In its latest installment, Almost Addicted: Is My (or My Loved One’s) Drug Use a Problem?, primary author J. Welsey Boyd and Eric Metcalf delve into the sensitive time when one’s drug use has become troubling, but has not yet reached the diagnostic criteria for addiction.

Is all drug use bad? How do we know if we need help and when or how to seek it? What can we make of the fact that two states recently legalized marijuana? Boyd sets out to draw a road map for these tough questions for both the substance user and his/her loved ones. A medical doctor and Ph.D., he uses his impressive list of credentials — including faculty psychiatrist at Harvard, staff psychiatrist at Boston Children’s Hospital Adolescent Substance Abuse Program, and co-founder/director of the Human Rights and Asylum Clinic. The end result is a useful guide — but with a few flaws.

Because the “almost” concept may seem foreign to someone who hasn’t read one of the previous books in the series, Boyd spends time going over exactly what this means. He writes that to qualify as an almost addiction, a behavior must fall outside of what is considered normal, but, at the same time, not meet criteria for a DSM diagnosis; that it’s causing identifiable problems; that it might progress to a full-blown condition or, at least, cause substantial suffering; that an intervention should be able to help; and that stopping the behavior will improve quality of life. The benefit of identifying drug-using behavior as “almost addicted,” he writes, is that it offers an opportunity to stop and turn your life around before a problem progresses into full addiction, which is much more difficult to treat. He compares the value of this early intervention to that of spotting glucose intolerance and pre-hypertension before they turn into diabetes, heart attack, or stroke.

There is a case study in each chapter to help reader determine if a drug use is an “almost addiction,” as well as to illustrate the points raised in each section in a relatable, anecdotal way. The book gives an overview of the classes of drugs and their effects, as well as the definition of addiction and how it differs from abuse. Later, it explores possible roots of addiction, including the role of one’s family history, a drug’s effects and initial appeal during a hard time, and self-treatment for a mental health issue.

One section is geared toward family members and friends who are concerned about another’s drug use. Boyd notes that almost addiction is especially hard to see in successful people, as the effects are not nearly as obvious as those of full-blown addiction. Even health professionals miss it a lot between their time constraints and the sensitivity of the issue, he writes. He also stressed that there are things you can and can’t do to help: for instance, you can cease enabling the behavior, but you can’t force a person to seek treatment.

Next, Boyd presents materials and resources aimed directly at the almost-addicted reader, including information on helping oneself and figuring out when it’s time to find professional help (there’s a helpful, if simplistic, chart on page 223). Boyd talks about the non-physical aspects of drug use, such as how it’s woven into a daily routine, and prepares the reader for what the recovery process could look like, and what to do afterward to continue living a drug-free life.

While Almost Addicted is, overall, a valuable addition to the literature on drug use and abuse, it does have a few issues. For starters, it is at once meant for an audience of almost-addicted readers and for an audience of concerned loved ones. Granted, Boyd does try to divide guidelines into separate sections, but it’s still difficult to distinguish the approach he intends for each group.

Boyd also attempts to mention and include all drugs, yet concentrates overwhelmingly on marijuana. Pot is becoming more and more accepted, though, and instead of scapegoating it as the source of all drug problems (which seems simplistic at best), I wondered why Boyd didn’t focus more on prescription drugs—especially since this is the fastest growing area of abuse and addiction.

Finally, there’s a bit of a problem in the last part of the book, where Boyd recommends seeing a primary care doctor to begin the recovery process: The suggestion comes after an entire section on how primary care practitioners don’t have time, motivation, or expertise to notice, let alone care about, the almost-addicted population.

Boyd himself identifies one problem with his “almost addicted” framework: “I wish I could offer some completely black and white advice about using drugs that would be applicable for everyone, but doing so would probably be intellectually dishonest,” he writes. “You’ll have to decide where to draw the line on what kind of presence that drugs — legal or not — can have in your life.”

Regardless of these issues, Almost Addicted is still a well-researched and cited work with information and advice for those who are verging on succumbing to addiction. The emphasis on early intervention, before one experiences traumatic consequences, is not only valid, but an essential concept that will hopefully push our notion of drug treatment forward.

Almost Addicted: Is My (or My Loved One’s) Drug Use a Problem?
Hazeldon Publishing (Harvard Health Publications), 2012
Paperback, 264 pages
$14.95

Dean, an English lawyer turned psychologist, is the founder and proprietor of the website PsyBlog, which he’s maintained steadily since 2004. This is his first book, and one suspects it won’t be his last. He effects a direct, bloggerly style, mercifully unclouded by the stultified prose plaguing many psychology authors whose backgrounds are different from Dean’s (i.e., career academics). Nevertheless, the book is carefully — even densely — footnoted with a trove of research studies, general readership psychology books, and online resources.

Professional psychologists likely won’t find a great deal of new material in Making Habits, Breaking Habits, and neither will voracious lay readers who’ve digested the likes of Dan Ariely, Daniel Kahneman, Timothy Wilson, James Pennebaker, Martin Seligman, and others of their ilk. Yet Dean’s book remains worth a look for these readers, if only to sift through the bibliography’s many nuggets and to read Dean’s thoughtful chapter on treating online habits.

Dean divides his book into three main sections: “The Anatomy of a Habit,” “Everyday Habits,” and “Habit Change.” He explains what habits are, how they show up in daily life, and how the average individual can set about changing, forming, or ceasing various personal habits ranging from the benign to the existential.

Habits in the popular imagination are most closely associated with either virtuous or vicious activities. On the vicious side, we think of deleterious behaviors like excessive alcohol consumption, cigarette smoking, and doughnut eating. On the virtuous end of the ledger we find beneficial routines like regular exercise, charitable donations, and daily meditation. Yet habits are inherently neither good nor bad, explains Dean. They are merely behaviors repeated with great frequency and regularity and most often performed with little to no conscious intention.

Whether good, bad, or indifferent, habits are an incredibly powerful and pervasive psychological phenomenon.

“In the war of habit versus intention,” Dean writes, “the fight is massively fixed.” Citing a large meta study by Wendy Wood and J.A. Oulette, Dean illustrates that regularly performed habits — from ordering coffee to checking email — involve little or no conscious intention. “It was only when [habitual] behaviors were performed once or twice a year — like getting a flu shot — that intentions took over from autopilot.”

Which is not to say that habits do not follow intentions, Dean tells us.

“Much of the time even our strong habits follow our intentions. We are mostly doing what we intend to do, even though it’s happening automatically,” he writes. “When washing our face each day, picking up an espresso on the way to work, or cleaning our glasses, it’s because at some point in the past we consciously decided (or someone decided for us) that these things were worthwhile activities, so we kept repeating them until they were automatic.”

If habits are automatic executions of intentions consciously set in the past, this means we can all end up performing behaviors that are misaligned with our long-term goals. For example, your expensive pre-work espresso stop may have made sense when your spouse was still earning an income, but does the habit serve you now that you’re a one-income household with a third mouth to feed? We know we should economize in this situation, and yet most of us will likely remain as profligately caffeinated as ever.

“What does this mean for our attempts to control ourselves and our chances of making changes?” Dean asks. He organizes the last two thirds of his book around answering this question. (Spoiler alert: consider re-routing your commute away from Starbucks rather than relying on a shaky mixture of willpower and good intentions for baby’s tuition fund.)   

In the book’s second section, Dean begins by elucidating how habits exert their omnipresent influence in daily life—from routine social interactions, to work, to travel, eating, and shopping. He then shifts to the darker side of habits, examining personal habit pathology as reflected specifically in obsessive-compulsive disorder and depression. Later, Dean zooms out to examine habit pathologies at the societal level relating to plane-crash prevention, seatbelt usage, and environmental protection.

Dean wraps up the second section with a strong survey of online habits, incorporating the latest psychological studies into an analysis of web multi-tasking, email, and Twitter. Synthesizing a wide range of research, Dean examines online behavior through the lens of Skinnerian pleasure reinforcement and through Csíkszentmihályi’s famous concept of “flow.”

Are you one of those people who just doesn’t understand Twitter? Perhaps the concept of variable interval reinforcement can shed some light:

As with email, on Twitter, an interesting tweet could arrive at any moment, but you don’t know when. You could get a batch of interesting tweets one after the other or nothing for a few hours. Because the intervals vary, users get used to the frustration of not getting anything interesting for a while—but they keep checking anyway.

