Monday, April 27, 2020

The Book is Finally Out

Hot off the presses, my new edited book is now out.

Friday, April 24, 2020

Drug Abuse “Intervention:” Why it Works

In Jonah’s Berger’s excellent new book, The Catalyst: How to Change Anyone’s Mindhe discusses effective ways to get people to look at things in new ways. Even die hard ideologues can sometimes be reached using many of his methods. He also talks about why persuasive arguments and presenting new information in an effort by one person to get another person to reconsider entrenched positions usually does not work

In the chapter called “corroborating evidence,” he uses a successful “intervention” with a drug abuser to illustrate how, in influencing others, having multiple people give information is often much more powerful than just one person’s speaking , especially when the multiple sources are all operating at or near the same time. 

In the Intervention technique in substance abuse treatment, the actual intervention is having an outside therapist come in and coach the family members to write out a speech about how much they care about the user and how his or her behavior is hurting everyone. They are instructed to avoid telling him what to do. Nonetheless, the therapist has a rehab facility lined up in hopes that the object of the intervention will agree to do something about his “problem.”

They each say how sad they are because of the problem and how much they miss him and want the drug abuser “back.” They also give the addict the message, “If you want to be an addict, we can’t stop you. But if you want to get high, you aren’t going to do it here.” 

With families, Berger points out, several members have often -  over time and individually – “asked, begged, yelled, screamed, and threatened. All to no avail.” But then he goes on to say things that consist of the usual wisdom about these sorts of things, such as “They (addicts) don’t believe they have a problem.” They are “in denial.” They may not remember wrapping a car around a lamp post” because they “blacked out.” If an addict doesn’t think he has a reason to quit, “is one person really going to change their mind?”

That sounds reasonable, but is it really? Doesn’t the addict find out what happened to the car after he comes to? Isn’t losing a good job and resorting to crime to finance an addiction considered by the drug abuser to be problems? As I often say, he would have to have the IQ of a kumquat – or maybe a rutabaga, I’m not really sure – to not “know” he had a problem. So what’s really going on here?

Berger attributes the relatively high success rates of organized family “interventions” to the number of people giving a similar message. He's partly correct. But he also seems subliminally aware that there is something else going on here. He states, “In order to get addicts to change, their entire ecosystem has to be altered. Without realizing it, friends and family members may be unintentionally enabling the problems. So for change to stick, the whole system has to change…”

Was the particular family the author described enabling the abuser, “Phil”? Why as a matter of fact, quite so. In the author’s description, the family didn’t seem to think of him as an addict for extended periods, especially at first, because he had a job and didn’t steal to support his habit. He did start to steal a bit later. They sent him to rehab 19 different times even though each of them was unsuccessful. They repeatedly let him move back home. They resorted to having him sign a contract promising to turn over a new leaf, but all that did was to “train him to be a better liar.”

Hearing this, it might seem fairly clear why Phil may have thought his family was actually invested in him continuing to be an addict, because they made it so damn easy! Unlike most of us, they know that family members are not that stupid even if they seem to be “in denial.” Of course, I have to put the usual caution here: since I haven’t personally evaluated this family I can’t say what follows with certainty, although IMO what I am about to describe is extremely likely.

Another hint that the above formulation may be on the mark is a statement by the book author that "family was everything to Phil." The author thinks that Phil realizing he was tearing the others to shreds was the motive for quitting. But again, how could Phil possibly think that this hadn't been the case all along? Because he thought the family needed him to be an addict!

In dysfunctional families with shared conflicts over certain behavior, say for example puritanical attitudes towards work and intoxication, several members are usually involved in either enabling or refusing to notice the problems of the addict. The addict is actually taking the cue to deny that he has a problem from the family. When one member occasionally seems to object about addict-like behavior, another family member may give the addict the opposite message. In such a situation, this can become a game without end even more easily than when just two people are stuck in this game. So no wonder the addict ignores the asking, begging, yelling, screaming, and threatening from any one family member.

