Chronic Pain and Addiction: Its Impact on Families

I wrote this article with Dr. Mel Pohl, Medical Director of Las Vegas Recovery Center and author of numerous works on chronic pain and addiction. A version of this article appeared in the October 2010 edition of Counselor Magazine.

Pain is universal and important to all beings—it is a warning that something is wrong and needs attention to prevent further damage to the body. Acute pain functions to protect the body while it heals from trauma or injury. Whereas acute pain protects the body while it heals from trauma or injury, chronic pain is simply ongoing, persisting beyond its usefulness.

People commonly react by resisting the pain; they tighten muscles, stiffen their posture, or try to avoid moving. Resistance causes anxiety, sadness, fear, anger, and frustration. The more resistance, the worse the pain and suffering. Chronic pain includes the physical pain coupled with the emotional pain (suffering), triggered in the brain and generated by the limbic system (the emotional center of the brain). Physical pain and emotional pain are equally real.
As our population ages, chronic pain and its costs—both financial and on a human level—are increasing. Today, medical systems treat chronic pain in over 70 million Americans with a methodology known as “pain management,” which typically includes medications and procedures such as injections and surgeries. The estimated cost of chronic pain treatment in the US is $100 billion annually. The longer we live, the more likely we are to develop pain from a variety of conditions: autoimmune disorders, diabetes, arthritis, cancer, etc. Every time there is a car accident or a sports injury, someone is set up for chronic pain. Furthermore, in the case of back pain, research suggests that obesity, depression, and/or increased awareness of the condition contribute to an increase in back pain. (Griffin, 2009)

Chronic pain syndrome is defined as:
 Intractable pain lasting longer than six months
 Marked alteration of behavior
 Depression or anxiety
 Marked restriction in daily activities
 Excessive use of medications and medical services
 No clear relationship to organic disorder
 Multiple, non-productive tests, treatments, and surgeries

Drugs and Chronic Pain
Addiction treatment professionals will see the similarities and the relationship of addiction to chronic pain. Both involve feelings and loss of control, both affect personality, both are characterized by preoccupation, rationalization, and denial, and both have a profound effect on those around them. If medications are used for chronic pain, it is not uncommon for dependence and compulsive use to occur, especially with opioid painkillers. People with chronic pain often end up medicating their anxiety, fear, anger, and depression with these same drugs. It is common for these clients to have difficulty differentiating physical from emotional pain.

Christine, who struggled with chronic pain from migraines for several years, repetitively commented, “It just hurts, and I want relief.” This was her rationale for continuing to use her drugs. But she had developed dependence, loss of control, and compulsive use—in other words, addiction.


Families and Chronic Pain
With the co-occurring disorders of pain and addiction, the treatment of each becomes much more complicated. Living with someone in chronic pain also has many similarities to living with someone with an untreated addiction.
The problems for families are more diffuse and life-altering than those of the person living with the pain itself. The family suffers along with the person in pain, developing their own dysfunctional symptoms, and they need to find strategies and solutions that allow them to cope in more self-enhancing ways. Just as addiction is insidious, the role of pain in a person’s life is also insidious, and in time, for those within the family’s intimate circle, it becomes the central organizing feature of the relationship. Everyone is focused upon and responding to the pain. Families often need to make adjustments to accommodate both the person in pain and the results of the pain. They have myriad feelings depending on their relationship and role, and those feelings ultimately drive the highly enmeshed family members to frustration, anger, and social isolation.

Kevin was in a severe sports accident as a teenager, which led to several surgeries and chronic back pain. Kevin’s father, now divorced from Kevin’s mother and remarried with much younger children, is blatantly angry with Kevin. He is angry at Kevin for not working and for making excuses for not working, tired of hearing how his son’s life has been ruined by the accident, tired of calls from his ex-wife about Kevin’s escapades. The latest problem is that she wants him to pay for drug rehab treatment because now Kevin has become addicted to drugs and his behavior is out of control—all related to the accident and what his dad calls “this so-called chronic pain.” Kevin feels victimized by his father and the chronic pain and views his mother as his only ally. He also feels entitled, after all, “look what happened to me.” Kevin’s mother is totally preoccupied with his life and problems and in turn views Kevin as a victim because of these horrible things happening to him. She is unable to set any limitations on his behavior, regardless of how upsetting it is to her and the family. His dad is lost in anger and blame, both of which are equally ineffective vehicles for improving his son’s life.

Bill’s wife Eleanor has been in bed twenty hours a day for nearly four years in chronic pain, originally emanating from scoliosis surgery, and more recently with a diagnosis of fibromyalgia. He handles her medical appointments, dispenses her medications, mediates any contact with other family members, and passes on the latest news. He is responsible for feeding her, for making sure she is somewhat comfortable, and for cleaning the house and doing the laundry, in addition to working full-time. When the decision is made for Eleanor to enter a chronic pain treatment program, he is beside himself. Fearful of being without her, he calls or e-mails multiple times every day to question the staff. He is asking not so much whether she will get better or what that will mean for her (or him); he just wants to know when she will be home. In effect, he is going through his own form of withdrawal from Eleanor in this highly enmeshed and dysfunctional relationship. Both these families are reacting to the many ramifications and complexities of having a family member in chronic pain.

