In this episode, we speak with the licensed therapist and substance abuse treatment specialist, Karen Perlmutter, to explore the many sides of alcohol and substance use and abuse. If you've been questioning your own or a loved one's relationship to alcohol and other substances then this conversation will offer useful information, hope, and a path to healing. Want to learn more about Karen Perlmutter's work? Visit her at www.collaborativecounselingllc.com
Moderator (M): Well Karen thanks for being here and being part of the podcast and I want our listeners to know that you're going to be at the low country mental health conference this summer which is July 26th through the 28th and for those of you who are interested in it's a great conference she's going to be giving a keynote on issues of substance abuse along with loved ones and that whole dynamic which is going to be really a great conversation and if you want to learn more about that because you can see her talk or listen to her talk you can do it in person or virtually and it's lowcountrymhconference.com so please check that out.
Why don't we just launch right into it here Aaron and this topic of alcohol and drug abuse. It's such a big topic for today and what causes a person to decide finally that it's time to get help?
Guest (G): I think that people typically have these stereotypes about what somebody with substance use disorder or what we typically call an alcoholic or society would call a drug addict, what they look like and we say like well you know it's the guy under the bridge with the paper bag of liquor or something like that. But the truth is there's a lot of people walking around that have unhealthy relationships with substances that are far from you know living under a bridge and I think it ends up being a very personal conversation with yourself about consequences and whether consequences are beginning to outweigh the benefits and that looks different for different people. There is a defined set of criteria for what we call substance use disorder but even that is a spectrum disorder right you could sort of have a mild variety you could have a moderate you could have a really severe or advanced stage version of that but the truth is there's probably a spectrum below the spectrum. You know where people sort of working their way up but not necessarily to a degree that there are consequences you know they're physical, social, emotional, consequences are bad enough that they meet criteria for the diagnosis so whether we're looking at the actual disease of substance use disorder or just somebody who has sort of disordered use of substances it really comes down to a conversation with yourself about consequences.
M: I was talking to you offline about this and, for me, it's a personal thing because I've been now a year and a half without drinking and so I think I would fall on that continuum you know because I don't use words like recovery or sober now or things like that but it was becoming a problem I thought and also physically, mentally whatever. It just felt like it was becoming a problem and so I was making an effort to stop and in so some of the challenges around that were pretty significant so I kind of can relate to what you were saying about that it's not just sort of the stereotypical of what people may view as somebody who has hit rock bottom.
G: I think that we're really looking at three different factors right for anyone who's starting to feel concerned or if you're concerned for a family member we're looking at a transition from I'm only having this glass of wine because I want to it serving some sort of a need right like I need it to sleep or I need it to be able to socialize or I need it to be able to get up in the morning or something like that but the latter being of course a more extreme version. We're also looking at risk because if you have a healthy relationship with substances you're not going to take risks in the name of it right? You're not going to be driving with drugs in your car where you could get caught you know you could get pulled over and you could lose your job over it that kind of thing. Once we cross over into risk we at least want to sort of be alerted that that maybe something's going on there and then the third of course is consequences. If we have a healthy relationship with substances it shouldn't come with consequences right? It should be something that we engage with socially through leisure but doesn't cause problems in our life.
M: I think for people that I know and for myself that I think that was it. It was kind of getting into sort of that riskiness where both for myself in terms of things that maybe I was doing but also just in terms of how I was feeling but there was this level of denial around it. They talk about denial when you're talking about addiction but I can really kind of understand it now as this super complex thing.
G: One thing that I have found is that the more success or stability or accomplishment you've had in your life, the harder it is to admit powerlessness over something right? Because they talk about powerlessness as the first step and you're saying you know I'm not powerless look at my CV or I'm head of a law firm. Like that's ridiculous, I've been able to overcome every hurdle in my life or you know I have 300 employees working underneath me or something like that. So it doesn't tend to resonate at first. It's a really tough sell yeah.
M: So what are some of the things that you tell family members they're concerned or that you did it sort of kind of breakthrough that that barrier for their loved one?
G: There's a maddening element to being a family member or a loved one when you're watching someone you love do something that doesn't seem healthy. They're beginning to deescalate right in front of you or self destruct in front of you because you know we can't convince another person that they have a problem or that they need to make a major change in their lifestyle anymore than you could convince me if I had right wing political views to become a left wing political view person or vice versa right? If I say hey you know could you just go ahead let me explain to you why you should switch over and become a supporter of X it would be a really tough sell right? I mean I don't think anyone could say anything to me to make me say oh I hadn't thought of it that way. I'm sold right you know and I think that's much the same that the way a person lives their life has really personal. I think one of the things that we can do is approach it with compassion instead of judgment. People are far more open and receptive to hearing feedback when you're coming from a place of curiosity you know like “how's that working for you?” Do you have any concerns rather than coming from a place of lecturing them and having a plan in place that you've decided is right for their life. The other thing I think families can do, and this is a tough one for families because it feels very unloving, if somebody is really beginning to evolve into more advanced stages of substance abuse unfortunately that's gonna naturally begin to come with consequences right? As their behaviors get riskier and they become less functional they're going to start facing consequences I remind families you kind of have to get out of the way. You don't have to create, you don't have to artificially manufacture consequences for them. You don't call their boss and try to get them to get fired so that they hit rock bottom or anything like that. I'd say they'll do a fine job creating their own consequences if this is the direction it's heading but you do need to get out of the way and you know don't pay for the attorney don't do the things that we typically do because it's loving. Because in order to get sober a person really needs to be able to see that the costs are outweighing the benefits in their life and that that is really on a on a very primal level because addiction affects a lot of parts of the brain but the part of the brain that really gets overtaken by addiction is the limbic system which is a survival part of the brain. It's a very primal part of our brain it's not really a thinking part of our brain. It's more the part that sort of makes our body sweat and makes our heart beat and that kind of thing and it's the part of the brain that says if this feels good it's probably good for my survival and that's it. It's a very simplistic formula so we need to allow some of those not so good feelings to enter their world so that they can begin associating that you know it's the substance that I'm using that is creating these not feel good feelings in my life. If we're stepping in to intercept their consequences they're not getting to feel.
