Congratulations to Barack Obama

As a college student at Wesleyan in '61 (or was it '62?) I joined with other white students to team with groups of black students from Howard University in an effort to integrate lunch counters in Glen Burnie, a suburb of Baltimore.  In some places we sat indefinitely without being served; in one, we were served coffee with salt in it; at another they locked the doors as we approached.  When we picketed the segregated local movie theatre, a mob of white men surrounded us as sheriffs watched.  A providential cloudburst scattered the crowd and allowed us to escape.  

On the night of election day in 1964, I arrived at the civil rights movement headquarters in Jackson, Mississippi, to begin a few months of volunteer work.  Nearly everyone was glued to the TV set to see whether the Democratic Party would seat the elected black delegates running under the banner of the Freedom Democratic Party.  The answer was, no.  

These and other memories came upwelling as I watched the inauguration of Barack Obama.   The party that wouldn't seat elected black delegates had nominated a black man for president.  A man whose father would not have been served at DC area restaurants 60 years ago was taking the oath of office.   Indeed, there has been some changes.

This morning's San Francisco Chronicle editorializes that Obama's new approach is "grounded in sobriety and hard work."  The "sobriety" that's meant here is, I assume, the metaphorical kind -- a pragmatic, realistic attitude -- and not the literal kind, meaning abstinence from alcoholic drink.  Yet there's a connection to reflect on, here.  

For me, personally, my time of active engagement in the civil rights movement was largely a time when my alcoholism (acquired in my freshman year in college) was in remission.  Engagement in life-changing work was hugely more interesting than drink.  My drinking habit only bloomed large during the years of reaction that followed, when it seemed that everything we had done was being undone.  Pessimism, despair, lack of hope were the atmosphere in which this illness flourished.  And I'm not the only one.  Is it an accident that the drug problem grew larger in rough proportion as conditions for the poor and middle class in America stagnated and deteriorated?  

Barack Obama's own history with alcohol and other drugs offers a refreshing contrast to that of his predecessor in office.  Obama has freely and openly admitted experimenting with drugs as a youth, but then stopped; he is trying to quit, or has quit, smoking.  What a contrast to the history of "W," whose claimed mid-life alcohol salvation story is widely believed to be a sham that covered up more than it revealed, notably a long history of cocaine use, some say.  

I've not yet seen anything in the way of Obama's statements so far that gives a clue to his specific policies on alcoholism and other addictions.  The federal government has many levers to pull and many dollars to spend in this area.  On general principles, I assume that Obama will support the recent extension of parity in the treatment of mental health and addiction treatment.  I assume that the federal agencies in this area will continue to be funded.  

The open questions in my mind are (a)  War on Drugs, and (b) Federal excise taxes on spirits and tobacco.  We need "change we can believe in" in the "war on drugs," a criminal exercise in hypocrisy and racial/economic persecution that is long overdue for radical reform.  An even more telling mark of Obama's mettle will be whether he supports Congressional action to raise the excise taxes on liquor and tobacco.  Public health advocates have long maintained that raising these taxes is the single most effective measure to reduce the social impact of these two most murderous addictive drugs.  Needless to say, the pillars of corporate greed stand deeply dug in on this issue.

The largest opening in the clouds under this new administration will be in the area of improving living standards and reducing inequities for the poor and middle class.  If the real and emotional environment of ordinary people in this country becomes infused with progress and hope, the problems of alcohol and other drugs will recede as if of their own accord.  It will take some time, but if the new administration succeeds in this largest and most difficult of goals, we will, in fact, see a new era of "sobriety" in both senses of the word.

Congratulations to President Barack Obama, and best wishes for the future.

P.S.  To date, the White House Office of National Drug Control Policy remains under an interim head, Patrick Ward, a Bush appointee who has held the post a bit over a year.  Obama's choice of Rep. Jim Ramstad to become the new Drug Czar has run into heavy fire for Ramstad's ties to abusive "faith-based" programs, his policy positions on prevention, and his ties to a massive investor fraud.  Read Maia Szalavitz's blog blast and the Drug Policy Alliance editorial.  Ramstad is not change, he's MOTSOS.  

