Posted by on in Alcoholism
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Posted by on in Drug Addiction

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Struggles with anxiety and substance use problems often occur together, and as the authors of a new study point out, young adults seem especially prone to develop these disorders. Dixon, Stevens and Viana (2014) hoped to clarify the nature of the relationship between anxiety and substance abuse. They accomplished this by investigating whether anxiety sensitivity (AS) had an impact on the relationship between trait anxiety and substance use disorders. (Anxiety sensitivity is a term used to describe an individual’s level of fear about experiencing such anxiety-induced symptoms as increased heart rate, sweating, muscle tension and headaches. People with a great deal of anxiety sensitivity typically believe that such symptoms will lead to a terrible physical, social or mental outcome. On the other hand, trait anxiety refers to the characteristic amount of stress that an individual experiences.)

The researchers looked at AS in a large group of young adults (mean age 18.7 years) and did find that for those who had a great deal of anxiety sensitivity, use of illicit substances increased as trait anxiety  increased. This effect seemed most pronounced for those who feared an adverse cognitive or physical impact of their anxiety symptoms. The authors of the study suggested that “interventions should target AS reduction in anxiety-prone individuals to reduce and prevent substance abuse.”

What might these interventions look like?  Dr. Sharon Galor posted a thoughtful and concise description of anxiety sensitivity in which she described the typical approach to treating this problem.  She wrote that:

“During therapy sessions, clients receive psycho- education about anxiety sensitivity and its implications as well as learn to practice relaxation techniques. Furthermore, common CBT techniques of cognitive reconstruction and exposure are applied. Cognitive reconstruction aims to identify, challenge and reconstruct irrational and catastrophic thoughts that raise anxiety i.e. the belief in the high probability and a high catastrophic level of outcome that the physical symptoms can cause. Exposure helps clients to directly face the fear inducing and stressful stimuli, as well as to learn to eliminate safety behaviors.  Repeated exposure produces habituation that gradually reduces anxiety felt from the trigger. It has been found that the combination of these CBT techniques helps to treat anxiety sensitivity successfully.”

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Posted by on in Drug Addiction

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A study  published in the August issue of the journal Addiction and summarized on PsychCentral by Richard Taite looked at the impact of second-hand trauma on later substance abuse.  Researchers looked for  traumatic medical events in the families of  1.4 million children born in Sweden between 1984 and 1995 by examining hospital discharge records. They were able to identify  children who  had  a parent or  a sibling who had been diagnosed with cancer or an immediate family member who suffered an injury which resulted in permanent disability or who had  been a victim of assault or who had died. They then assigned each child a score of 0-4 depending on the amount of secondhand trauma s/he experienced. Then the  researchers turned to medical, legal and pharmacy records to see which of these children  were  diagnosed with substance abuse problems when they reached their 20’s.

The researchers took care to control for other factors that might promote  substance use, such as socioeconomic status, drug use by family members, psychological wellbeing and parents’ educational level. What they found was striking: Children who experienced even one of the four secondhand traumas under study had twice the risk of later drug abuse.  Children who experienced the death of a parent were at greatest risk.  Having a parent or sibling who was the  victim of violent assault was the second most powerful factor. The PsychCentral report points out that “substance abuse was even higher in children whose siblings had experienced trauma than it was in children whose parents had been traumatized”.  The authors of the study had high confidence in their findings since they were able to conduct annual sampling of a national population over a period 16 years and because they had access to multiple data sources in order to identify cases of substance use disorders.

Of course, previous studies have noted the  impact of adverse childhood events (ACEs) on childrens’ emotional development.  As I explained in another post  researchers have found that  people who endure a great deal of toxic stress spend much of their lives in fight, flight or fright.  As the ACEs Too High Newsletter explained in October 2012:

“(These children) respond to the world as a place of constant danger. With their brains overloaded with stress hormones and unable to function appropriately, they can’t focus on learning. They fall behind in school or fail to develop healthy relationships with peers or create problems with teachers and principals because they are unable to trust adults. Some kids do all three. With despair, guilt and frustration pecking away at their psyches, they often find solace in food, alcohol, tobacco, methamphetamines, inappropriate sex, high-risk sports, and/or work and over-achievement. They don’t regard these coping methods as problems. Consciously or unconsciously, they use them as solutions to escape from depression, anxiety, anger, fear and shame. (http://goo.gl/VEl0ez)  (Please continue reading)

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Posted by on in Drug Addiction

Increase*

“But the thing about remembering is that you don’t forget.”

