Sunday, February 24, 2013

How to Kick Everything


Christopher Kennedy Lawford on recovery.

Christopher Kennedy Lawford’s ambitious, one-size-fits-all undertaking is titled Recover to Live: Kick Any Habit, Manage Any Addiction: Your Self-Treatment Guide to Alcohol, Drugs, Eating Disorders, Gambling, Hoarding, Smoking, Sex, and Porn. That pretty much covers the waterfront, and represents both the strengths and the weaknesses of the book.

There’s no doubting Lawford’s sincerity, or his experiential understanding of addiction, or the fact that the raw ingredients were present in his case: bad genes and a traumatic early environment. He is related to Ted Kennedy, two of his uncles were publically murdered, and he started using drugs at age 12. But this book doesn’t dwell on his personal narrative. Lawford is a tireless supporter of the addiction recovery community, and Recover to Live is meant to be a one-stop consumer handbook for dealing with, as the title makes clear, any addiction.

To his credit, Lawford starts out by accurately pegging the addiction basics: A chronic brain disorder with strong neurological underpinnings. He cites a lot of relevant studies, and some questionable ones as well, but ultimately lands on an appropriate spot: “You can’t control which genes you inherited or the circumstances of your life that contributed to your disease. But once you know that you have the disease of addiction, you are responsible for doing something about it. And if you don’t address your problem, you can’t blame society or anyone in your life for the consequences. Sorry. That’s the way it works.”

Once you know, you have to treat it. “It can turn the most loving and nurturing home into a prison of anger and fear,” Lawford writes, “because there is no easy fix for the problem, and that infuriates many people.”

 Lawford includes good interviews with the right people—Nora Volkow, Herb Kleber, and Charles O’Brien among them. And he makes a distinction frequently lost in drug debates: “Nondependent drug use is a preventable behavior, whereas addiction is a treatable disease of the brain.” Due to our penchant for jailing co-morbid addicts, “our prisons and jails are the largest mental health institution in the world.” He also knows that hidden alcoholism and multiple addictions mean “rates of remission from single substances may not accurately reflect remission when viewed broadly in terms of all substances used.”

One nice thing about Lawford’s approach is that he highlights comorbidity, the elephant in the room when it comes to addiction treatment. Addiction is so often intertwined with mental health issues of various kinds, and so frequently left out of the treatment equation. The author is correct to focus on “co-occurring disorders,” even though he prefers the term “toxic compulsions,” meaning the overlapping addictions that can often be found in the same person: the alcoholic, chain-smoking, compulsive gambler being the most obvious example.

The curious inclusion of hoarding in Lawford’s list of 7 toxic compulsions (the 7 Deadly Sins?) is best explained by viewing it as the flipside of compulsive shoplifting, a disorder which is likely to follow gambling into the list of behavioral dependencies similar to substance addictions. In sum, writes Lawford, “If we are smoking, overeating, gambling problematically, or spending inordinate amounts of time on porn, we will have a shallower recovery from our primary toxic compulsion.” Lawford sees the exorcising of childhood trauma as the essential element of recovery—a theory that has regained popularity in the wake of findings in the burgeoning field of epigenetics, where scientists have documented changes in genetic expression beyond the womb.

But in order to cover everything, using the widest possible net, Lawford is forced to conflate an overload of information about substance and behavioral dependencies, and sometimes it doesn’t work. He quotes approvingly from a doctor who tells him, “If you’re having five or more drinks—you have a problem with alcohol.” A good deal of evidence suggests that this may be true. But then the doctor continues: “If you use illicit drugs at all, you have a problem with drugs.” Well, no, not necessarily, unless by “problem” the doctor means legal troubles. There are recreational users of every addictive substance that exists—users with the right genes and developmental background to control their use of various drugs. And patients who avail themselves of medical marijuana for chronic illnesses might also beg to differ with the doctor’s opinion.

Lawford attempts to rank every addiction treatment under the sun in terms of effectiveness (“Let a thousand flowers bloom”), an operation fraught with pitfalls since no two people experience addictive drugs in exactly the same way. Is motivational enhancement better than Acamprosate for treatment of alcoholism, worse than cognitive therapy, or about as good as exercise? Lawford makes his picks, but it’s a horse race, so outcomes are uncertain. Moderation management, web-based personalized feedback, mindfulness meditation, acupuncture—it’s all here, the evidence-based and the not-so-evidence based. Whatever it is, Lawford seems to think, it can’t hurt to give it a try, and even the flimsiest treatment modalities might have a calming effect or elicit some sort of placebo response. So what could it hurt.

Lawford’s “Seven Self-Care Tools” with which to combat the Seven Toxic Compulsions vary widely in usefulness. The evidence is controversial for Tool 1, Cognitive Behavioral Therapy. Tool 2, 12-Step Programs, is controversial and not to everybody’s taste, but used as a free tool by many. Tool 3 is Mindfulness, which is basically another form of cognitive therapy, and Tool 4 is Meditation, which invokes a relaxation response and is generally recognized as safe. Tool 5, Nutrition and Exercise, is solid, but Tool 6, Body Work, is not. Treatments like acupuncture, Reichian therapy, and other forms of “body work” are not proven aids to addicts. Tool 7, Journaling, is up to you.

One of the more useful lists is NIDA director Nora Volkow’s “four biggest addiction myths."

First: “The notion that addiction is the result of a personal choice, a sign of a character flaw, or moral weakness.”

Second: “In order for treatment to be effective, a person must hit ‘rock bottom.’”

Third: “The fact that addicted individuals often and repeatedly fail in their efforts to remain abstinent for a significant period of time demonstrates that addiction treatment doesn’t work.”

Fourth: “The brain is a static, fully formed entity, at least in adults.”

Finally, Lawford puts a strong emphasis on an important but rarely emphasized treatment modality: brief intervention. Why? Because traditional, confrontational interventions don’t work. The associate director of a UCLA substance abuse program tells Lawford: “I haven’t had a drink now in 25 years, and this doctor did it without beating me over the head with a big book, without chastising me, or doing an intervention. What he did was a brief intervention. Health professionals who give clear information and feedback about risks and about possible benefits can make a huge difference. A brief intervention might not work the first time. It might take a couple of visits. But we need more doctors who know what the symptoms of alcohol dependence are and know what questions to ask.”

If your knowledge of addiction is limited, this is a reasonable, middle-of-the-road starting point for a general audience.

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