The family is a complex organism with diverse parts that make up the whole. It functions best when all the different elements are in good working order. When one member is in pain, the equilibrium of the family shifts, and family members change, adjust, and accommodate in response to the strain on the family system. While this is understandable, unfortunately, in time, even if someone has a strong sense of self and worth, the concerned other finds him- or herself acting out self-defeating behaviors.
Families need to develop an understanding of the consequences of their emotional and behavioral responses that may be impeding healthy family function. As an alternative, they need to develop positive coping and relational skills. Often, families may benefit from time apart (which treatment affords) so the person with chronic pain can improve and the family has some breathing room to do work on their own recovery and their healing process.

Biology of Caring
Neuroscience has done much to help us understand what occurs in the brain of the addict, and now it also offers us a better understanding of what occurs for family members. The brain is wired to react empathetically to someone in pain in order to warn others of danger and elicit help. Functional MRI scans show that when watching someone undergo electric shock, the observer’s brain lights up in the same areas in which the brain of the person in pain lights up. (Bufalari et al, 2007) One doesn’t have to witness the painful experience for the brain to react, simply seeing a person act as if he or she is in pain causes the brain to light up. When the person in pain is a family member, the reaction to his or her pain is exponentially stronger.
In another study, when researchers delivered electric shocks to people with chronic pain, they found that in the presence of a solicitous spouse, pain levels and brain activity increased substantially. This study suggests that even though well-intentioned, when a caring person is present, the pain is reinforced. (Flor et al., 2002)

Lessons for family members are:
 You are suffering as you witness your family member suffer, but your concerned and doting manner causes more pain in the very person you want to help.
 This research implies that family connections may well be the biological basis for enabling a loved one in chronic pain.
 Treatment implications involve developing a sense of equilibrium despite another’s experience of pain.

Fundamental Therapeutic Issues for Family Treatment
Chronic Loss
To be in a relationship with a person in chronic pain results in multiple losses. There is the loss of the relationship as it once was, loss of shared social and recreational opportunities, loss of financial security, loss of hopes and dreams being fulfilled, and loss of sexual satisfaction and intimacy, to name a few.

With these losses come a multitude of feelings:
 Fear that he or she will not get any better
 Fear of financial ruin (e.g., bankruptcy, poverty)
 Fear that your life is over
 Anger for thinking he or she is not trying hard enough
 Anger for what happened to cause this (e.g., God, the drunk driver who was responsible for the accident)
 Anger with the medical system for not having the answers
 Anger at the doctors for creating and perpetuating the addiction
 Anger at insurance companies for denying procedures and holding up the approval processes
 Anger at friends or family for not being there to help
 Embarrassment for his or her behavior when overmedicated
 Guilt for being angry
 Guilt for not being able to do more to make a difference
 Guilt for wanting out of the relationship and feeling trapped
 Sadness for the lost social times
 Loneliness that comes with social isolation
 Loneliness because of the emotional disconnection as he or she is preoccupied, distant, medicated

Understandably, family members often feel guilty just for having these feelings, knowing that the pain is not willful behavior. Their reluctance to express their feelings reinforces the dysfunctional family “Don’t talk” rule. In family systems in pain, people learn to minimize, discount, and deny their feelings. So what do they do with all of those feelings? They learn to stuff them, reinforcing another dysfunctional family rule, “Don’t feel,” which culminates in being stuck in a perpetual, unresolved grief process. Consequently, as with addiction, and to an even greater extent, family members become increasingly more emotionally isolated, not sharing their thoughts and feelings with others.

In addition to the emotional disconnection, they are increasingly socially isolated. They become restricted to the home, not wanting to leave the person in pain for fear that he or she will be need them or fear that he or she will put the house or someone else in jeopardy due to being under the influence of drugs. They become the caregiver, nurse, chef, and parent—their lives consumed with telephone calls, medical appointments, and wading through paper work. They limit people visiting for a host of reasons, such as not wanting to face the questions visitors ask, or not knowing to what degree the person in pain will be overmedicated on any given day.

Chronic Caregiving / Perfect Helper
It is only natural to do what is necessary to help when seeing a loved one in pain, but the role of caregiver often becomes overwhelming and burdensome. Sometimes efforts to make things better actually make them worse. The primary caregiver becomes the insurance expert and patient advocate, running interference with major medical systems and other family and friends, and often takes on a nurse-like role, controlling the dispensing of medication. When this continues for years, it often becomes the caregiver’s primary source of identity and esteem. The consequence of accepting such a role is the essence of codependency: becoming selfless in the service to another. No longer knowing what your own needs and wants are, the needs don’t get met and desires are abandoned. In the process of being a good caregiver, self-care is forgotten. The ultimate consequences for such a lifestyle encompass the unhealthy expression of anger, experiencing yourself as a martyr, sacrificing your needs to the needs of another, believing there are no options, and feeling helpless to create change in your own life. Without support and clarity about what is happening, caregivers can ultimately spiral into their own depression or find themselves self-medicating with food, alcohol, and/or other drugs.