― Tim O’Brien, The Things They Carried

While addiction is viewed in most corners of the treatment and recovery communities (including the American Society of Addiction Medicine)  as a chronic and relapsing brain disease,  as I have pointed out in previous posts, this is usually a  difficult idea for families and friend of addicts to accept.  It is particularly hard when relapse occurs after a long period of sobriety.  Loved ones wonder how   a loss of control can  occur when life has been normal and predictable   for an extended period of time.  It seems as though the addict made a terrible choice, with no thought at all about the impact such an eventful decision would have on everyone else.  Is that the case?   Yet another complicated question, but it is important to understand that, even after extended periods of sobriety and stability,  brain structure and brain chemistry still matter. (Please continue reading)

Animal studies and imaging studies of the human brain have taught us that all natural reinforcerssuch as food and sex, and all psychoactive drugs  increase the production of dopamine in the nucleus accumbens, which is a structure in the basal forebrain sometimes referred to as the brain’s“pleasure center”.  When this part of the brain receives  a massive  hit of dopamine from the ingestion of a drug, the user feels high, and the experience of this huge reward constitutes  a powerful learning experience. Repeated experiences of intense reward eventually make other parts of life far less interesting and important to the brain than the pursuit and use of addictive substances and activities. Moreover  and very importantly, the flow of dopamine to the nucleus accumbens  increases not only when the addict is using a drug, but when the addict’s brain anticipates receiving it because it is coming into contact with cues that are associated with use.  This is why 12-step programs remind people in recovery to avoid “slippery people places and things”. Those slippery entities are paving the way to relapse by priming the brain with a dopamine rush.

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Posted by on in Co-dependency

Increase

Psychotherapy is a biological treatment, a brain therapy. It produces lasting, detectable physical changes in our brain, much as learning does.” –Dr.  Eric Kandel (Professor Columbia University and recipient, 2000 Nobel Prize in Physiology or Medicine)

This is the third in a series of articles about children of alcoholics who remain trapped in an alcoholic lifestyle as adults. Parts 1 and 2 explained that children who grow up in addicted families are likely to reproduce harmful features of their families of origin in their adult lives. When they involve themselves with destructive partners and activities that evoke feelings and patterns of behavior similar to those they witnessed and experienced as children, their lives become unmanageable. I examined the neurological and psychological underpinnings   of this painful “infinite loop” of chaos and disappointment that captures and captivates many adult children. In brief, neurological changes caused by traumatic experiences in childhood remodel the brain, producing chronic states of emotional distress that are difficult to soothe.  Moreover, parental neglect and abuse depress self-esteem and leave children feeling valueless, mistrustful and confused about how to construct rewarding relationships.

This week I’ll begin a discussion of ”exit strategies” that adult children from addicted families can employ to escape the infinite loop. These strategies hinge on exciting research aboutneuroplasticity that are a result of  advances in the field of   functional neuroimaging, including single photon emission CT (SPECT), positron emission tomography (PET), and functional MRI. Mental health theorists and clinicians once believed that changes in the brain occur only   during early childhood. Now that we can obtain actual pictures of the structure and activity of the brain, we understand that it continues to respond, throughout life, to events and interactions with others, by creating new neural pathways and altering existing ones.  So, while adverse events in childhood severely roil emotions and disrupt perception and behavior by changing the brain, we know now that there are activities people can undertake, even in adulthood, to normalize the brain. (Please continue reading)

It is very important for adults who were highly stressed and traumatized in addicted families to identify activities and experiences that facilitate neural growth and positive brain change, because, as last week’s post highlighted, anxiety and depression that stem from childhood trauma cause ongoing damage to brain circuitry. That is, there is the potential for “negative plasticity” in adult life, as well as positive brain change. And, as Dr. Robert Sapolsky, a neurobiologist at Stanford pointed out, “Early-life stress and the scar tissue that it leaves, with every passing bit of aging, gets harder and harder to reverse. You’re never out of luck in terms of interventions, but the longer you wait, the more work you’ve got on your hands.”