However, when the whole family comes together to give the same message – that they all will no longer deny that the addiction has become a problem — and all clearly state that all of their enabling behavior in toto is going to cease, their wanting him to stop becomes far more believable. So it isn’t just multiple sources of info as Berger assumes, but the fact that they are all indirectly acknowledging their own contributions to the addict’s continuing addiction.

Of course, the addict may still be skeptical. If Phil leaves yet another rehab program without success, and his parents still let him return home, nothing will stick. In this case, that fortunately did not happen.

Wednesday, April 1, 2020

Family Dynamics and the Brain: Implications for Psychotherapy

IMO, the most important contribution of neurobiology to psychotherapy is our understanding, albeit quite partial and preliminary, of the mechanisms by which we are programmed to respond to attachment figures. This understanding is sort of what is meant by sociobiology, if I may use a politically incorrect term. 

I found early on in treating personality disorders in therapy that I was no match for a patient’s parents in triggering or reinforcing their problematic (or even their positive) behavior patterns in the long term. I could coach them on how to be assertive with difficult family members ‘til the cows came home, and this might even work for a time, but after a while the old patterns of self-defeating behavior almost invariably re-emerged unless something was done about this.

Even so-called “oppositional” behavior follows this path: oppositional children think and later automatically respond to their family as if the family wants or needs them to be a black sheep for various reasons.

Therapy outcome studies seldom follow patients with self-destructive or self-defeating behavior patterns for more than a year after therapy ends, but the few studies I’ve seen that do are consistent with this clinical experience. So I had to figure out a way to help patients to make changes in their long term repetitive dysfunctional interactions with attachment figures.

When mothers and their babies interact, huge numbers of synaptic connections in the brain are made every second (see These large numbers are “pruned” significantly during adolescence. We don’t know exactly how or why certain synapses are retained, but I suspect it is those that keep us aligned with the social behavior of our kin group and tribe. There is preliminary evidence that the pruning is dependent, much like the strength of many brain neural connections, on how often a particular neural pathway is stimulated.

Another factor involved is something called the myelination of neurons in existing neural pathways. This is the process of coating the body of each neuron with a fatty coating called myelin, which protects the neuron and helps it conduct signals more efficiently. This process does not become complete until an individual reaches late adolescence.

With these two processes, we lose some flexibility in the brain, but the proficiency of signal transmission improves. Since we are talking in particular about those that form during interactions in infancy, it is reasonable to suspect that these interactions continue to do this. In particular, behaviors that occur in response to social cues may become more automatic in order to preserve higher thinking ability for novel situations.

In addition to this, fear tracks formed early in life in particular are not as plastic as are other tracks in the brain. They never really go away, although they can be overridden by newly formed neural pathways. (Lott, D. A. [2003]. Unlearning fear: calcium channel blockers and the process of extinction. Psychiatric Times, May, 9-12).

According to Neuroscientist David Eagleman on his PBS show, The Brain, about 80% of our behavior is done automatically in response to environmental cues (especially social cues, I might add) without any conscious deliberation. In a sense they are subconscious.

This does not mean that we lack the capacity to decide to think about and break the social rules we are usually bound by. We certainly can – this is where the family systems theorists have been wrong. But when we do, we are often faced with massive invalidation by our families, which is extremely powerful in delivering the message, “You’re wrong, change back.” When we distance ourselves from our social alliances, our level of the attachment hormone oxytocin dips and we start to feel unsafe.

The negative feelings generated by this invalidation is probably the biological price we pay if we don’t: the highly disturbing feeling of groundlessness described so eloquently by Irvin Yalom. This is nature’s way of telling us to behave ourselves for the good of our kin group. This has survival value for the group.

The implications for therapy are clear. In order to prevent problematic automatic behavior patterns that have been and that are continually reinforced through this powerful process, neither insight into which behaviors are performed automatically, nor which automatic belief systems keep us on the straight and narrow for our kin group, is usually enough. These patterns need to be interrupted at their source in order to help patients extinguish bad habits of thinking (or, more often, not thinking) and behavior.