Distorted Boundaries
Feeling sorrow and pity for someone in pain, families often take on responsibilities for that person, when in fact he or she is capable of managing those responsibilities independently. This not only creates an unhealthy dependency, it creates a disparate relationship and doesn’t allow the person in pain the opportunity to maintain self-accountability. Enmeshment is extremely common, fueled by feelings of guilt (often false guilt) and fear. Consequently, family members of people in pain act on their behalf, not allowing them to act for themselves.

Kevin and his mother were so used to her taking care of his needs, that he had become virtually helpless. She acted from a place of sympathy rather than empathy, which only reinforced Kevin’s helplessness. Engaging in empathy rather than sympathy will allow Kevin to maintain a stronger sense of self.

High Tolerance for Inappropriate Behavior
People who are in pain and on various medications frequently act out anger in hurtful ways. They feel frustrated, helpless, and scared.

Kevin's family members are experiencing these emotions, but also want to be empathic with Kevin. As a result, they have developed a high tolerance for inappropriate behavior. They are often raged at, called names, and treated with hostility. In spite of Kevin’s physical limitations, family members were also physically abused by him when he would throw objects at them. They made excuses for his behavior and developed a level of tolerance that had disastrous results, including Kevin’s dad ending up hospitalized for a bleeding ulcer. The belief that Kevin’s pain means he can’t help himself only leads to an abnormally high tolerance for inappropriate behavior. This allows Kevin to become an offender, and his family to move into a victim/martyr role. “After all, poor Kevin is in pain—who am I to complain because he shouts every once in a while? I can take it since I’m the healthy one.” Lacking healthy boundaries, Kevin and his parents are using faulty judgment and in danger of making poor decisions.

Preoccupation
As helpless as family members feel about the pain that is experienced, they often become highly vigilant and preoccupied with the pain and with the person in pain who becomes the central force in their lives.
The family members come to faulty conclusions based on assumptions and inadequate information. They are practicing mindreading, which frequently leads to misinterpretation of the truth. For example:

 When Bill’s wife says, “You go, I’ll be fine,” that must mean she wants him to stay home with her.
 When she rolls over in bed that must mean the pain is worse and she needs more medications.
 When Kevin doesn’t say he feels better that must mean he’s ready to have another temper tantrum.

The preoccupation with the pain and the person in pain also leads to social and emotional isolation.

When Bill is with others he cannot focus on connection, let alone have fun because he is consumed with not being present for Eleanor. Bill talks himself out of being with others so he can stay vigilant, believing Eleanor is incapable of managing for herself. He even started working from home so he could keep an eye on her, not being satisfied with his daughters’ offers to help him.

Controlling Behavior
In an effort to bring stability to what is a fragile situation, family members become controlling and preoccupied by trying to read everything they can find about the problem, searching out all possible remedies. While there is no doubt that everyone needs advocates within the healthcare system, in time this became Bill’s identity and only focus, negating all other needs. Eleanor had cause to be more dependent; for Bill there is a fine line between trying to be helpful and taking over. Controlling behavior is having things done your way, in your time frame, without respect for other people’s needs and boundaries. It is created by a fear (an often unrealistic fear) of imminent disaster, and then it feeds on itself. This controlling behavior is demonstrated not just toward the person in pain, but also toward healthcare providers, other family members, and all aspects of life. The chronic pain has become the central feature of the family member’s life.

Secondary Gain
Preoccupation of this type is also very connected to secondary gain. Family members frequently, consciously or unconsciously, sabotage recovery by being attached to their identity within the caregiving role. It becomes the major source of their identity and esteem, and without it they don’t feel of value. They feel displaced. They may have found a power in such responsibility and are left with a sense of worthlessness when they don’t get to operate in that role. While recovery may be consciously desired, the human element of “but what about me?” needs to be acknowledged and addressed.

Bill’s identity and worth is totally attached to attending to Eleanor’s needs. Likewise Kevin’s mom relies on her relationship with Kevin for the meaning in her life. As Kevin and Eleanor get well and more independent, Kevin’s mother and Eleanor’s husband find their sense of self falters, requiring them to rediscover their own life. As Kevin improves and becomes more accountable for himself, his dad loses the primary focus of his deep-seated anger, which stemmed in large part from his own issues of an abusive childhood. Having more clarity about his feelings enables him to respond in a healthier manner to the present reality.

Treatment Goals
Successful treatment must include family members. Similar to any effective treatment for codependency, clinicians should consider the following when working with families:

1. Offer a framework to understand the differences between emotional and physical pain.
2. Validate that all pain is real.
3. Validate the experience of loss.
4. Help family members decrease their isolation.
5. Help family members recognize codependent behaviors as self-defeating to both themselves and their partner/family member in the long run.
6. Offer them a framework to understand the basis of their codependency.
7. Assess for primary disorders, including pain, addiction, and psychiatric co-morbidities.
8. Assist them to engage in greater self-care practices and establish their own program of recovery.