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Posted by on in Co-dependency

 

Increase“Trauma is to mental health as smoking is to cancer.”-Dr. Steven Sharfstein, Past President, American Psychiatric Association

Last week, I posted the first in a series of articles about children of alcoholics who remain trapped in an alcoholic lifestyle as adults. I examined the neurological underpinnings of a compulsive and  “infinite loop” of ongoing and deeply painful  involvements with partners and activities that reproduce the chaos of the addicted family of origin and endanger physical, psychological, and spiritual well-being. But while psychologists are increasingly interested in the neurology of compulsive behavior, we tend to believe that it stems from a variety of causes.  Most  of us look for“biopsychosocial” explanations for behavior, including the  compulsion to repeat.  When treating adult children who are recapitulating a  painful past,   one psychosocial angle we typically want to explore is the quality of parent-child relationships in a patient’s family of origin. The nature of parent-child interactions is important for several reasons.  In this post, I will discuss howrelationships with caregivers either perpetuate an adverse infinite loop, or inoculate a child against an alcoholic lifestyle by shaping self-esteem and expectations of others, and by affecting a child’s ability to regulate intense feelings and to process and heal from difficult events.

Nearly everyone understands that our earliest  relationships affect us all our lives because theyprovide a model for us to follow as we engage with people outside the family. From the first moments of life, we form impressions of the world through interactions with our caregivers. Over time these impressions evolve and  are stored in the mind as mental representations of the self and  the other. Characteristic exchanges between self and others are also stored. When we internalizenurturing figures along with a representation of ourselves as loveable, it gives us a huge head start with respect to healthy adult adjustment.  It stands us in particularly good stead  as we strive to form healthy relationships with people outside our families.  The  support, encouragement and unconditional regard we receive from our parents forms the basis for good self-esteem and instills optimism about the world as a welcoming place.  If our parents cherish and love us, we tend to feel that we should be, and are likely to be valued and loved by others. In addition, our positive mental representations of our parents can be recalled and recruited, when no one else is around, to establish a sense of calm and hopefulness when troubling events occur. The ability to self-soothe is a critical resource in life, and it is a source of protection against the abuse of substances and activities that we might otherwise turn to in order to numb emotional pain. (Please continue reading.)

It is hard for parents who are preoccupied with alcohol and drugs, and stressful conflicts about alcohol and drugs, to be reliable sources of support and love for children.  Children in addicted families are more likely to be abused, exploited and neglected.  As a result, their mental representations of themselves and others, and their expectations about the type of treatment they can expect from others are pessimistic. Even if they can’t quite verbalize this, and don’t consciously think about it, they view others as untrustworthy and potentially dangerous.  And they view themselves as unlovable and unworthy of respect. Children from addicted families are more likely to accept insensitive and abusive treatment from other life partners because this is what they feel they deserve, and because it seems “normal” to them—it fits with the information they’ve stored in their minds about how relationships are supposed to go. If they grew up feeling responsible for their parents’ pain, as so many children in addicted families do, they may also feel compelled to rescue and reform partners who are desperate and even abusive.

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Posted by on in Co-dependency

Increase

 

The term “infinite loop” comes from the field of computer science and refers to a programming error that leads to the perpetual and unsuccessful recapitulation of an algorithm, or problem-solving procedure. In my book Adult Children of Alcoholics: The Struggle for Self and intimacy in Adult Life, I used this concept as a metaphor for the way in which many adult children seem irresistibly drawn to an “alcoholic lifestyle”.  The alcoholic lifestyle can include compulsive drinking and drugging, ongoing destructive involvements with addicted or enabling parents, and the acquisition of new life partners who reprise important psychic themes of the childhood home, including instability, exploitation, dishonesty, and betrayal.

In recent posts, I’ve talked about genetics, trauma,  and substance-related  changes in the brain as the “usual suspects” behind many addictive problems.  They are also frequently the culprits when adult children–even those who avoid substance abuse and dependence–remain ensnared in the destructive and painful relational dynamics they experienced as children. It is well-known that genetics affect temperament as well as risk for mental illness and substance abuse and addiction.  But environmental factors such as stress and trauma are also powerful factors that influence the development and maintenance of an alcoholic lifestyle.  This is the first in a series of posts aimed at helping ACOA’s with an alcoholic lifestyle  to exit their infinite loop, and it explains how trauma-related changes to the brain predispose them to become mired in it.