(If you’re reading this article online — perhaps at the office — do you truly understand how you arrived at this page? You might do well to order Making Habits, Breaking Habits before you get back to what you were doing when your Twitter feed announced a new book review on Psych Central.)

The book’s final section moves through a survey of practical techniques for forming beneficial new habits and for breaking undesired old ones. The latter activity turns out to be a difficult proposition indeed. With considerably less grace than old soldiers, “old habits really do die hard,” writes Dean. “Even after habits have apparently faded away through lack of repetition, they still lie in wait to be reactivated.”

The reason cigarette smoking is so addictive, Dean says, is that it combines two cast-iron habits: daily contextual behaviors (like coffee drinking) plus the biological imperative for regular nicotine infusion. That’s the bad news. The good news is that “the best way to break a bad habit is to pair it with a new one.” For example, you pair your biological nicotine craving with the new behavior of chewing gum instead of lighting a Marlboro.

Dean concludes with a guide to practical habit formation and de-formation techniques relating to health, creativity, and happiness. He examines smoking, exercise, art, and work. As in the rest of the book, Dean’s academic overview of habit changing techniques and mechanisms is solid and substantial, though I wish he had provided more personal or third-person examples. While Making Habits, Breaking Habits is more scientifically grounded and less prone to overly tidy conclusions than Charles Duhigg’s 2012 bestseller The Power of Habit, Dean’s book lacks the compelling narrative force that the journalist Duhigg so effectively imposes on the material.

In addition to craving more specific and involved anecdotes, I found myself wishing Dean had sharpened and expanded upon his practical advice, which at times became repetitive. The book likewise could have benefitted from the addition of some interactive, “workbook”-like material. An attractive feature of recent heavyweight works like Kahneman’s Thinking Fast and Slow and Seligman’s Flourish lies in the frequent opportunities afforded the reader to test and measure herself with a variety of simple but highly informative psychological diagnostic tools.

Ironically, these weaknesses derive from one of Dean’s major strengths: namely, modesty. Dean neither evangelizes for a favored theory nor beats the drum for his own proprietary “habit cure.” Commendably, he merely sets the table for a reader to make his own decisions and implement his own modification regime. For my part, I took away a newfound enthusiasm for some long-forgotten CBT techniques and a resolution to avoid sugar and Twitter in the new year. Unfortunately, in so doing, I fell into the classic pitfall of over-general intentions that Dean warns about near the end of his chapter on healthy habits:

The true aim of personal change is to turn our minds away from miracle cures and quick fixes, and adopt a long-term strategy. Habit change isn’t a sprint; it’s a marathon. The right mindset is to wake up tomorrow almost exactly the same person, except for one small change—a small change that you can replicate every day until you don’t notice it anymore, at which point it’s time to plan another small change….

Fair enough. When I feel like desert at night, I’ll brush my teeth instead. My nasty Twitter habit will just have to linger on until I’m svelte and cavity-free.

Making Habits, Breaking Habits: Why We Do Things, Why We Don’t, and How to Make Any Change Stick
Da Capo Lifelong Books, January, 2013
Hardcover, 272 pages
$26

Enabling is “removing the natural consequences to the addict of his or her behavior.” Professionals warn against enabling because evidence has shown that an addict experiencing the damaging consequences of his addiction on his life has the most powerful incentive to change. Often this is when the addict “hits bottom” – a term commonly referred to in Alcoholics Anonymous.

Codependents often feel compelled to solve other people’s problems. If they’re involved with addicts, particularly drug addicts, they usually end up taking on the irresponsible addict’s responsibilities.

Their behavior starts as a well-intentioned desire to help, but in later stages of addiction, they act out of desperation. The family dynamics become skewed, so that the sober partner increasingly over-functions and the addict increasingly under-functions.

This builds resentment on both sides, along with the addict’s expectation that the over-functioning partner will continue to make things right when the addict doesn’t meet his or her responsibilities.

The Al-Anon program suggests that you don’t do for the alcoholic what he or she is capable of doing. Yet, codependents feel guilty not helping someone, even when the person caused the situation and is capable of finding a solution. It’s even harder for codependents to say no to requests for help. The pressure to enable can be intense, particularly coming from suffering or angry addicts, who generally use manipulation to get their needs met.

Examples of enabling include: giving money to an addict, gambler, or debtor; repairing common property the addict broke; lying to the addict’s employer to cover up absenteeism; fulfilling the addict’s commitments to others; screening phone calls and making excuses for the addict; or bailing him or her out of jail.

How to Stop the Enabling Behavior

Often addicts aren’t aware of their actions when intoxicated. They may have blackouts.

It’s important to leave the evidence intact, so they see how their drug use is affecting their lives. Consequently, you shouldn’t clean up vomit, wash soiled linens, or move a passed-out addict into bed. This might sound cruel, but remember that the addict caused the problem. Because the addict is under the influence of an addiction, accusations, nagging, and blame are not only futile, but unkind. All these inactions should be carried out in a matter-of-fact manner.

Stopping enabling isn’t easy. Nor is it for the faint of heart. Aside from likely pushback and possible retaliation, you may also fear the consequences of doing nothing. For instance, you may fear your husband will lose his job. Yet, losing a job is the greatest incentive to seeking sobriety. You may be afraid the addict may have an auto accident, or worse, die or commit suicide. Knowing a son is in jail is sometimes cold comfort to the mother who worries he may die on the streets. On the other hand, one recovered suicidal alcoholic said he wouldn’t be alive if his wife had rescued him one more time.

You may have to weigh the consequences of experiencing short-term pain vs. long-term misery, which postpones the addict’s reckoning with his or her own behavior. It requires great faith and courage not to enable without knowing the outcome. Although enabling can prolong the addiction, not all addicts recover, even despite counseling and going to many rehabs. This is why the 12 Steps are a spiritual program. They begin with the recognition that you’re powerless over the addict. The desire for sobriety must come from him or her.

To avoid unnecessarily suffering the consequences of an addict’s drug use, it’s vital you begin to reclaim your sense of autonomy and take steps wherever possible not to allow the addict’s drug use to put you in jeopardy. Allowing the addict to drive you or your child while under the influence is life-threatening. On the other hand, taking on the role of designated driver gives the addict free license to use or drink. The spouse might refuse that enabling role by taking a separate car. If the addict is charged with DUI, it might be a wake-up call.

Always have a Plan B to cope with addicts’ unreliability; otherwise, you end up feeling like a victim. Sometimes, Plan B might be going to a 12-Step meeting or just staying home and finishing a novel. The important thing is that it’s a conscious choice, so that you don’t feel manipulated or victimized.

It’s a good idea to follow through with plans, whether it’s keeping counseling appointments or social engagements that the addict refuses to attend at the last minute. This precludes the addict’s attempt to manipulate the family.

Having some recovery under his belt, one husband resolved to remain on vacation with the children when his alcoholic wife suddenly decided she wanted to return home. He later remarked, “It was the first time in years that my mind was free of obsessing about her.”

In another situation, an alcoholic husband picked a fight an hour before guests were arriving for dinner. He threatened to leave unless they were uninvited. When his wife refused, he stormed out and hid in the bushes, while his wife enjoyed herself. Feeling ashamed, he never repeated that ploy.

Enabling has implications for all codependents, because they generally sacrifice themselves to accommodate others’ needs, solve others’ problems, and assume more than their share of responsibility at work and in relationships.

Common examples are a woman looking for a job for her boyfriend, a man paying his girlfriend’s rent, or a parent meeting his child’s responsibilities that the child can do or should be doing. Learning to be assertive and set boundaries are often the first steps in stopping enabling. See my book How to Speak Your Mind – Become Assertive and Set Limits.

Email me if you’d like to hear an interview I gave on enabling.

Verbal abuse takes many forms: from loud rants to quiet comments; from obvious put-downs to not-so-obvious remarks that undermine the partner. What all the methods have in common is the need to control, to be superior, to avoid taking personal responsibility, and to mask or deny failures.

The myth in Hank’s and Mary’s relationship is that he is much, much smarter than she is. She does admire him, but not as much as he admires himself. He trumps anything she says with a stronger, maybe louder opinion. He calls her ideas naïve or ill-informed or even idiotic. Mary thinks he may be right. Since marrying Hank 3 years ago, her self-confidence has plummeted.