End Stage

Is nothing sacred? Michael Shermer, Scientific American's Skeptic columnist, reports in the November issue that one of the icons of psychology, the five stages of grief, has been debunked.

Launched by Elizabeth Kubler-Ross in her book On Death and Dying (1969), the model of denial-anger-bargaining-depression-acceptance is one of the most widely known paradigms in modern psychology. But, according to Shermer's sources, there appears to be no evidence that most people most of the time go through most of those stages in that order, or any other order.

The five stages of grief, along with similar "stage" theories, Shermer says, satisfy people's craving for simplicity and predictability. Unfortunately, the scientific basis for them is just not there. And they can also impose feelings of guilt and shame on people who are not feeling what they think they should. And, in today's world, people who follow the simple "stages" narrative are the exception, while diversity and individual variation are the rule.

Good grief! What's next? Are we going to learn that there is no evidence that most people recovering from addiction go through a certain well known set of steps?

Genetics of mental illnesses: More is Less

Genetic research into psychiatic disorders appears to be undergoing a systemic deflation not unlike that in the financial markets. As I posted a couple of weeks ago, a survey article in the then-current Scientific American showed that genetic studies of human intelligence had labored mountainously and brought forth a 0.4 per cent mouse. Today comes a special issue of Nature Neuroscience dedicated to the neuropsychiatric diseases, and it's the same story. The initial radiant hope that today's mega-billion dollar genetic research apparatus would nail the culprit genes responsible for schizophrenia, autism, bipolar disorder, or depression, has dimmed to a faint glimmer. The more we can see, the less we find.

In the roundup article, Steven Hyman (Department of Neurobiology, Harvard) works hard at sounding upbeat, but has little to work with. Family studies, rich in anecdotal material, suggest that autism, schizophrenia, bipolar illness, and major depression must have major genetic components. Therefore it should be a simple matter to find the genes, and then to develop medications that target those genes.

Over the past two decades, however, efforts to identify risk-conferring alleles for the common forms of neuropsychiatric disorder have largely been unrewarding. Despite the significant role for genes highlighted by aggregate measures of their influence (Table 1), the underlying genetics of common neuropsychiatric disorders has proved highly complex, as attested by unpredictable patterns of segregation in families, lack of Mendelian ratios in twin studies and serious difficulties in replicating genetic linkage studies.

Anecdotes notwithstanding, the given illness frequently appears in people without the suspected genetic traits, fails to appear in people with the traits, and appears in people with other traits believed to be associated with an entirely disparate disorder. Current technology can easily identify "highly penetrant" genetic variations that cause a narrow subset of disorders, such as some types of Alzheimer's disease and macular degeneration, but the candidate genes involved with the most common psychiatric disorders make only a very slight dent in the etiology. It doesn't help that the clinical definitions of the psychiatric disorders tend to lack objective physiological markers, so that diagnosis rests ultimately on clinicians' opinions, which may vary widely.

Neither Hyman's article nor the remaining items in the special issue of Nature Neuroscience focus on addictive substance abuse, but you could substitute "alcoholism" into the paragraphs just quoted and come out with the same result. I've summarized the research on that topic in my forthcoming book. By April, when the book comes out, it should be amply clear that the deflation of the genetic myth in alcoholism is only part of a larger panorama of reassessment. The better our genetic research tools become, the more clearly we can see, the more obvious it becomes that we cannot blame our genes for our disorders, nor can we hope for a magic pill to set us right. It's just not going to be that easy.

Spirituality strikes out

Two controlled trials of the effect of spirituality on addiction recovery showed no improvement for the patients given spiritual guidance as part of the usual treatment regimen, either in their addiction recovery or in their spiritual practices.  In fact, in one trial, the patients provided with spiritual guidance made less progress in overcoming depression and anxiety than the patients not given spiritual treatment.