Critical throughout the process is to help the client and family members discuss their hopes and expectations. Expectations are many times simply fantasy—the expectation that there will be instant intimacy, healthy communication, and no conflicts. Counselors should remind families that they are not performing “brain transplants” in treatment, simply eliminating toxic substances and helping clients’ change their patterns of thinking, feeling, and behaving as the first steps in establishing a healthy lifestyle. As with the client, the family members need their own self-care plan wherein they identify both the behaviors and thinking that need to stop, and the behaviors and thinking that support recovery. They must also learn the areas that are triggers for self-defeating thoughts and behaviors and develop a way in which to address them. Family treatment will facilitate learning healthy communication skills to assist in family members’ ability to talk about the process as they engage in their newly learned ways of relating to the fact that the pain is real, but that the suffering is modifiable and optional.

Successful recovery practices for the client and family draw from many disciplines. Through mindfulness, cognitive practices, and twelve-step philosophy, families and clients can develop skills to work around the “edges” of the pain. (Kabat-Zinn, 2005) Instead of being absorbed in the search for a cure, families can learn that the solution lies with accepting the situation and the condition. Drawing from the gifts of addiction treatment, recognizing your powerlessness ultimately leads to genuine acceptance and improvement of health for the person in treatment and the family.

Kevin gradually learned about pain recovery—the process of knowing that the pain exists, will always exist, and will not kill him. Though they came from opposite directions, Kevin’s parents ultimately came to a mutual understanding and acceptance of healthy boundaries. As a consequence of Bill’s recovery work, he and Eleanor both took responsibility for their part in coping with the pain and now were better able to take responsibility for their part in establishing a healthy, interdependent relationship with one another.

By giving up the struggle, pain is lessened and suffering diminishes for the person in pain and his or her family.

References
Bufalari, Ilaria et al. “Empathy for Pain and Touch in the Human Somatosensory Cortex.” Cerebral Cortex, 17 (November 2007): 2553–2561.

Flor, Herta et al. “Conditioning: Learning that Pain Can Elicit Reward.” Presented at Society for Neuroscience Annual Meeting, Orlando, Florida, November 2–7, 2002.

Griffin, Morgan R. “Is Chronic Pain on the Rise?” Pain Management Health.
http://www.webmd.com/pain-management/features/is-chronic-pain-on-the-rise.

Kabat-Zinn, Jon. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. Bantam Dell, 2005.

Under the Influence: Kids of Alcoholics

Dear friends,
NACoA has been working over the past year on an important program about children of alcoholics (COAs) and featuring adolescent COAs. The program promises to be enlightening and moving not only for children and youth so desperately trying to cope with parental alcohol abuse, but it will also open the eyes of people of all ages and in all kinds of families.

Premieres Sunday November 14th at 9:00pm ET/PT on Nickolodeon

For more information about the program click here: http://news.nick.com/11/2010/05/when-parents-are-alcoholics/

Difficult Family Relationships

The struggle for so many recovering adults is how to interact with members of their childhood family — their parents and siblings. Cultural and family values influence the messages and feelings you received regarding family loyalty and commitment. Typically, you want to stay connected with your family. But, how do you re-enter the arena of family relationships and be true to who you are and what you believe? Your efforts may be tentative at first; you will have to learn somewhat from trial and error. Everyone's situation is unique and every individual will need to sort through these issues in a way that is comfortable to them.

It is common to hear adults express loneliness and sadness that their recovery has further alienated them from various members of the family. When a family has not developed healthy alliances, communication patterns, etc., one family member's recovery is often confusing for the non-recovering members.

Being with family members may mean having more superficial interactions — sharing the daily routine without intimacy, recreational interactions, carrying on family rituals. Traditional occasions may be one way to maintain connection to ones you love. Even superficial contact provides connection. Your choice (remember, you do have choices here) may be to choose this level of involvement over no involvement at all. Limited involvement in connection is okay.

It is helpful to know why you are engaging with family. Do you feel a sense of loyalty, duty, enjoyment, or love? People differ as to their history and values, which impact decisions about being loyal and dutiful. In spite of family pain, many people still feel love, and many people have found ways to enjoy certain family members. Or, are you still unconsciously seeking validation or approval?

It doesn't seem to matter how old we are, we all want to know that we are valued by our parents. When we don’t receive validation in our growing up years, it often becomes an even more urgent, yet usually denied, need. Unfortunately, validation and approval are not as apt to be offered by sick or unhealthy parents. They are often no more capable of offering that to us today than they were when we were children. In fact, it is more likely they are now seeking that from us. So know your expectations. And ask yourself if your expectations are realistic. Are they based on hope from seeing behavioral changes, or is it possibly a fantasy?

The holiday season is approaching and this is a time for recognizing your choices about how you spend time with family.

Present Day Relationships

By creating healthier beliefs and developing new skills, you will create new ways of relating to family members with whom you were raised, and others you meet in your life — friends, co-workers, partners, husbands, wives, and children. You have choices about who you invite into your life and how you interact. Yet, you may still be confused about what creates a healthy relationship. One of the most important concepts in creating healthy relationships is to understand that relationships have different levels and purposes.