Jake, on the other hand, hides his need for control in his relationship with Marilyn under sarcasm, jokes and puns. “Why,” he says, “doesn’t Marilyn understand I’m just joking?” Why? Because she is the object of those sarcastic remarks, “jokes” and puns. He both publicly and privately keeps her off-balance by joking about her insights, her goals, and the things she cares most about. She has come to question her judgment about her ideas and about him. Lots of people think he’s funny. Maybe, she thinks, he doesn’t mean it. Maybe, she tells herself, she needs to have a better sense of humor.

Frank can’t stand to be seen as responsible for any failure. When he makes a mistake, his mantra is “I may be wrong but you are wrong-er.” If his wife says he has hurt her feelings, he claims not to remember having said what he said or having done what he did. He tells her she is “too sensitive.” He whines about being a scapegoat for other people’s problems. He doesn’t seem to get that he is the perpetrator, not the victim.

Al isn’t subtle. His wife and kids never know what to expect when he comes home. Will loving, caring Al be at the door with treats for the kids and something nice for his wife? Or will the Al who flies into rages, who threatens them with physical abuse and swears and calls them names show up? The whole household walks on eggshells. Even when loving-Al is around, things can change in an instant if he is the least bit frustrated. Last week when his 5-year-old spilled milk at the dinner table, he yelled at her for an hour. When his wife tried to intervene, he backhanded her. Everyone got real quiet. Then – the storm blew over and Al left for the rest of the evening.

If you recognize yourself in any of the above scenarios, you are being verbally abused. Make no mistake: Although verbal abuse doesn’t leave visible scars, it does do damage. The victims’ self-esteem is eroded. Children who watch one parent being put down and diminished by the other develop a skewed and sad view of how relationships are supposed to be.

6 Signs You Are Being Verbally Abused

1. Like Mary, you feel you just can’t win. No matter how carefully or kindly you try to work out a problem, your partner says things that make you feel like you’re in the wrong.
2. Your self-esteem and self-confidence are shot. Your partner isn’t your greatest fan but your greatest critic. He often tells you that his comments are “for your own good.”
3. When you say he has hurt your feelings your partner, like Frank in the scene above, tells you that you are too sensitive. When you point out that he has said something inappropriate or hurtful, he accuses you of trying to make him look bad. You notice that he rarely takes responsibility for his part of a problem. Somehow he manages to convince himself and even you that anything that goes wrong is your fault.
4. You often are the brunt of jokes that make you feel bad. The guy who is fun and fun-loving outside the family unleashes a more vicious or undermining humor inside. Other people don’t believe you that the guy they know is so different from what you experience. Like Marilyn, you find yourself constantly questioning yourself.
5. You have to walk on eggshells at home. Your home isn’t a sanctuary for you and your kids. It is the place where you are most afraid and embarrassed. You and the kids stay away as much as you can. When you are there with your partner, you all do everything you can to make sure nothing happens that could set him off.
6. If you’re not very careful, the verbal abuse escalates to physical altercations. Even if you are very careful, what starts with words can end up with physical aggression toward you or destroying things, especially things you value.

Whoever made up that rhyme about “sticks and stones will break my bones but names will never hurt me” was just plain wrong! Words do hurt. They can break a person on the inside just as surely as a whack with a stick bruises the outside. People who are subjected to verbal abuse suffer. People who are subjected to it over time can get so used to it that they lose their sense of themselves as people worth loving. If you see yourself in any of these stories, know you are not alone. There are things you can do. Part II of this article will discuss them.

Codependency underlies all addictions. The core symptom of “dependency” manifests as reliance on a person, substance, or process (i.e, activity, such as gambling or sex addiction). Instead of having a healthy relationship with yourself, you make something or someone else more important. Over time, your thoughts, feelings, and actions revolve around that other person, activity, or substance, and you increasingly abandon your relationship with yourself.

Recovery entails a 180-degree reversal of this pattern in order to reconnect with, honor, and act from your core self. Healing develops the following characteristics:

• Authenticity
• Autonomy
• Capability of being intimate
• Integrated and congruent values, thoughts, feelings, and actions

Change is not easy. It takes time and involves the following four steps:

1. Abstinence. Abstinence or sobriety is necessary to recover from codependency. The goal is to bring your attention back to yourself, to have an internal, rather than external, “locus of control.” This means that your actions are primarily motivated by yourvalues, needs, and feelings, not someone else’s. You learn to meet those needs in healthy ways.Perfect abstinence or sobriety isn’t necessary for progress, and it’s impossible with respect to codependency with people. You need and depend upon others and therefore give and compromise in relationships. Instead of abstinence, you learn to detach and not control, people-please, or obsess about others. You become more self-directed and autonomous.

   If you’re involved with an abuser or addict or grew up as the child of one, you may be afraid to displease your partner, and it can require great courage to break that pattern of conceding our power to someone else.

2. Awareness.It’s said that denial is the hallmark of addiction. This is true whether you’re an alcoholic or in love with one. Not only do codependents deny their own addiction – whether to a drug, activity, or person – they deny their feelings, and especially their needs, particularly emotional needs for nurturing and real intimacy.You may have grown up in a family where you weren’t nurtured, your opinions and feelings weren’t respected, and your emotional needs weren’t adequately met. Over time, rather than risk rejection or criticism, you learned to ignore your needs and feelings and believed that you were wrong. Some decided to become self-sufficient or find comfort in sex, food, drugs, or work.

   All this leads to low self-esteem. To reverse these destructive habits, you first must become aware of them. The most damaging obstacle to self-esteem is negative self-talk. Most people aren’t aware of their internal voices that push and criticize them — their “Pusher,” “Perfectionist,” and “Critic.”¹

3. Acceptance.Healing essentially involves self-acceptance. This is not only a step, but a life-long journey. People come to therapy to change themselves, not realizing that the work is about accepting themselves. Ironically, before you can change, you have to accept the situation. As they say, “What you resist, persists.”In recovery, more about yourself is revealed that requires acceptance, and life itself presents limitations and losses to accept. This is maturity. Accepting reality opens the doors of possibility. Change then happens. New ideas and energy emerge that previously stagnated from self-blame and fighting reality. For example, when you feel sad, lonely, or guilty, instead of making yourself feel worse, you have self-compassion, soothe yourself, and take steps to feel better.

   Self-acceptance means that you don’t have to please everyone for fear that they won’t like you. You honor your needs and unpleasant feelings and are forgiving of yourself and others. This goodwill toward yourself allows you to be self-reflective without being self-critical. Your self-esteem and confidence grow, and consequently, you don’t allow others to abuse you or tell you what to do. Instead of manipulating, you become more authentic and assertive, and are capable of greater intimacy.

4. Action.Insight without action only gets you so far. In order to grow, self-awareness and self-acceptance must be accompanied by new behavior. This involves taking risks and venturing outside your comfort one. It may involve speaking up, trying something new, going somewhere alone, or setting a boundary. It also means setting internal boundaries by keeping commitments to yourself, or saying “no” to your Critic or other old habits you want to change. Instead of expecting others to meet all your needs and make you happy, you learn to take actions to meet them, and do things that give you fulfillment and satisfaction in your life.Each time you try out new behavior or take a risk, you learn something new about yourself and your feelings and needs. You’re creating a stronger sense of yourself, as well as self-confidence and self-esteem. This builds upon itself in a positive feedback loop vs. the downward spiral of codependency, which creates more fear, depression, and low self-esteem.

   Words are actions. They have power and reflect your self-esteem. Becoming assertive is a learning process and is perhaps the most powerful tool in recovery. Assertiveness requires that you know yourself and risk making that public. It entails setting limits. This is respecting and honoring yourself. You get to be the author of your life – what you’ll do and not do and how people will treat you.²

The four A’s are a roadmap. Learn all you can about recovery. Join a 12-step program and begin keeping a journal to know yourself better. Codependency for Dummies lays out a detailed recovery plan with self-discovery exercises, tips, and daily reminders. Your recovery must be your priority. Most important, be gentle with yourself on your journey.

1. To help you, I wrote a handy ebook, 10 Steps to Self-Esteem — The Ultimate Guide to Stop Self-Criticism.
2. Because being assertive is so fundamental to recovery, I wrote How to Speak Your Mind — Become Assertive and Set Limits.

Bill Wilson, the founder of Alcoholics Anonymous, was influenced by Carl Jung. In correspondence, Jung wrote Wilson that the cure for alcoholism would have to be a spiritual one — a power equal to the power of spiritus, or alcohol.