Details are in the Journal of Substance Abuse Treatment, July 25 2008.  The abstract is here.  Thanks to David Kaiser Ph.D. for flagging the item.  

Dual diagnoses have same root?

Substance abuse and mental illness very commonly go together. One hypothesis to explain the correlation is to see the patient using alcohol/drugs to medicate the mental disorder. Another view sees the mental disorders as the symptoms of excessive drug/alcohol ingestion. Now comes Dr. Andrew Chambers and his researchers at the U of Indiana Medical school with a study that suggests both theories are wrong. Based on experiments with adult rats, Chambers found that both substance abuse and mental disorders probably stem from a malfunction in the amygdala, a small region within the brain that plays a role in numerous processes, including the memory of emotionally charged events. Read details. Read blogger Jason Schwartz's piece on the same issue, here.

Treating substance abuse in schizophrenics

Patients diagnosed with schizophrenia show higher rates of substance abuse than the general population. Because substance abuse, including smoking, may greatly complicate treatment of and recovery from schizophrenia, clinicians are looking for pharmacological tools that are effective with this population. This discussion in Psychiatric Times suggests that newer "atypical" anti-psychotic medications are more effective in combating substance abuse in schizophrenics than older, conventional anti-psychotics. Read details here.

Alcoholism a "disinhibitory disorder"

Alcohol dependence is linked with impaired impulse control, as are several psychiatric disorders, a study led by Bernice Porjesz, professor and director of the Henri Begleiter Neurodynamics Laboratory at SUNY Downstate Medical Center, has found. The study is said to be the first that strongly links alcoholism to malfunctions in the frontal lobe of the brain. Older studies typically locate factors associated with alcoholism in the more primitive lower brain regions. Discussion. Abstract.

Chief justice was addicted and delusional

Former chief justice William Rehnquist was addicted to what the Associated Press described as a "powerful prescription pain-relief medication" for at least ten years and suffered from paranoid delusions, FBI files released today under a Freedom of Information Act request show.

Rehnquist was on a prescription for Placidyl from 1970 to 1981, the files show. Placidyl (ethchlorvynol), known on the street as "jelly bellies," was an addictive drug having slurred speech (a Rehnquist trademark on the bench) among its side effects. Withdrawal from Placidyl can bring psychotic episodes. It was yanked from the U.S. market in 1999.

The FBI file, citing one of his physicians, said Rehnquist experienced withdrawal symptoms that included going to the hospital lobby in his pajamas in a bid to escape. He imagined that there was a Central Intelligence Agency plot against him, and he also seemed to discern changes in the patterns on the hospital curtains. Rehnquist thought he heard voices outside his room discussing various plots against him. Source.

P.S. As pointed out in comment No. 1, below, Placidyl was in fact not prescribed for pain but for insomnia. It is a sedative and a hypnotic. Source.

Man busted in nicotine withdrawal rage

Braunschweig, Germany: A smoker in nicotine withdrawal called police to complain he was going mad. He then took a hammer to a cigarette vending machine. He was arrested shortly afterward. Details.

Australia study confirms cannabis, psychosis links

Use of marijuana can activate a pre-existing family disposition to schizophrenia and can cause schizophrenia symptoms even in people without that disposition, a study by the Mental Health Council of Australia has found. Details.

Smoking depletes important brain chemical

Chronic smoking significantly depletes levels of an important amino acid in the brain's anterior cingulate cortex (ACC), the part of the brain that processes pleasure and pain, German researchers have found. Depletion of this amino acid is linked with a number of psychiatric and mood disorders, including schizophrenia, dementia and bipolar disorder, as well as in cases of substance abuse, particularly alcohol dependence. Source.

Smoking cessation in psychotic patients

People with a psychotic disorder can benefit from a smoking cessation intervention consisting of nicotine replacement therapy plus motivational interviewing and cognitive behavior therapy, according to a new study.

