Julie Miller's Mental Health Blog

Archive for March 2010

Recovery from compulsive gambling looks similar in some ways to recovery from drugs/alcohol addiction.  Ultimately, abstinence from the problem behavior is the goal.  “Harm reduction” is another approach, based in substance abuse treatment, which which the individual’s potential harm from the problem behavior is reduced, but the behavior is not eliminated.  Perhaps one just drinks a couple beers a day instead of a 5th of vodka.

I’m not clear exactly how harm reduction might work with process addictions, but perhaps just gambling when one is in Las Vegas (and of course, the individual doesn’t live in Las Vegas).  Or maybe just cutting down, staying on a budget and only gambling with $100 instead of $10,000.

Frankly, harm reduction may have a place in substance abuse treatment, but I can’t see how it could be beneficial in the long run for anyone with a process addiction, like gambling.  The compulsive behavior continues, but in with an attempt to control it.

A classic sign of any addiction is an inability to control one’s substance use or compulsive behavior, so further efforts to control it by “cutting down” seem destined to fail in the long run.

Abstinence from the behavior is not generally achieved over night, and progress, not perfection, is the intermediate goal.  An individual with a food addiction must eat to sustain life; however, certain foods (sugar, junk food, etc.) are not required to sustain life.  Similarly, drinking fluids is required to sustain life, just not drinking alcohol.

I do not need to gamble to sustain life.  I do not need to go to a casino or betting track to sustain life.  Frankly, I don’t even need the internet (at least not yet) to sustain life.  Abstinence from any and all gambling behaviors can be realistically achieved, with work, willingness, and motivation.

An addiction is a coping skill, a way to cope with life when I don’t know anything else to do.  I might be bored, angry, sad, or scared.  Those are some internal triggers for acting out in the compulsive behavior.  I might see the odds for who will win the NCAA Basketball Tournament on TV, triggering the urge to gamble.

How can I deal with my feelings or external triggers without gambling?  Support and professional help.  Some folks can overcome their problem behaviors without help, from friends or family or professionals.  Many, however, do need that “leg up” to find their way out of the cycle of problem gambling.

Many services, free or low cost, are available.  Gambler’s Anonymous is a 12-step group supporting members in abstinence from problem gambling.  It is run by other recovering problem gamblers and has no fees or dues.  It can be found online and in-person meetings exist wherever there are people with gambling issues.  Here’s their website:

http://www.gamblersanonymous.org/

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Problem gambling is a “process” addiction, not a substance addiction.  Process addictions are things like eating disorders, sex addictions, spending/debting addiction – whatever is compulsive and “addictive,” that is not a chemical, drug or other substance.  Sometimes the addictions go together, as in drinking and gambling at a casino.

Gambling is a process addiction that does not create a physiological dependence on a substance and therefore does not create withdrawal symptoms upon abstinece; however, there are many similar dynamics to a physiological dependence on a substance and withdrawal.

Withdrawal symptoms from compulsive gambling may include cravings, urges and longing to return to gambling, anxiety, irritability, a sense of emptiness or loneliness, depression, euphoric recall (remembering gambling as a wonderful thing, and forgetting all the pain caused by it), etc.

I know several individuals who gamble, either with card games, sports betting, casinos, or online gambling.  Most of these individuals have a set limit of the money they will spend and use gambling as truly a recreational activity.  When they’ve used up the funds they set aside, it’s over.  They don’t lie about it or hide it from family or friends.  They are not preoccupied with gambling or with planning their next gambling adventure.  They do not need to gamble with increasing amounts of money to achieve the desired level of excitement (also known as tolerance).  They do not use gambling as a way to escape problems or relieve uncomfortable feelings (such as anger, sadness, helplessness or guilt).  They do not commit illegal acts such as forgery, fraud, theft or embezzlement to finance gambling.  They do not rely on others to provide money to relieve a desperate financial situation caused by gambling.

These behaviors are indicative of a problem.  Do you notice that you relate to some of these behaviors?  Perhaps you relate, but not with gambling; perhaps you relate with shopping, internet, food, or working.

Process addictions can be as damaging to oneself and to one’s family and friends as any chemical addiction.  With the advent of legal casinos in Arizona, run by Native American Tribes, problem gambling has increased, along with options for getting help.

Next time, we’ll talk about what recovery looks like!

An individual suffering from factitious disorder is utilizing the sick role to gain benefits such as nurturance, sympathy and/or attention.  This is not the same as malingering, in which an individual feigns illness of some kind to benefit financially or to avoid military service.