The 12 Steps are that spiritual remedy. They outline a spiritual process of surrender of the ego to the unconscious, or a higher power, and very much resemble the process of transformation in Jungian therapy.

The following is a description of that process. However, the fact that it is described in a linear fashion is misleading, because the Steps are experienced both simultaneously and in a circular manner. Although the same process is applicable to recovery from addiction to a substance (e.g. alcohol, drugs, food) or a compulsion, such as gambling, debting, or caretaking, the focus of this article is on alcohol and drug addiction and the family members in a codependent relationship with the alcoholic or addict.

Facing the Problem

The beginning of recovery is acknowledging that there is a problem involving drugs or alcohol, that there is help outside oneself, and the willingness to utilize it. This also represents the very beginning of trust in something beyond oneself (such as a therapist, sponsor, or the program), and the opening up of a closed family system. Invariably, it takes years to face the problem.

With growing understanding of the problem, denial further thaws. In Step 1: “We admitted we were powerless over alcohol — that our lives have become unmanageable.”¹ The addict begins to understand she or he is powerless over the drugs or alcohol, and the codependent begins to understand that she or he cannot control the substance abuser. The struggle not to drink and the codependent’s vigilant watching the addict begin to slip away. Gradually, attention starts to shift from the substance, and, for the codependent, the substance abuser, to focus on oneself.

There are deeper levels of working the First Step. The first stage of coming out of denial is to acknowledge that there is a problem; second, that it is a life-threatening problem over which one is powerless; and third, that actually the problem lies in one’s own attitudes and behavior.

Surrender

The acknowledgment of powerlessness leaves a void, which formerly was filled with mental and physical activity trying to control and manipulate the addiction or the addict. Feelings of anger, loss, emptiness, boredom, depression, and fear arise. The emptiness that was masked by the addiction is now revealed. It is an awesome realization when you acknowledge that you or your loved one has a life-threatening addiction over which you are powerless, subject only to a daily reprieve. Now, with a modicum of trust, one acquires a willingness to turn to a power beyond oneself. This is Step 2: “Came to believe that a Power greater than ourselves could restore us to sanity.”

In the book Alcoholics Anonymous, it states: “Without help it is too much for us. But there is One who has all power — that One is God.” (p. 59). That power can also be a sponsor, therapist, the group, the therapy process or a spiritual power. Reality itself becomes a teacher, as one is asked to continually “turn over” (to that Power) an addiction, people, and frustrating situations. The ego gradually relinquishes control, as one begins to trust that Power, the growth process, and life as well.

Self-Awareness

What has been happening up until now is an increasing awareness and observation of one’s dysfunctional behavior and addiction(s) – what is referred to as “insanity” in the Second Step. This crucial development signifies the genesis of an observing ego. Now one begins to exercise some restraint over addictive and undesirable habits, words, and deeds. The Program works behaviorally as well as spiritually.

Abstinence and forbearance from old behavior are accompanied by anxiety, anger and a sense of loss of control. New, preferable attitudes and behavior (often called “contrary action”) feel uncomfortable, and arouse other emotions, including fear and guilt. From a Jungian perspective, one’s “complexes” are being challenged:

“Every challenge to our personal habit patterns and accustomed values is felt as nothing less than the threat of death and extinction of our selves. Invariably such challenges evoke reactions of defensive anxiety.” (Whitmont, p. 24)

Group support is important in reinforcing new behavior, because the emotions triggered by these changes are very powerful and can retard and even arrest recovery. Additionally, resistance is experienced from self, family, and friends for the very same reasons. The anxiety and resistance may be so great that the addict or abuser may go back to drinking or using.

There is help in Step 3: “We…turn our lives over to the care of God as we understood God.” This is the practice of “letting go” and “turning it over.” As faith builds, so does the ability to let go and move toward more functional behavior.

1. Other words, such as “food,” “gambling” or “people, places and things” often are substituted for the word alcohol.

Or maybe you’re a bundle of nerves. You are so anxious you just want to hide. You’re nervous about your job. You’re scared to speak up even when you know you should and could. You are so anxious that you are anxious about being anxious.

Or maybe the issues are about relationships. You don’t have one or the one you have isn’t the one you want. You and your partner are fighting all the time. Every day seems to be “same fight, different day.” Trust has become a huge issue. Neither one of you can relax into your relationship. You each wonder where the love and sweetness and tenderness have gone.

And then there are family issues: The mother you can’t get along with. The father who expects too much or too little of you. Siblings who are mean-spirited, favored, or so self-centered that you feel constantly taken advantage of. Parents who are fighting. Parents who are splitting. Family you are expected to like but who are entirely unlikeable – and here comes another painful family event.

Any of these types of issues can stretch a person beyond his or her ability to cope. Any of them can challenge the most creative, caring, and responsible person, You’ve tried your best. You’ve tried to look at a brighter side, to be rational, to be smart about whatever it is. But you still can’t figure things out. You still feel alone in your troubles and without the inner resources or the outer supports to change things. This is when people often go to therapy. You wish you could. But you have no insurance and you know it can be costly. The situation seems hopeless.

It’s not. Serious, yes. Hopeless, no.

Inexpensive and Alternative Treatment Options

There are many ways to get the help you need, therapist or no. Before you give up on the idea of getting some therapeutic help, consider these alternatives.

Sometimes therapy is free or low-cost.

Depending on your problem, there may be funded or subsidized therapy available to you. Many communities have women’s centers that offer free services to women who are being abused. Many have free services for adolescents. And an increasing number of communities have men’s resource centers to help men with anger management, relationship or vocational problems. Go online and check.

Employee Assistance Programs (EAP).

Many businesses and companies offer a limited counseling benefit. Usually the company provides three to six sessions. If you need further help, the counselor will refer you to a local therapist. Check with your human resources department to see if there is an EAP counselor at your workplace. Often even a couple of focused sessions is enough to offer some relief.

Sliding scales and free slots.

Many mental health clinics and many therapists in private practice have sliding fee scales so that people can pay what they can afford. Ask your doctor if he or she knows who offers this service. Call some of the therapists in your area and ask. Many therapists keep a number of slots at a lower rate as their way of giving to their community.

Support groups.

Often a support group can be very therapeutic. By talking to people with a similar problem, you will feel less alone. Often there are people in the group who are a little ahead in their healing and who can offer you good practical advice as well as emotional support. Local hospitals, libraries, churches, and schools often offer support groups for grief, parenting issues, managing chronic illness, etc.

PFLAG (Parents and Friends of Lesbians and Gays) offers support to those supporting family members and friends who are coming out. There are also support groups online and in the community for gays, lesbians, and transgendered people who need information and advice.

Parent education classes.

Not all problems are mental health issues. Parenting is difficult. Often people new to parenting or new to a stage of parenting could just use some additional information and the reassurance and advice that can come from parents who have been there and done that. Often such groups are offered through the school system or through local parent centers.

12-step Groups.

Alcoholics Anonymous, Al-Anon (for families of problem drinkers) and Alateen (for teenage family members) offer support to people who are struggling with alcoholism and to their families. Other spinoffs include Overeaters Anonymous, Narcotics Anonymous, Clutterers Anonymous and Parents Anonymous. If you think a 12-step program is for you, search your issue and “anonymous” and you are likely to find a group.

The National Alliance on Mental Illness (NAMI) has chapters throughout the U.S. They often offer support groups for those struggling with mental illness as well as for family members.

Online support groups.

Name a problem and there is probably an online support group for it. Here at PsychCentral, there are over 100 such forums and groups. Members are not professionals. They are people who are grappling with the same issue you are. Their compassion and understanding can help you feel less alone. Often members offer experience and wise suggestions.

Are you a veteran? Every branch of the service has a program for military personnel and their families. Call your local Veterans Administration office for information.

Are you a teen? Many high schools have free counseling available through the guidance department. Often the guidance counselors are themselves counselors and can be very helpful with both individual and family problems. Sometimes they know which therapists in town have free or nearly-free services and where you can go for further help.

Are you in college? Check to see whether the health services at your school include a mental health department. Often the health insurance you pay for at school can enable you to see a local therapist for at least a few sessions.

Hotlines and warmlines.

There are important hotlines and warmlines in almost every country. In the U.S., the National Suicide Prevention Lifeline (1-800-273-8255) is available 24/7. The Boys Town National Hotline is also available 24/7 for teens (girls as well as boys). Google “hotline” and your problem and you are likely to find a number to call.

Houses of worship.