It is important to know that many adults who grew up with addicted and  codependent parents, whether or not they abuse substances themselves,   manifest brain anomalies that can predispose them to a variety of psychological problems, such as  depression, anxiety, post-traumatic stress and compulsive involvement with substances, activities and destructive partners. These changes occur as a result  of chronic and severe levels of stress that so often occur in families where parents are preoccupied and propelled by the disease of addiction. The neurological impact of  the physical and verbal abuse and neglect that are common in alcoholic families can be seen  when imaging studies of the brain are performed, and they occur in some of the same  areas of the brain that are affected by drug and alcohol abuse.  For a good discussion of how adverse childhood events (ACEs) affect the brain, see this article: /healthland.time.com/2012/02/15/how-child-abuse-primes-the-brain-for-future-mental-illness/

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Posted by on in Alcoholism

Increase

I didn’t really expect the Godfather to figure prominently in any of my blog posts, but I thought that paraphrasing Michael Corleone  here might be a good way to start a discussion about addiction as a disease vs. addiction as a choice.  It is my experience that family members (and addicts themselves) still struggle greatly with the feeling that  excessive drug and alcohol use are essentially moral problems.  So I think it’s always important, in treatment, to look at  the mounting evidence that addiction to substances, as well as certain compulsive activities,  actually change the brain in ways that undermine the ability to make  healthy choices. Learning about the neurological impact of addiction can help everyone affected by it to find compassion for their struggle with a devastating illness.

There is an ever-increasing amount of data, including results  from neuroimaging studies, that support the definition of addiction held by the American Society of Addiction Medicine, which is that,”Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry”.  Today we understand for example, how substance abuse and even activities like gambling, affect the action of dopamine in the brain.  Dopamine is the substance released by  neurons in the reward centers of the brain whenever we do something pleasurable.  The brain has evolved to reward us for doing things useful to the survival of the species–such as  eating and procreating, and a flood of dopamine is the reward we get for participating in these activities.  However, drugs of abuse, gambling, binge-eating  and even excessive internet use can cause the reward centers of the brain to release far more dopamine than we’re used to getting, and if this  happens on a regular basis, the brain remodels itself to defend against the flood of  dopamine it’s receiving.  It begins to produce less of the stuff on its own and it becomes less sensitive to  it as well.  As addicts develop this “tolerance” to their drug or activity of choice, they need more and more of it to achieve the pleasure they’re used to getting from their habit, and the brain’s reluctance to produce dopamine on its own means that they also feel less pleasure from doing the things that used to make them happy. Consequently, drug rewards eventually become more important to addicts than anything else. I believe addicts when they tell me that their need to get high  actually makes them stop thinking about other things, including food and including people, that are otherwise important to them.  I believe them because what they’re saying is completely consistent with changes that technology now allows us to  see in the reward centers of  addicts’ brains.

Other parts of addicts’ brains change too.   In addition to this malfunction of the reward circuitry, there is a weakening of the executive control mechanisms in the pre-frontal cortex.  This is the  part of the brain that  helps people to regulate emotions and impulsive behavior.  So heavy drinking (including intermittent binge drinking) undermines the very functions that are needed to make healthy decisions about future drinking. Moreover,   the brain isn’t so quick to heal once someone abstains from alcohol and other drug use. A recent study of current and former cocaine users for example,  found that even after 4 years of abstinence, there were abnormalities in some brain regions involved with reward processing.

But family members , friends and romantic partners can’t see a broken brain the way they can see a broken leg, and so the addict’s destructive behaviors  feel very  personal to them.  It really  hurts to come in a distant second, time and time again, to opportunities to drink or drug. It hurts to be lied to,  stolen from and blamed for everything that goes wrong in a relationship.  These and other terrible betrayals actually cause a cascade of stress-related changes in the brains of people who love addicts.  Or, to state it a little less clinically, the addict breaks their hearts.

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