Ever called in sick to work because you didn’t want to get that unpleasant assignment from your boss?  Or what about telling the professor that you have the H1N1 flu, and could you take the test at a later date?  Of course, on the phone, you sniffle or cough just to improve the effect.  Anyone ever get out of an important work obligation by reporting that your mother is sick or died or that her father died, or her mother?  This would be malingering, not a factitious disorder, as the benefit is not simply to gain sympathy or nurturance, but indeed to escape a responsibility.

You may recall the TV series M*A*S*H, and Corporal Max Klinger feigning various psychological symptoms or bereavement issues in an effort to get out of the army (transvestitism, frequent deaths of mother, grandmother, aunt, father, brother, etc.).  Malingering.

The cost to the sufferer of a factitious disorder and their family and friends may be steep, including fear, resentment, anger, hurt and sadness.  Treatment includes psychotherapy for the individual with the factitious disorder, and family therapy to address the impact of the illness on the family.  The disorder tends to be chronic and difficult to treat, requiring acquisition of painful insight and family involvement.

“F” is not an easy letter in the DSM-IV.  When I came across factitious disorder, that seemed particularly relevant, given that I recently worked with a young man who clearly suffered from this diagnosis.  I could tell you the details of that case, but then I’d have to kill you.

The individual induces or simulates the illness or disease process, either in themselves or in the victim, and then presents for medical care (with the victim in the case of proxy).

The DSM-IV describes a factitious disorder as “physical or psychological symptoms that are intentionally produced or feigned in order to assume the sick role” (p. 471, DSM-IV).  For example, perhaps a man has a wound on his leg that he continues to re-injure (intentionally), keeping it from healing, so he can to to the emergency room and receive concerned attention and nurturing from the staff.

If it is factitious disorder by proxy, it is the deliberate production of physical or psychological symptoms in another person while that person is under the individual’s care.  Formally known as Munchhausen by Proxy, an example of factitious disorder by proxy is portrayed in the film, “Sixth Sense.”  A girl is slowly poisoned to death by her mother, and the mother receives benefit through the sympathy provided by friends and family in response to the child’s illness and death.

These behaviors seem outlandish to the vast majority of us, and yet the behaviors make sense for the person with the disorder.  It is a solution to a problem that is solved by assuming the sick role, or by assuming that role by proxy.  The  need for attention, sympathy or nurturing may have gone unmet as a child, and certain defenses may have been generated to allow the individual to take on the sick role to have these needs met, but he or she lacks insight into their behaviors.

Like many mental health issues, stress may trigger the behavior.  Threatened loss of a relationship may trigger a woman to create a physical illness (simulated or induced) to keep her partner with her (who can leave someone who has cancer?).  Loneliness, threat of overwhelming adult responsibilities, even job or family stress, legal or financial responsibilities might be alleviated (at least temporarily) by feigning of illness in oneself or another in order to receive sympathy or nurturance.

I wonder what questions folks have out there about EMDR…  I’ve been asked if it’s like hypnosis, and I always say:

No.

EMDR does not change your level of consciousness, or brain waves, like hypnosis.  EMDR cannot be used to dredge up repressed memories.  EMDR is not intrusive and does not change memories (other than to reduce the level of distress associated with them).

I’ve been asked if EMDR can erase memories that someone wants to get rid of.

No.

EMDR can reduce the level of distress associated with distressing memories.  It can help reframe what one thinks of oneself (e.g., “I am responsible; it was my fault” can reframe to “I did the best I could with what I knew at the time; it wasn’t my fault.”)

I’ve been asked if it’s like brainwashing.

No.

EMDR doesn’t wash your brain, or anything associated with it.

EMDR is intended to kick-start the adaptive information processing system (AIP, as explained by Francine Shapiro) so that previously unresolved overwhelming (i.e., “traumatic”) experiences can finally be brought to adaptive resolution.

There is so much information available about EMDR online.  If you are interested in learning more, please check one of the following sites:

www.EMDR.com

www.EMDRIA.org

EMDR is one of the most amazing forms of therapy out there.  Yes, I’m biased.  I am a certified EMDR therapist and spend most of my work life conducting EMDR sessions.  I’ve had EMDR as a client as well, and I can attest to its effectiveness.

Like most humans, you are probably wondering, “Now, how does EMDR work?” I’m here to tell you that we (meaning, researchers and practitioners of EMDR) don’t know it’s mechanism.  Much like penicillin, we still don’t know why or how it works.  We just know it does.

SPECT scans (Dr. Daniel Amen’s studies especially) seem to show that blood flow in certain areas of the brain increases after a client has EMDR.  Other forms of brain studies have shown that parts of the right side of the brain “go dark” when a client thinks about a traumatic incident from their past, signifying that the event or incident was overwhelming to the individual’s central nervous system.  The right side of the brain appears  necessary to processing events and experiences we have as humans, so when it’s dark, it’s not working, and we can’t process that experience or event.  EMDR appears to bring the “lights” back on in the right side of the brain, and keep them on, while the client is talking about and focusing on the overwhelming event or experience.  This enables a fairly rapid processing of the targeted event.