Spiritual leaders often have had training in counseling as well as in the practices of their faith. See if your church or synagogue or house of faith offers such help. If your spiritual leader isn’t comfortable dealing with secular problems, he or she may be able to refer you to someone who can.

Journaling or writing letters you will never send can be an important method for self-help. Don’t get put off by having to put something down. You’re the only one who is going to see it. Writing out what troubles us often helps us put our feelings into perspective. Often enough, a solution will come as you work to make your problems clear.

Bibliotherapy is a fancy name for reading a book. Whatever your problem, someone else has probably written about it to share their journey of healing. Sometimes we learn best from reading how someone else did and did not address issues. Search for your issue at one of the major online bookstores and you can find what you are looking for.

Prayer, meditation, chanting.

Anything that helps you relax and get out of yourself for a bit can do wonders for your state of mind. Turning your problems over to God, your higher power or the universe can help relieve the pressure and begin the healing.

Get off the screens and go outside.

Mother Nature is a great therapist. Stop spinning about your problem with online friends who are in the same spin and go for a long walk instead. Open your senses to the outdoors and you may be able to cut your problems down to a more reasonable size.

Talk to a trusted friend or family member.

You know who they are. Many of us have a friend or relative who is wise and loving and supportive. Don’t waste your time on anyone else. People who are critical or judgmental will make you feel worse. Reach for the people in your life who will listen with their hearts and who will validate your strengths.

Take care of yourself.

Getting enough sleep, eating right, and making sure you get a little exercise each day can do wonders for your troubles. You may not feel like doing any of it. But doing it, whether you feel like it or not, can help you start to feel a bit better. You will have taken a step toward self-care and self-love that is the basis for any therapeutic action.

Blind Devotion: Survival on the Front Lines of Post-Traumatic Stress Disorder and Addiction gives a taste of the Prinsen’s gutsiness at the outset, as she begins by acknowledging that she herself has played a part in her family’s difficulties. In this, her first book, the author tells the searingly honest and remarkably brave story of her family’s battles with mental illness, charting the ongoing chaos they’ve faced following Sean’s service in Bosnia.

After his discharge, Prinsen tells us, her husband returns home to the States and is given a prescription for narcotic pain medication to help him cope with the pain of a neck injury he suffered during military training. It is here that things begin to quickly spiral out of control, as Sean becomes addicted to his pills and begins to self-medicate with additional over-the-counter medications and alcohol. His behavior throws the entire family into disarray.

“Alcoholism is an enigma,” Prinsen writes, “— as complex as it is puzzling. It follows no rules and has no boundaries. Like a giant vacuum, alcoholism goes after everything and everyone in its path. It is a family disease — everyone in the family gets sick.”

Because Sean is reluctant to speak about the trauma he experienced in the military, or to share the truth about his depression with anyone, Prinsen assumes that her husband is simply suffering from addiction. It takes many years for her to understand and recognize the nature of PTSD and to connect the dots between the trauma Sean experienced in Bosnia and his subsequent depression and substance use.

“For so long, in the early stages of Sean’s addiction, I didn’t understand the destructive interplay between Sean’s PTSD, his depression, and his substance abuse,” she writes, explaining:

… Only he understood the desperate need to escape from the crippling flashbacks and the intrusive thoughts that blindsides him without warning, bringing with them the full force of the emotions that he felt in the original traumas. Only he understood the exhausting anxiety that kept him on high alert for ‘danger’ 24/7 and the need for something — anything — to keep that anxiety at bay. Only he understood how the pills helped him get through a night that would otherwise be plagued by the alternating horrors of nightmares or insomnia.

Sean’s PTSD continues to go undiagnosed, until he finally reaches crisis point. One night, in 2007, Sean suffers a complete breakdown and attempts what is known as “police-assisted suicide.” He becomes threatening and aggressive, arms himself with a loaded weapon, and calls the police to the house, almost as a challenge.

Prinsen recalls the horrific events of this evening, as she and her two young children are forced to witness Sean’s breakdown and frightening behavior, fearing not only for his life, but for their own. Sean survives, is arrested, and is subsequently jailed. Then, incredibly, after his release, the same thing happens again exactly a year later, as he suffers a repeat breakdown and once again challenges the police to come and get him, putting his family’s lives at risk in the process. By this point you’d be easily forgiven for wondering why on earth Prinsen doesn’t just leave, but it’s here that the relevance of the book’s title becomes clear. Prinsen adopts the military philosophy of “No One Gets Left Behind” and refuses to abandon Sean, no matter what anyone else tries to convince her, or how tempting it might sometimes seem. Looking back, she realizes that she plays a codependent role in the relationship, too.

But Prinsen doesn’t let her husband off the hook lightly, either, and always holds him fully accountable for his actions. “It took me many more years to fully grasp the reality that abuse isn’t just physical,” she writes. “Sean was a master at manipulating my emotions to get just what he wanted, and as difficult as it is even today to say the words — that is abuse.” Sean also used threats of suicide and self-harm to keep her from leaving or setting healthy boundaries, she tells us, recognizing it as a form of abuse. His “screaming, the holes in the wall, the slammed doors, and the broken objects” are also “definitely abuse.”

Later, Prinsen recounts, with brutal honesty, how she at times longed for her husband’s demise:

Sean stayed in our home, but I was finally starting to understand that Sean would never get help until he hit rock bottom. He needed to fall hard if he was ever going to get up again. I did something then that I’ve since found out is common behavior for the loved ones of addicts: I began to systematically pray for my husband’s downfall. I didn’t want him to get hurt. I didn’t want him to injure someone else and live with the regret. I didn’t want him to suffer lifelong consequences. I just wanted him to suffer enough to want to get help for himself.

It is rare to find these sorts of frank admissions in a personal memoir, let alone a first book, and it is this fearless honesty that makes Prinsen’s story so powerful. One can only imagine how difficult it must have been for her to put all of this into writing, knowing that her husband, friends, and family would all be able to read it. At one point in the story she finds herself wondering, “What will people think when they see this in the newspaper?”

In addition to sharing her own raw experiences, Prinsen also follows every section of the book with a short factsheet, providing the reader with a brief summary of the fundamental topics covered and links to further resources. These factsheets might easily have seemed disruptive or out of place, but Prinsen keeps them concise and informative.

The author also raises some vital ethical and political issues, questioning the morality of a government that puts soldiers in situations that destabilize their mental health, then prosecutes them as criminals. “How can we expect our veterans to come back to their homes and be ‘normal’ again after they have seen humanity at its worst?” Prisen recalls thinking angrily as she and Sean walked out of court one day. She feels sick when considering that Sean, who had never had any trouble with the law before he was deployed to Bosnia, was now a twice-convinced criminal. “What kind of a country is this to condemn and shame its own soul-wounded soldiers in such a way?” she asks. “Why don’t we just help them?”

Blind Devotion lives up to its name as a remarkable testament to the unquestioning power of love against all other odds, including the most destructive forms of mental illness. This is a story of survival, with protagonists who are determined to conquer their personal demons and triumph, no matter what. Prinsen’s writing will appeal to every reader, regardless of whether or not they’ve had to deal with PTSD. For the hundreds of thousands, if not millions, of military families who can relate to her experiences firsthand, hearing Prinsen speak about them so openly and shamelessly will surely be a relief.

Blind Devotion: Survival on the Front Lines of Post-Traumatic Stress Disorder and Addiction
Hazelden, September, 2012
Paperback, 348 pages
$14.95

An estimated 23 million Americans struggle with addiction. Many of these addicts seek AA or NA as part of their road to recovery. A number of rehabilitation centers focus on the 12 steps and urge those in recovery to continue attending meetings on a regular basis to maintain their hard-earned sobriety.

The 12-step program is responsible, in part, for saving many lives. This cannot be debated, but neither can the reality that the program is not effective for everyone. Those recovering from addiction recover in different ways, and the underlying spiritual elements of AA and NA can be confusing and uncomfortable for some.

Deborah’s story is common: Drugs and alcohol, once something she could control, began to define her life after a time. It is also important: It sheds light on the reality that recovery does not necessarily have to be found within “-Anonymous” programs. In fact, some of the principles of the steps can be frightening for people.

Deborah has been sober for over seven years, although she still and will forever describe herself as “a recovering addict.” This is the general consensus in regard to addiction recovery. Similar to chronic mental or physical illness, the nature of addiction requires those living with it to constantly monitor mood changes, life events, and triggers that may spawn relapse. Addiction is, in fact, categorized as a mental illness.