Some people are only in our lives, or we are only in theirs, to provide a practical service. For example, the bus driver's role is to see we are driven safely to a destination. The barber's role is to provide a satisfactory haircut. A co-worker's role is to develop a relationship that allows the goals of the workplace to be met. The intimacy we develop with friends and partners offers a greater sense of meaning, purpose and connectedness than our more casual and superficial relationships. I do not want to discount that we develop caring feelings toward those who work with us or provide services, but some people overwhelm others in an attempt to garner intimacy with all they meet. As a result, they often distance people in their unrealistic expectations, feel let down when others don't reciprocate, and have little intimacy with anybody. They find they have less time for those they've made commitments to and more with those whose relationship is more superficial.

The levels of adult relationships are:
Casual Involvement occurs in relationships where people interact in a casual manner and have little or no commitment to one another.
Companionship involves two persons associating for the purpose of sharing a common activity. The activity is more important than the person and the person becomes interchangeable.
Friendship is where two people associate for the purpose of mutual support and enjoyment of each other. The person is most important. The activity is secondary.
Romantic relationships are when friendship is shared with sensuality, passion, and sexuality. Romantic love is more than passion and sexuality. Passion and sexuality can be experienced in the context of casual involvement.
Committed relationships are when we commit to working on taking responsibility for our part and mutually agree to do what we say we are going to do. We trust that when there are problems, it does not mean the relationship is over. We agree to work on whatever problems arise with a mutual trust of sincerity and intent. Commitment does not mean you stay in a relationship irrespective of what may occur. At times, as people change, relationships are renegotiated. Commitments are reinforced or lessened, but when we make a commitment, we do what we can to make the relationship work, not allowing ourselves to be abused, nor allowing ourselves to give up our integrity in the process.

While it is not always reality, it is healthiest for people to move through these levels as listed. Once a relationship has moved into a romantic or committed level, the couple continues to incorporate the previous levels into their daily lives. Committed relationships incorporate casual contact from the standpoint that superficial routine is a part of daily life. For people with a troubled childhood, it is important to learn that casual contact is not abandonment. The ability to move in and out of these levels will be incorporated into a committed relationship.

As well, there can certainly be intimate moments and experiences with strangers or companions. Those who experience natural crisis at the same time, those who are witness to a beautiful scene together, may connect in a highly intimate fashion. While such moments may be fleeting in time, they may affect us for life. Those times are seldom forgotten, yet it is with our close friends, partners, and family members that we experience our greatest ongoing intimacy.

Excerpt from Changing Course

The Power of Secrets

Secrets are powerful because they can control you. Very often, the problem with a secret is not the content of the secret itself, but what you must do to keep the secret information out of sight. In a family, it is the proverbial skeleton in the closet and everyone in the family is held responsible to remain on guard in case someone outside the family gets too near the closet door.

Whether secrets are passed down unbeknown to others or people actively collude to hide the information, it is fair to say that as a young child you had no choice in the matter; you were more or less coerced to keep the family secret. As an adult, you are now enforcing that secrecy on yourself. You may not be aware of it but you are the one making the choice to keep certain information away from prying eyes. The secret is just that — only information — and the choice is yours to tell it, to admit it, or to keep it hidden.

By admitting the reality of what is, you deflate the power of the secret. You can't drink away, exercise away, eat away, work away, or by any other effort rationalize away the power of the secret. The only way is to end denial, to admit, to open the closet door — that is the only way to get free.

The Emotional Injury of Distorted Boundaries

Many times abandonment issues are fused with distorted, confused, or undefined personal boundaries. We experience abandonment when parents have a distorted sense of boundaries, their boundaries and ours. They want us to like what they like, dress like they dress, and feel as they do. If we in any way express differences from our parents, or make different choices than they would, we know we run the risk of rejection.

How many of us attended colleges that our parents chose for us? How many of us married who we did or when we did because that was expected or desired by our parents? Having done what our parents expected, wanted, or demanded does not mean that it was the wrong thing to do. It just means that the decision was never totally ours. Certainly, many people do exactly what their parents don’t want them to do. Often this is an attempt to be a separate person. We choose to marry the person they would like the least, or simply choose to not attend college at all. It is not the outcome that is the issue as much as it is the decision-making process. Instead of choosing freely, we make a reactive decision based in anger.

When parents hold children responsible for what should be their responsibility, they are expecting something impossible of a child. In effect, they are telling children that they have more power than they truly have, setting them up to experience futility and inadequacy.

Many times parents develop relationships with their children in which they are their friends, their peers, their equals. In doing so, they share information that is not age-appropriate for a child. Inappropriate information often creates a sense of burden, or even guilt, for children. That is not fair.