"Despite extremely high rates of smoking among individuals with psychotic disorders and the associated financial and health costs, few studies have investigated the efficacy of smoking cessation interventions among this group," Dr. Amanda Baker, of the University of Newcastle, Australia, and colleagues write in the current issue of the American Journal of Psychiatry. Details.

Montana adopts integrated treatment model

Substance abuse and mental illness, long treated as distant cousins, become conjoined in the latest treatment model in Montana.

Community Program Officer Mary Jane Fox with Montana’s Addictive and Mental Disorders Division came before the Kalispell Mental Health Local Advisory Council recently with a clear message.

“Individuals with co-occurring disorders need to be thought of as the expectation, not the exception,” Fox said.

To move toward integration, Montana contracted two top experts, Dr. Ken Minkoof and Dr. Chris Cline, for training and consultation.

Their model stresses screening every mental illness client for substance abuse and every substance abuse client for mental illness in a welcoming atmosphere. Success comes from “empathetic, hopeful, continuous treatment relationships.”

“There is no one correct treatment approach,” Fox said. “Everyone is an individual.” Source.

"We are not 12-step sponsors for pay"

BURBANK, CA: H. Westley Clark, M.D., J.D., M.P.H, director of the Center for Substance Abuse Treatment of the federal Substance Abuse and Mental Health Services Administration (SAMHSA), gave the keynote at the annual addiction counselors' conference in Burbank this morning. In the course of reviewing the high rate of turnover, the low level of educational preparation, and the low pay scale in the addiction counseling profession, he said that some people are confused about what counselors do. "We are not 12-step sponsors for pay," Clark emphasized. "I love 12-step programs but we are not. We are driven by state of the art knowledge in a very complex field."

The remark drew vigorous applause from maybe a third or half the audience of several hundred addiction professionals in the ballroom of the Burbank Hilton. The main reason for the low pay and the low esteem in which addiction counselors are held is the constant recruitment of 12-step graduates who see the job primarily as a service opportunity, work for peanuts, and bring with them little but their own experiences. A lot of people in addiction counseling are in fact no more than "12-step sponsors for pay," and this holds back the profession.

At the start of his Powerpoint presentation, Clark showed a photo of Pres. Bush with a sentimental quote about people helping people. As a high federal employee, Clark probably had to show such a slide. Not a single person in the audience applauded.

An Effective Choice-Based Treatment Approach

A client-centered recovery program that designs services to fit “clients’ individual experiences, perceptions, and needs” and where staff works with clients “on learning choice-making skills as an essential part of recovery” has scored impressive outcome improvements with a challenging dually-diagnosed populations, says an article in the July issue of Behavioral Healthcare (www.behavioral.net). The choice-based program, called CHANGES, targeted a high-risk population with multiple psychiatric hospitalization histories, including jail time. As a result of the program’s individualized approach, “clients previously considered ‘treatment avoidant’ became treatment receptive.” (p. 36)

This finding will not surprise savvy LifeRing participants (or other readers of the Recovery by Choice workbook). The traditional mental health and substance abuse approaches too often are designed to serve the interests of the providers and payors, rather than clients. Providers frequently assume as rock-bottom truth that clients are incapable of making choices, and therefore must have prefabricated solutions rammed down their throats. Instead of learning to make choices, clients are made to dwell on their moral defects and to affirm their powerlessness to change. Why are people surprised that this kind of approach produces “treatment avoidant” clients and has a dismal outcomes track record?

Millions of taxpayer dollars are wasted every month on treatment programs that are ineffective and in many instances abusive. Lonny Shavelson’s “Hooked” details many of the absurdities in the system. The CHANGES program — embodying some central tenets of the LifeRing philosophy — not only showed significant outcomes improvements, it yielded substantial cost savings. The CHANGES approach deserves consideration and creative emulation by other professionals in the mental health / substance abuse fields.