Deborah has two children, both under the age of 15, and she has been married for 23 years. She works part-time as a nurse and spends her spare time hiking and with her family and a close group of friends, many of whom also are in recovery. While this may sound like the stuff of a normal, everyday life, it was not always this way.

Deborah describes the impact of her addiction on her family:

My children were young when I was active in my addiction. I don’t believe they understood what was going on, though my husband worked to be honest with them. He told them I was sick and would become well. When I was an addict, my family, while important, were not as important as drugs. I felt I needed drugs in order to function, and I did function for some time. I managed to complete my nursing degree, but it all fell to pieces. Addiction nearly killed me, and I needed help. I finally realized, after five years of serious addiction, that I could not do it on my own.

During her stay in a rehabilitation center, Deborah was taught that the 12 steps were an important part of her success. However, she struggled with some of the core principles, the spiritual principles in particular. She is not alone.

The basic text of Narcotics Anonymous states as part of its 12 steps:

We admitted to God, to ourselves, and to another human being the exact nature of our wrongs… We were entirely ready to have God remove all these defects of character… We sought, through prayer and meditation, to improve our conscious contact with God as we understood Him, praying only for the knowledge of His will for us and the power to carry that out.

I presented these excerpts to Deborah; she was already well aware of them. In fact, she’d spent a very long time working to understand them and to apply the steps to her recovery journey. While the steps do make a point of mentioning that a person is to understand God “…as we understood Him,” implying that the program does not require a person to be religious nor adhere to any specific principles, the words do still feel stifling to those of other belief systems.

Deborah spent the better part of a year attending the meetings at least three times a week. She obtained a sponsor, a commonly recognized hallmark of the program, in order to work toward completing the 12 steps.

Nevertheless, as hard as she tried to work the program, she felt confused.

My sponsor, an exceptionally kind woman, worked to help me understand the concept of a ‘Higher Power.’ We spent hours over coffee discussing my innate reluctance to approach recovery in this fashion. It became difficult for us, as the months passed and I remained uncomfortable with the ideas, to maintain a healthy relationship with her. I realized then, after I had a year of sobriety under my belt, that the program would not work for me. I had initially assumed that because it has worked for so many people, it would work for me if I tried hard enough. I had to find another approach to my recovery. I had to find my own way.

After deciding to leave the program, Deborah and her family were anxious:

I had spent a long time thinking about what direction I would take. Instinctively, I knew the program would not work for anymore. My husband was understandably nervous. He urged me to stay and give it more time, but I had put enough time into trying to fit the mold. Yes, I was afraid, but not because I thought leaving would cause relapse. I was afraid of recovering alone.

Although she decided the 12 steps were not for her, Deborah recognized the difficulty — if not impossibility — of recovering alone:

It was sort of scary at first, but I was certain I was not the only one who needed to approach recovery in a unconventional way. I was surprised to find support groups that focused on recovery without any of the spiritual elements. I met fantastic people, and while we had meetings, we also took a different approach. We hiked together and found different outlets, doing things we had never done before. I actually skydived this year, something I never would have done otherwise.

Addiction is an isolating disease. While 12-step programs undeniably help many addicts, other options do exist for those who feel they do not fit in. The goal for addicts is ultimately to find a life free of addiction, no matter the route taken to get there.

References

Bill W. (n.d.). In Wikipedia. Retrieved September 14, 2012, from http://en.wikipedia.org/w/index.php?title=Bill_W.&oldid=511410040

Egan, Pamela. (n.d.). 23 million Americans addicted to drugs and alcohol. Pamela Egan: Nurse Practitioner, Diabetes Education and Health Columnist. Retrieved from http://www.pamelaegan.com/articles/addiction/

J., Deborah (surname intentionally withheld). September 14, 2012. Personal interview with author.

Narcotics Anonymous. 2008. Narcotics anonymous. (6th ed.). Chatsworth, CA: Narcotics Anonymous World Services, Inc.

What makes the workbook so successful is the down-to-earth yet enlightening way in which its author, Patrick Carnes, writes. His approach is realistic and practical. His wisdom and knowledge are seemingly unparalleled.

In the latest edition of his classic text, he adds worthwhile information, while keeping what has made the book so important.

Carnes writes:

“One of the hallmarks has been that anybody can use it. It works for all kinds of addicts; it works for co-addicts; it doesn’t matter what fellowship you are in. Each edition of the book provides a concrete, structured way to implement what the authors of Alcoholics Anonymous discovered and described in the 1930s. It gives readers a focused path for integrating the Twelve Steps into their lives in a practical, doable way. With each new edition, my goal has been to make that path clearer, more helpful, and more profound.”

What distinguishes the latest edition from its predecessors is new information about addiction discovered through neuroscience research. Inserted before the first chapter is an essay titled “The Neuroscience of Recovery,” it gives a brief yet detailed overview of how addiction affects the brain, and what can be done to reverse any damage.

Many of the exercises and discussions from previous versions have also been expanded upon in light of this new information. The basic premise is essentially the same. It is only the level of understanding that has changed.

As Carnes writes: “Thanks to recent developments in neurology, radiology, and genetics, we now have a clear picture of how addiction takes hold in the human brain. We also have solid scientific evidence that working a Twelve Step program literally rewires our brains for recovery.”

After the initial essay, he writes a little about the program and what to expect. He also discusses why people are addicts and how they can learn to take control of their lives. The key is no secret: the famous “Twelve Steps.”

The bulk of the book is devoted to Step One, admitting powerlessness. Since this is without question the hardest step for any addict, it’s sensible and appropriate that he devotes so much space to it. It is important to set the groundwork and make sure everything is in order before moving on. After all, for most addicts, this is the biggest decision of their lives.

Most of it is interactive, with Carnes providing some preliminary orientation before asking the reader to supply his personal information. Some of the things he asks for from the reader include:

* Meaningful, personal affirmations.

* An inventory of the consequences of the habit.

* A family tree of addiction.

* Personal history of addiction.

* Reflections on the habit.

After going through a litany of necessary exercises, Carnes writes a bit before moving on to Step Two:

“The most important element of recovery is the ability to choose. Addiction robs much of our power of choice by hijacking our brain, over and over, until we become powerless over our addiction and our life becomes unmanageable. But addiction does not take away every choice from us. In Step One, we choose to acknowledge our powerlessness and admit what our life has become. We accept our limitations and the realities that addiction presents to us.

“This Step connects us to memories that show us how our addicted brain has seduced and hijacked us. These memories help us wake up to how cunning addiction is. We can look back and see that many of the decisions our addicted brain made were harmful ones. Only then can we begin to recognize the stinking thinking that is part of our addiction. Only then can we begin to know what wise decisions look like.”

“A Gentle Guide Through the Twelve Steps” is not really a book for educational purposes. Yes, it is written by an expert and  it is certainly informative.

However, its primary purpose is to be used as a workbook or a guidebook. In this way, it’s meant for people currently going through, or thinking about going through, the twelve steps.

And for those who do make the leap, there probably isn’t a better place to start.

A Gentle Path Through the Twelve Steps: The Classic Guide for All People in the Process of Recovery
Patrick Carnes, PhD
Paperback, 340 pages
Hazelden, Third Edition published May 2012
$15.86

In her book, Campion discloses the events leading up to every parent’s worst nightmare: the death of her daughter, Luce. Campion describes the heartbreak of witnessing her daughter’s descent into depression and drug use, and the helplessness and guilt she felt as both a psychiatrist and a mother. Sshe and her family were unable to prevent Luce from the early death which seemed inevitable from a young age. In her painfully honest account, Campion also explores her history and that of her family in trying to figure out what may have contributed to Luce’s death.

“Luce looked at me straight on. ‘It really sucks. I get the manic-depressive gene from you, and the weird drug reactions from Dad.’”

Campion talks of her own battle with depression and reveals her youthful suicide attempts. She also talks of her husband’s alcoholism, and the trials her family has endured because of addiction and the trauma of losing Luce. Campion confesses that she didn’t fully realize the scale of the problem until it hit her own family:

I didn’t know then that major depression strikes about one in ten women every year. According to U.S. public health data, among adults experiencing a major depressive episode, fifty-six percent thought that it would be better if they were dead, forty percent considered suicide, fifteen percent made a plan, and ten percent an attempt. Suicide is the eleventh leading cause of death among adults and accounts for well over thirty thousand deaths per year. I would learn only later that what we now call bipolar and unipolar major depressive disorders had surfaced with regularity in my family for several generations.