When parents are disrespectful of their children's boundaries and violate them, the message given is that they don't value the child as a person. That message becomes internalized as "I am not of value. I am not worthy." When parents don't acknowledge children's boundaries, the message they give is "You are here to meet my needs," and/or "I am more important than you," and/or "It is not okay to be your own person with individual feelings, desires, or needs." When children experience chronic abandonment with distorted boundaries, they live in fear and doubt about their worth. The greater the clarity a child has around boundaries, understanding who is responsible for what, and the greater a child's self-esteem, the more likely a child will be able to reject, rather than internalize, shameful behaviors and messages.

As children we cannot reject parents, because they are so desperately needed. Instead, we take on the burden of being wrong or bad. In doing this, we purge parents of being wrong or hurtful, which reinforces a sense of security. In essence, outer safety is purchased at the price of inner security.

What we must understand now is that our abandonment experiences and boundary violations were in no way indictments of our innate goodness and value. Instead, they revealed the flawed thinking, false beliefs, and impaired behaviors of those who hurt us. Still, the wounds were struck deep in our young hearts and minds, and the very real pain can still be felt today. The causes of our emotional injury need to be understood and accepted so we can heal. Until we do, the pain will stay with us, becoming a driving force in our adult lives.

Excerpt from Changing Course

Understanding the Pain of Abandonment

When children are raised with chronic loss, without the psychological or physical protection they need and certainly deserve, it is most natural for them to internalize incredible fear. Not receiving the necessary psychological or physical protection equals abandonment. And, living with repeated abandonment experiences creates toxic shame. Shame arises from the painful message implied in abandonment: "You are not important. You are not of value.” This is the pain from which people need to heal.

For some children abandonment is primarily physical. Physical abandonment occurs when the physical conditions necessary for thriving have been replaced by:

• lack of appropriate supervision
• inadequate provision of nutrition and meals
• inadequate clothing, housing, heat, or shelter
• physical and/or sexual abuse
  

Children are totally dependent on caretakers to provide safety in their environment. When they do not, they grow up believing that the world is an unsafe place, that people are not to be trusted, and that they do not deserve positive attention and adequate care.

Emotional abandonment occurs when parents do not provide the emotional conditions and the emotional environment necessary for healthy development. I like to define emotional abandonment as “occurring when a child has to hide a part of who he or she is in order to be accepted, or to not be rejected.” Having to hide a part of yourself means:

• it is not okay to make a mistake.
• it is not okay to show feelings, being told the way you feel is not true. “You have nothing to cry about and if you don’t stop crying I will really give you something to cry about.” “That really didn’t hurt.” “You have nothing to be angry about.”
• it is not okay to have needs. Everyone else’s needs appear to be more important than yours.
• it is not okay to have successes. Accomplishments are not acknowledged, are many times discounted.
  

Other acts of abandonment occur when:

• Children cannot live up to the expectations of their parents. These expectations are often unrealistic and not age-appropriate.
• Children are held responsible for other people's behavior. They may be consistently blamed for the actions and feelings of their parents.
• Disapproval toward children is aimed at their entire beings or identity rather than a particular behavior, such as telling a child he is worthless when he does not do his homework or she is never going to be a good athlete because she missed the final catch of the game.

Many times abandonment issues are fused with distorted, confused, or undefined boundaries such as:

• When parents do not view children as separate beings with distinct boundaries
• When parents expect children to be extensions of themselves
• When parents are not willing to take responsibility for their feelings, thoughts, and behaviors, but expect children to take responsibility for them
• When parents' self-esteem is derived through their child’s behavior
• When children are treated as peers with no parent/child distinction

Abandonment plus distorted boundaries, at a time when children are developing their sense of worth, is the foundation for the belief in their own inadequacy and the central cause of their shame.

Abandonment experiences and boundary violations are in no way indictments of a child’s innate goodness and value. Instead, they reveal the flawed thinking, false beliefs, and impaired behaviors of those who hurt them. Still, the wounds are struck deep in their young hearts and minds, and the very real pain can still be felt today. The causes of emotional injury need to be understood and accepted so they can heal. Until that occurs, the pain will stay with them, becoming a driving force in their adult lives.

Excerpt from Changing Course

The Lois Wilson Story

When Love is Not Enough: The Lois Wilson Story, is a new "Hallmark Hall of Fame" presentation starring Winona Ryder and Barry Pepper which will broadcast Sunday, April 25 (9:00-11:00 PM, ET/PT) on the CBS Television Network.

Spanning more than 30 years, this movie is based on the biography by William G. Borchert and is the true story of the enduring but troubled love between Lois Wilson (Ryder), co-founder of Al-Anon, and her alcoholic husband Bill Wilson (Pepper), co-founder of Alcoholics Anonymous.

I had the wonderful opportunity to meet Lois just two years prior to her death at age 97 in 1988. A representative of World Service Al-Anon took me to her home where I shared with her my children's book My Dad Loves Me My Dad Has a Disease. She had a great love for children, but was physically unable to bear her own and Bill's drinking interfered with adoption possibilities. She was a delightful woman, and most gracious. We also connected about being bicycle riders, as that day she had just gotten off her stationery bike!