Processing the event allows the client to bring all the adult resources and experiences the client has to bear on the issue, quickly coming to adaptive resolution.  This means that the images, sounds, smells, somatic sensations, even tastes associated with the experience are less disturbing.  The emotions associated with the incident become less intense, less disturbing.  And finally, the thoughts the client has about him/herself are reframed in a way that feels true.

Let’s take the example of a car accident in which the client is a passenger.  The image might be sitting on the ground after getting out of the car, looking at the crumpled car, smelling the burning rubber of the tires.  The sound of  the sirens approaching from afar.  The thought “I should have done something.”  What the client wants to believe is that, “It wasn’t my fault; I couldn’t have done anything to avoid it,” and perhaps this positive belief currently feels completely untrue.  The emotions might be fear, pain and guilt.  The intensity of the distress is a 7 on a scale of 0-10.   The physical sensations in the present moment is tension in the stomach and chest, and a clenched jaw.

In processing through this experience, the individual comes to a place where the image feels further away or blurrier, and has no emotional impact.  He or she can no longer hear the sirens or smell the burning rubber when they think of the original incident.  The client moves from fear, hurt and shame through anger to calm.  He or she believes the thought, “It wasn’t my fault; I couldn’t have done anything to change it.”  The level of distress moves down the scale from a 7 to a zero or 1.  No distress is felt in the body.

The client can then also take this new perspective on the accident into other memories or experiences in which they felt as if the situation was their fault.  This may include earlier experiences as a child, or other situations in the present.  The client can imagine possible future situations in which he or she typically feels responsible for things that are not his or her fault, and can imagine how he/she might respond differently NOW, given this new perspective.

Freedom from the past.  Options about the present and future situations.

A single incident like this example could conceivably be processed in one session of target work in EMDR.  Obviously, there are no guarantees, but I have worked with individuals who completed their work on a single incident in one 90 minute session.

Relief in 90 minutes – worth it?  You bet.

“EMDR” is an acronym for “Eye Movement Desensitization and Reprocessing.”  This therapeutic process was first stumbled upon by Francine Shapiro in the 1980s.  The story I heard when I was first trained in 2000 was as follows:

Francine had some family issues going on, and had received a letter from her brother.  She was upset.  She went out for a walk, and on one side of the sidewalk was a fence that cast shadows to the other side of the sidewalk.  Francine voluntarily moved her eyes as she walked by each shadow, moving her eyes from right to left and back again.  When she got to the end of the sidewalk, she noticed she wasn’t distressed about the letter any longer, and she had not forgotten about it, not been hypnotized, not dissociated, and not been distracted.  When she brought up the letter, the distress was simply gone.  Being a graduate student at the time, she became interested in what had happened, and began to look into it.  She practiced on family and friends, and developed the trauma protocol we basically still use today.  She began working with Vietnam-era vets in the VA system and discovered EMDR works to reduce disturbance about past traumatic experiences that continue to impact on the individual’s life.

Through the last two decades, research has been conducted with EMDR that shows not only its effectiveness in reducing distress about unprocessed traumatic experiences, but also in working through just about any issue you would go to a therapist to address:  anxiety, depression, chemical dependence, eating disorder, grief/loss, phobias, chronic pain, etc.  Research has also shown that it is not the eye movements that are the key to how it works; it’s any form of bilateral stimulation (BLS) that kick starts the innate information processing system all humans have in the central nervous system.  This information processing system is adaptive, allowing us all as humans to learn from our day-to-day experiences.  If that system gets overwhelmed by any particular event or series of events, the processing system gets stuck and we can’t get through the process of learning from the experience, throwing away the garbage, and filing the memory away in old storage.  If we can’t get the experience(s) to run through the adaptive information processing system (a phrase coined by Francine Shapiro), then the system starts to just repeat repeat repeat, hoping maybe THIS time it’ll run through.  Like a broken record, skipping and going back to the same place every time, never moving forward.

With unprocessed traumatic material, this “skipping” process looks like recurring dreams/nightmares, flashbacks, intrusive thinking, getting triggered, avoiding triggers, hypervigilence and dissociation.  My system is trying to get it processed through, but keeps getting stuck.

EMDR helps kick-start that processing system that’s gotten stuck around a particular issue, and keeps it’s engine running as you work through the process.  You will focus on a particular issue (like Francine and her letter) and the bilateral stimulation will keep you processing alone instead of the system shutting down.

EMDR must be conducted by a highly trained clinician who has plenty of experience using EMDR.  You can find more information about EMDR and trained clinicians at the following sources:

http://www.EMDRIA.org

http://www.EMDR.