Much of the book comes across as Campion’s attempt to make sense of her loss and move on from it. Guilt is a recurring theme throughout the book. As Campion recalls trying to help her daughter, she comments that “Every decision I’d made during her illness could be used to flagellate myself.” Any parent will be able to identify with the agony Campion faces as she repeatedly asks herself what she could have done differently.

Looking back on that time, the hardest thing to do is recapture how dense my ‘not-knowing’ was. From today’s vantage point, it is hard – no, impossible – to ignore what would be revealed a few months later in the full-blown manifestation of Luce’s manic-depressive illness. I want to flog myself for not considering what seems so plain in hindsight: her excessive confidence, single-minded purpose, intense energy, and powers of persuasion could indicate a manic episode. Why didn’t they raise my suspicions? Some psychiatrist! Or was I, her mother, just too tempted to welcome her new bright optimism, focus, and appetite for life after years of confusing doubt… The guilt of failing my own child swells up in me like a flooding river, dirty and cold, hauling dangerous debris.

The book serves not only as an incredibly revealing, painfully honest account of a parent’s loss but as a reminder of the importance of family. It is clear from the start how important Campion’s family is to her, and how much the family relies on each other throughout their struggles:

Every single one of us had been traumatized… I thought the best way to heal was to give each other warmth, to huddle close, in order to withstand the real world’s harshness.

Indeed, Campion examines in great depth the effect the tragedy had on each family member. It is this systemic analysis of her story, taking into account the role of each individual family member, which doubtless evolves out of Campion’s professional experience as a psychiatrist. Campion wonders how and why the family were able to stay so strong and reliant on each other during their experiences, and ponders the importance of attachment:

Equally mysterious, and possibly closer to the truth: I have a strong affiliative need that I think is hardwired in most humans and other mammals, expressed in loyalty to their tribe or pride. As if the family was the basic organism whose survival may be more essential than any individual’s, the whole being greater than the sum of the parts.

While this powerful memoir will appeal to anyone who has lost a close family member, it also serves as an important reminder to all mental health professionals that they are not immune from any of the conditions which might plague their clients.

Did I think I was any better than those patients and their families, that I deserved to be spared? By virtue of what? I knew better, except that, deep down, I must have hoped that all the energy I had spent battling addiction and mental illness for years would count in my favor. As if I could bargain with fate, buy protection for my contributions. But destiny is crueler than any mafia goon.

This will be familiar territory for any professionals who might be wounded healers themselves, particularly those who have dealt with their own loss, trauma, addiction, or depression while still attempting to see clients. Campion talks of her own battle to carry on working, until she realizes that it would be unethical, and refers her clients elsewhere:

Another patient told me, on the tenth anniversary of her own suicide attempt, ‘I have been able to resist all those years because you’ve been on my side. But since your daughter died, you’re not as strong and I think I’ll kill myself.’ Her words stabbed me, but she was right and I convinced her to work with another doctor.

Although the book is at times so searingly honest that some readers may find it hard to take, this is ultimately a story of redemption. Writing this book undoubtedly was cathartic for Campion, and a therapeutic means for her to reach some kind of closure over these awful experiences. In the end, it is the simple capacity for happiness and hope which seem to have saved Campion from the same demise as her daughter:

I have been blessed with an innate ability for joy that bubbles easily in me except during the severe depressions I’ve had four times in my life. Even after months of low moods, I recovered completely and regained a buoyancy that reminds me of my grandmother, who soothed us with bedtime stories during the war… I have worked hard to deal with traumas and temper my neurotic traits, but that inborn undeserved talent for enjoying life is a gift I can only give thanks for and celebrate… Luce had no such luck.

Hope triumphs, even through the unknowable. And, for that, we must all be grateful.

Through the Unknowable: Family Life with Depression, Alcohol and Love
By Elsa Campion, MD
Vantage Press:  March 16, 2012
Paperback, 162 pages
$13.95

Essentially a sequel, Twelve Principles picks up where Twelve Steps left off. As Carnes breaks it down, the first book is for addicts currently in recovery: it teaches them how to use the twelve steps to overcome their addiction. Upon finishing the steps, though, something else is needed—a method of integrating the twelve principles into one’s life for sustained sobriety.

In the introduction, Carnes is quick to point out that the principles are not rules. The latter has a different, more negative connotation, and does not fully encapsulate what a principle means. Carnes writes:

Principles represent a higher level of learning and thinking than rules or guidelines do. A rule is something to follow, usually in the precise way prescribed, but a principle is something to reflect on, implement, and live into. Rules are typically remembered and recited verbatim; principles are experienced in our hearts, guts, and brains. (Italics in text)

1. Acceptance
2. Awareness
3. Spirituality
4. Responsibility
5. Openness
6. Honesty
7. Courage
8. Commitment
9. Responsiveness
10. Trusting
11. Meaning
12. Generativity

Each principle gets its own chapter, with Carnes dedicating roughly equal attention to all. The book is divided into four sections: “Making Sense” contains the first five principles, “Creating Congruence” the next four, “Growing Vision” gets the next three and “Living Into the Principles” composes the final two.

A Gentle Path Through the Twelve Principles is more or less constructed like its predecessor: after some preliminary information in each chapter, the book turns into a workbook where individuals literally work through the principles.

Chapter 2, “Awareness,” contains some interesting exercises to use as examples. Carnes commences by writing:

Addiction gives us tunnel vision and narrows our attention to those things that satisfy its demands, creating a poverty in our inner and outer lives. Recovery expands our attention—first beyond our addiction, then beyond our fear and stinking thinking, and ultimately far beyond ourselves, into deep awareness.

When an individual is addicted, he loses virtually all sense of awareness, finding himself consumed by physical and psychological urges that will not dissipate until acted upon. When sober—as well as in the process of sobering up—it is important, and according to Carnes, vital, to cultivate awareness. In this way, after accepting and surrendering, through the first principle, to “the irrevocable realities of our life,” it becomes necessary to truly understand them.

The exercises for this principle are fascinating because of the way they demand the individual to confront his demons. When Carnes asks readers to list the worst and best moments of their lives, he is forcing them to relieve those times, both terrible and glorious. But this is not without purpose: Carnes wants the individual to meditate on and reconsider the severity (or lack thereof) of those moments. He asks: “Did it force you to take action or make a decision? What was that action or decision? Did it change your life for the better? In what specific ways? Did it change anyone else’s life for the better? In what ways?”

What Carnes is doing by forcing the individual to undergo this line of questioning (as well as several more) is getting him to become aware of those moments. Instead of merely remembering them and then feeling either happy or sad, Carnes tries to get to the root of those feelings. Why did it make you happy? Why did it make you sad? In so doing, awareness is cultivated and the addiction is understood on a higher level.

Just as he was for A Gentle Guide Through the Twelve Steps, Carnes should be praised for his newest contribution. He saw a void, and he filled it intelligently and perceptively. None of the exercises or discussions is unnecessary, uninteresting or redundant.

Carnes is one of the foremost experts in his field, and he is someone worth learning from. For anyone who is in need of professional advice on how to live post-addiction, A Gentle Guide Through the Twelve Principles is a great place to start.

A Gentle Path through the Twelve Principles: Living the Values Behind the Steps
By Patrick J. Carnes, PhD
Hazelden: June 26, 2012
Paperback, 280 pages
$15.95

Several factors play a part in addiction, including family and social environment, overall mental health, genetics, and family history of addiction. It often is not the case that those with a family history choose not to abuse alcohol or drugs. Many individuals exposed to substance abuse and addiction grow up to be addicts, even if their drug of choice is different.

A history of trauma may contribute to the development of addiction. This trauma can include any form of abuse or exposure to any traumatic events. If the trauma is not addressed, individuals may try to suppress their feelings. This leads to poor coping skills and poor stress management. Using drugs can be a form of stress management.

The early use of drugs also may be a factor. Research has shown that individuals who begin to experiment at a young age have a higher chance of addiction later in life. This is why it is important to notice early the signs of substance abuse in teens and young adults. Most individuals begin abusing at least one substance before becoming full-blown addicts. Recognizing these early signs may allow parents to intervene before their teen moves from abuse to dependence.