Lois stuck by her husband through many years of tormented and abusive alcoholic drinking, believing that her unconditional love could get him sober. It could not. This loving and determined woman watched her husband, Bill destroy his career, his relationships and his health, checking into and out of alcoholic sanitariums as he neared the point of death and insanity. Finally through a life changing spiritual experience Bill was led to another alcoholic, Robert Smith, and together in 1935 they founded AA.

As Bill and Bob attained lasting sobriety, Lois began to question the value she had in her own marriage. After devoting 17 years to healing her sick husband, Lois felt isolated and resentful that he was sober without her help. Lois eventually discovered that she was not alone. She slowly engaged the wives of the men in Bill's program and came to realize that while Bill was addicted to alcohol, she was addicted to him - and that the family and friends of alcoholics are, in some ways, as sick as their loved ones. Lois gained the necessary understanding needed to repair her fractured relationship and to help millions of others do the same. She co-founded Al-Anon in 1951.

Al-Anon is one of the most successful forces for good in the world today. The Twelve Step programs developed by Lois and her husband are the basis for multiple self-help groups growing around the world today, from Narcotics Anonymous to Overeaters Anonymous. Al-Anon groups can be found throughout the world, where ever one lives there will be a group meeting nearby.

The story of Lois Wilson is a poignant account of her life, its impact on the recovery world and on addiction in families.

Deceived: Denial & Minimizing

When as a partner of a sex addict rationalizations become weak, the tendency to minimize comes next. That only strengthens the denial. Minimizations common to those in relationships with sex addicts are:

• It’s not that bad.
• I’m the only one who really understands him.
• He needs me ─ now more than ever.
• It’s just a phase.
• It’s not his fault that whore went after him; he didn’t have a chance.
• I’m not that interested in sex anyway.
• It could be worse. At least he is not addicted to ____ (something other than sex, i.e. alcohol, drugs, gambling, etc.)
• It doesn’t matter if I don’t know everything he does.

How often have you had these thoughts?

Think about the beliefs and fears that bolster your rationalizations and minimizations. Partners of addicts share common beliefs and fears. Some of them are:

• I can’t live without him.
• No one else will ever love me.
• I don’t deserve better.
• He’s the father of my children, and they need their father.
• All men are like this.
• I would have to give up some of my lifestyle because there is not enough money.
• My family might find out and I’d feel humiliated.
• The kids might find out and I won’t know how to handle it.
• I’ve never balanced a checkbook, paid bills, or paid attention to our retirement and I am not capable.
• If others found out about his sexual behavior they would think I’m not a good sexual partner, because if I were, he would not stray.
• If he is a sex addict, then all the good times in the past were a lie.

Does any of this sound familiar?

It’s easy to start to berate yourself, to feel like a fool. If you are beating yourself up, stop. Denying, minimizing, and rationalizing are the most natural responses to living with someone acting out an addictive disorder. Of course you want to protect yourself. You want to believe it’s not the problem it is. You want to give him the benefit of the doubt. It’s so painful to get to the truth when the reality is only he can change his behavior; you can’t do it for him. But you can honor yourself; that starts with challenging your own addictive behavior − your denial. This begins with identifying what you know and/or suspect and seeking out literature to learn more about codependency, sexual betrayal and sexual addiction. You don’t have to believe it’s addictive but be open to understanding what the addiction may look like. Pay attention to his behavior, not his words. Be willing to seek out a clinician trained in working with sexual betrayals and addiction.

Deceived: Denial & Rationalizing

As a partner of a sex addict you minimize, discount, rationalize, deny, and pretend things are different than they really are because you want to trust your partner. You want to believe the relationship has a strong foundation. You want to be able to believe all is okay. That is absolutely understandable. Don’t be critical of yourself. If you see the situation for what it really is and don’t know what to do, it is natural to slide into a state of hopelessness and helplessness. The truth taps your greatest fear, that you are unloved and abandoned. You feel shame and humiliation. So as long as the addict denies or minimizes it, you can rationalize, deny, and pretend as well. The illusion of safety and security is an enticing fantasy. But in the process you quit trusting yourself, your inner voice.

Denial induces numbness. Now couple your need for denial with the fact that sex addicts are masters of misdirection. They can quickly tap into your vulnerability, and charm you or shame you right out of your distrust. His manipulations may include being charming, bullying, threatening, and playing the victim and often using the combination of any or all of those. This conduct is beyond hurtful. It’s cruel, abusive, and traumatizing. It is also a natural aspect of addictive behavior, a manipulative attempt to take the focus off of him.

Examples of denial are thinking such things as:

• The pornography doesn’t really bother me, it’s only pictures.


• He can’t help it if other women throw themselves at him.


• Work must be his problem; if he would just change jobs.


• If we move he will stop this behavior.

Your denial is supported by extensive rationalization.

• Men will be men.


• He is an honest person; he would not lie to me.


• He’s not really staring at women; he’s just interested in watching people.


• It doesn’t hurt to look at pictures (porn) – at least he is not having an affair.


• It’s easier for him to be friends with women – that doesn’t mean he is having an affair.


• His business takes priority over me and the kids but I understand – it’s just while he is building his career.