Below are several warning signs indicating that your teen is abusing alcohol or other drugs:

• Changes in appetite or sleep patterns.This could be characterized by a marked increase or decrease in either or both. For example, individuals abusing amphetamines may show a diminished need for sleep and food. Those abusing marijuana may sleep more and have an increased appetite.These effects may vary depending upon the drug being abused. If you are interested in the effects of specific drug use, you may want to conduct some online research or call your local drug and alcohol commission or mental health clinic for more specific information.
• Deterioration of physical appearance. Typical teenagers are very concerned about the way they look to peers and friends and may be very specific about clothing, makeup, and overall hygiene. Individuals abusing substances often start to focus less on their physical appearance as their substance use increases.
• Withdrawal from social or important activities. You may notice your teen stops showing interest in things he or she once found pleasurable. For example, they may start missing school or participate less in sporting events or other social activities. They may also stop attending family functions or gatherings such as church because their drug use has become more important, or they may be embarrassed and try to hide their use from others.
• Unexplained need for money or secretive about spending habits. Individuals abusing drugs may begin asking for money without a clear reason. Generally an abuser will not ask for very large amounts, but rather small amounts over periods of time. They may also become more secretive about spending habits. For example, he or she may claim to need more for something than they actually need and pocket the extra money.
• Sudden change in friends or locations. The abuser’s friends or hangout spots may change. For example, a teen may start hanging out with a different crowd of friends. You may notice where they hang out may change as well. They may suddenly think their old friends are no longer “cool.” They also may start to break curfew or lie about where they are hanging out.
• Increased interpersonal or legal problems. Individuals abusing substances may start having more interpersonal problems, i.e., increased arguments with parents, friends, or other authority figures. They may begin to get in legal trouble for shoplifting or other crimes and cited for possession or underage drinking.
• Change in personality or attitude. This one can be a little tricky. Given the raging hormones of teenagers, personality and attitudes can change regularly. In someone abusing substances, this will look a little different. The mood swings would be unlike typical teenage attitudes. Depending on the substance being abused, you may begin to notice marked hyperactivity or extreme happiness followed by a “crash” where the mood becomes just the opposite. The individual may appear very lethargic or more irritable than usual. Thinking and behaviors may become irrational and unpredictable.
• Neglecting responsibilities. If your teen is normally very responsible and there is a change in that behavior, this may be a sign. Substance abuse often begins to take precedence over other things that were once deemed important. As a result, responsibilities are often neglected and the teen becomes more and more irresponsible over time.
• Using despite knowing it is dangerous. Most teens are very aware of the negative effects and possible consequences of substance use. If your teen is using despite this knowledge, this is a sign of abuse.

If you notice any of these signs, it may be time to talk to someone – starting with your teen. Approach them in a non-confrontational, non-threatening manner. Remember, the object of the conversation is to get them to talk to you, not for them to shut down.

If you suspect drug use, even if you think it’s just a little – start talking. If you realize your teen does have a substance abuse issue, don’t be afraid to seek help. Drug use is typically an “escape” for teens. It’s important to seek help for the drug use, but more important, to find the cause of it. You may wish to seek out a private counselor or find your local drug and alcohol treatment facility. Most facilities are well-equipped to work with teenagers with substance abuse issues.

Substance abuse is something that can and likely will get worse over time. Be proactive and remember that a short conversation could be the one thing that keeps your teen from full-blown addiction.

As stated above, the most important of the traditions is the one that urges anonymity. On this, the authors quote from the foreword of the first edition of the book, Alcoholics Anonymous:

When writing or speaking publicly about alcoholism, we urge each of our Fellowship to omit his personal name, designating himself instead as ‘a member of Alcoholics Anonymous.

Very earnestly we ask the press also, to observe this request, for otherwise we shall be greatly handicapped.

We are not an organization in the conventional sense of the word. There are no fees or dues whatsoever. The only requirement for membership is an honest desire to stop drinking. We are not allied with any particular faith, sect or denomination, nor do we oppose anyone. We simply wish to be helpful to those who are afflicted.

Given the importance placed on anonymity throughout AA’s history, it is somewhat startling to note the disconnect between the group’s intentions and the intentions of certain famous individuals. Often celebrities seemingly use AA or similar organizations as a pawn—part of a public plea to save face and get people to stop slandering them. This line of thinking is in direct contrast, as well as a slap in the face, to the integrity of all AA members.

Moreover—and perhaps I am alone on this—I was not aware of the existence of the twelve traditions before reading this book. As I saw it, AA used its twelve-step program to combat alcoholism; the twelve traditions, however, were never in my mind.

The traditions act as something of a constitution or a charter. They implore members to find solidarity behind ideas such as: not having an opinion on outside issues so that the group can never be drawn into public controversy; not promoting, but simply taking in those who come; having each group be autonomous; and ensuring that the sole requirement for membership is a stated desire to stop drinking.

The twelve traditions have worked quite well for the group. The authors write:

The general feeling of unity we have in AA today is remarkable, especially since the membership is made up of people who acknowledge false pride and resentment as major personal problems. Right from the beginning, however, the AA pioneers envisioned in the Big Book that, ‘Every alcoholic who journeys will find a Fellowship of Alcoholics at his destination.’ This has been true for decades, and it’s now possible to find a welcoming AA group throughout much of the world.

The central reason AA has been such a success, the authors write, is because of its rock-solid traditions. Although the members comprising the group may change, what binds them together will not. It is for this reason that the authors beg those who pervert the traditions to refrain from doing so.

Living the Twelve Traditions in Today’s World is a well-researched, well-written history and explanation of AA. Mel B. is a longtime AA member who has authored several notable recovery books, and Fitzpatrick is one of the leading archivists and historians specializing in the creation of AA’s twelve-step movement. The authors do a commendable job of combining historical records, firsthand accounts, primary knowledge, and excerpts of speeches to create a compelling narrative that not only details the reasons for the traditions’ development, but also their importance to the success and integrity of AA.

Living the Twelve Traditions in Today’s World: Principles Over Personality
By Mel B. and Michael Fitzpatrick
Hazelden: July 3, 2012
Paperback, 240 pages
$14.95

As an atheist, Ackerman’s point of view is unique among recovery-oriented and 12-step literature. Many people struggling with addiction don’t try 12-step programs because of their emphasis on a “higher power.” Ackerman also focuses on what he believes are misconceptions surrounding 12-step programs.

I chose to review this book because it was different. I am a Christian. I also happen to have an eating disorder. As part of my treatment, I briefly participated in a 12-step group. Prior to reading this, I never knew that anyone who identified themselves as an atheist ever took part in such a group. I was excited to read about it from a new perspective.

Ackerman does a good job summarizing some of his experience into short, easy-to-digest sections that also are easily to relate to. As someone currently struggling with an eating disorder, I certainly related to his frustration with wanting to stop his behavior, but feeling powerless in doing so. I also greatly appreciated his brutal honesty.  His occasional humor was also a welcomed and unexpected surprise. This is definitely not your average 12-step book. However, he does leave much to be desired.

For one thing, Ackerman never explains the 12 steps themselves. This would confuse a reader unfamiliar with the structure of such programs. 12-step programs take participants through a series of “steps” to aid in recovery. These steps start with admitting there is a problem and seeking support. They end with a commitment both to aid others who are still struggling and to continue carrying the lessons learned through the rest of the participant’s life. Although this began with Alcoholics Anonymous (AA), the general idea has been tweaked many times over to fit everything from drug to sex addictions and more.

This is a book centered around the 12-step recovery model, and I realize that. However, Ackerman spends much of the book praising the program, without even mentioning the many other programs out there. Instead, he sings the praises of the 12-step recovery model as if it is the absolute cure-all for all addictions and mental illnesses. This is simply untrue. If Ackerman were right, there would be no need for any other rehabilitation centers or support groups for addicts and others who are mentally ill.

“No one comes into a 12-step program by the grace of God or with a firm belief in a Higher Power.” Bold statements such as this are common in Ackerman’s book. In the section titled, “God (?)” Ackerman defends his point by saying that addicts worship their drug of choice, not a higher power. While one can see his reasoning, I don’t think a person’s mental health issues translate into having no faith in God.

[A]Musings of a Spiritual Atheist left me conflicted. I liked some of it, while utterly disliking other parts. It was certainly an interesting and thought-provoking read.

[A]Musings of a Spiritual Atheist
By Andrew J. Ackerman
www.lulu.com: January 23, 2012
Paperback, 204 pages
$19.95