• I must have gotten this STD from a toilet seat – he told me I couldn’t have gotten it from him.


• He told me the long distance calls were not his – the phone company must have made a mistake.


• Those Internet spammers are infiltrating our email with porn sites.


• The police are exaggerating his behavior.


• He’s such a good dad.


• It's not his fault that I can’t fulfill him sexually.


• I am the one he comes home to.
  

Does any of this sound familiar? If so, they are rationalizations that will keep you in denial.

March 2010 News Letter

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Deceived: Denial In the Face of Truth

Whether you are in the media, such as Elin Woods, or the unnamed spouse out of public site, yet living with chronic deception, you may ask, “How did I get to this place?” Denial is one reason, not just your partner’s denial but your denial. As partners of alcoholics frequently feel guilty for the behavior of the alcoholic − that if they were better partners, if they could just do the right thing, the alcoholic wouldn’t drink so much − partners of those who are acting out sexually nearly always believe that his behavior is a statement about themselves. They believe they must not be pretty enough, sexy enough, smart enough, thin enough, alluring enough, ample-breasted enough, long-legged enough. The list is never ending.

You probably operate from the belief, “I need to do or be something different and that will make him stop.” First and foremost you need to understand that you are not the cause of his acting out behavior. It isn’t about you being different. He engages in his activity because of his own emotional wounding that now manifests in a pathological relationship with a mood altering behavior which for him is sex.

For years partners of addicts, irrespective of the addiction, have pretended that things are different than how they really are. When the addictive behavior is sex instead of alcohol or drugs, gambling, food, etc., denial for the partner is often accelerated because of the greater degree of shame and implied messages about the person acting out and the coupleship. Partners deny in an attempt to hang on to what is really an illusion, the fantasy that all is really okay. The fact is life is out of control; the addiction is in the driver’s seat. But deny you must when you can’t see your way out. It is a form of self protection.

After hearing time after time that you have quite an imagination, or that you are the one responsible for his unhappiness, or that it’s your job to shut up and be grateful for what you have, or that you simply have trust issues, you learn to keep quiet. You keep fears and doubts to yourself while your self esteem erodes away.

Simply put, denial is dismissing your own intuition. It is blatantly overlooking what is right in front of you. Often there are clear indicators that you have a serious problem but you may choose not to see it. Denial stems from a yearning to believe that all will be fine or that all will return to how it was before this acting out behavior reared its ugly head.

Do not chastise yourself for your denial but learn from it. It is a natural response to hurt and loss. Unfortunately it only perpetuates your situation and your pain in the long run. For your own well being it is critical you recognize the many ways you’ve rationalized. That is a start in stopping this well practiced defense.

Conway Hunter Award

At the SECAD Conference held February 21-24 in Nashville I received the prestigious 2010 Conway Hunter Society Award for service of excellence in the field of addictions. Here I am with Eileene and John McRae of the Conway Hunter Society.
The award is a big, round gold medal and it was so heavy, I had to take it off. I felt like I was at the Olympics!

Children of Addiction

Thirty years ago I began working with children impacted by addiction in the family. Addiction in the family is a legacy that continues to thrive, although today we have a much better understanding of how children are influenced when raised with the chaos and fear that permeate an addictive family. Yesterday I was confronted with issues of children on two fronts. I was working in a treatment facility in their four day family program and had the opportunity to work with some children of clients - a 15 year old, 17 year old and 23 year old. These young adults were aware of how their lives were negatively impacted via their relationships with others, their own use of drugs, and how fear in general was influencing their decisions about many aspects of their lives. Then while sitting in an airport, I received a call from a desperate mother wanting to know what she should do as her husband, in an alcoholic fury, had just hit their preteen age son. These are just four of the estimated 27.8 million children in the U.S. affected by or exposed to a family alcohol problem. This number does not include those affected by or exposed to other drug problems.

These children are at increased risk for a range of problems, including physical illness, emotional disturbances, behavioral problems, lower educational performance and susceptibility to alcoholism or other addictions later in their life.

It doesn’t have to be this way. Through our churches, schools, other community venues, and online social networking sites there is an opportunity to advocate for these vulnerable children who are not in a position to advocate for themselves.

Children living with addiction in their family, be it an addicted parent, sibling or other relative, need to know that the addiction and the resulting behavior is not their fault. They need to hear the message that they did not cause it nor can they control it. They need to hear they are not alone. Most importantly they need to hear there are people they can talk to, adults in their school, their church or synagogue, a friend’s parent, an extended family member, etc. As concerned family and community members and helping professionals we need to recognize the role we can play in these children’s lives.

Now is the time to be willing to rise to the occasion. Sunday February 14th through Saturday February 20th is Children of Alcoholics Week 2010, a week dedicated to bringing awareness to the needs of these children. NACoA, the National Association for Children of Alcoholics has a wealth of free information about children, and even more so about resources and ways for you to become involved this week and in the future. ACO week can be about you educating and creating greater numbers of people who reach out and let children know they are available to them and they will understand.

It is my hope we all recognize that we are in a position to impact these children not just this one week but for 365 days a year.