M: That's interesting what about the person themselves you mentioned kind of like doing an inventory I guess but what would you say if somebody's on here listening to this podcast who maybe they have sort of an inkling or an itch that that they're having a problem. What can you tell them is certainly some steps that they might take?
G: I think that what I like to tell people is that the journey is yours. I have no right to take away your freedom. I have no interest in taking away your freedom. As a substance use therapist, my job is to support you in figuring out what's right for you. So I think a good therapist is going to sit by your side and help you weigh out the pros and cons. I think there's this sort of feeling that your rights are going to be robbed from you the minute that you admit to the people that love you or that care about you or that they're working with you professionally that suddenly that freedom of choice is going to be taken away from you. I sometimes think we need to see the value and just sitting with somebody and being an ally as they figure out what's right for them and what I find and what research shows about change behavior is sitting with somebody as an ally and their change is far more effective in helping them move the needle on change than enforcing change for somebody. So find the people in your life that can do that for you.
M: What are your thoughts on the whole umbrella of treatment options or continuum of it that is available to people now?
G: I think if somebody is a heavy drinker and just beginning to have an unhealthy relationship with substances it's great to try to take a dry January right? It's great to try moderation. There's a program in Charleston called moderation management for people that are just trying to have accountability to moderation, however, when you get to a point that you're really meeting criteria for substance use disorder we probably are in a different category at that point and you know I've always said to my clients that I'm open minded to the notion that maybe somebody would find a way to crack the code. I've had clients so many times over the years who want to maintain some relationship with substances either because they have a deep love for the substance and what it's done in their life or the fun or the surface elements of it or because you know letting it go isn't an admission of failure or whatever the reason is. I think that letting it go is terrifying to people but maybe something that is necessary if the other efforts that we're making aren't working. We tend to think of people who have substance use disorder as almost having an allergy to their substance. Now it's not actually an allergy. It doesn't work like an allergy. It's referenced that way in the big book of AA because it's a fair analogy. It's sort of like you're sitting next to somebody who's eating a beautiful juicy lobster and you're like that looks so good but unfortunately I have a shellfish allergy I just can't I can't have it. That stinks right and it sort of works that way for people who truly have a substance use disorder. They can't. Their body and their mind do not respond well to that substance so when we get into some of the more advanced stages of the illness we sometimes do need to take more extreme measures or go to more intense levels of service you know in the really extreme advanced stages of addiction. There are even times that we need to remove ourselves from our home environment because at that point, our brain is incapable of stopping and if you'd like me I can talk a little bit about why that is in the more advanced stages.
M: Well let's get to that in a second because I'd like to follow up on this more. Let's say somebody says “OK I think I have a problem”. And maybe they're deciding I'm going to do a dry January or whatever month it may be. What are some of the hurdles for somebody to stay clean and sober?
G: Again I think that it's going to look different if this is somebody who's a heavy drinker versus somebody who has crossed over into that substance use disorder lane. For somebody who's a heavy drinker we're going to be looking at changes to people places and things. We're going to be looking at our changes to our relationships with friends. We're going to be questioning do we have certain friends that I thought they were great friends but maybe they were just drinking buddies those types of things and then also alcohol usually meets a need that is beyond just the substance. You know drugs meet a need beyond just the substance. There's a whole social life that revolves around it. There's a high and getting ready to go out at night right those types of things and you know we were saying before we started recording that when you stop using there's sort of like a substance shaped hole sitting in your life and people usually need to find recreation or extreme sports or hobbies that they can get into that are of interest to them and that can take a while. And finding friends that you can connect with not just over substances can take a while if we're looking at it from the perspective of substance use disorder. We look at substance use disorder as a brain disease and some of the things that end up changing in the brain make it incredibly hard to stay sober and this gets us into some of the hurdles for somebody trying to stay sober. So one of the things that's happening is that when you stop drinking your brain has become incredibly dependent on that substance to release and to give you the dopamine that you need and our brain doesn't think of dopamine as a luxury it thinks of dopamine as a necessity for survival. So your brain goes into this state this dopamine depletion or deficiency and really begins screaming at you to get this substance back. To find something to give you dopamine so it's saying you've got to find your way back to dopamine whether it's drugs or sex or something that's going to give you dopamine. The other thing that's happening simultaneously in the brain is that the prefrontal cortex which is responsible for really important human functions like the more sophisticated functions like having morality, having good judgment, having long term planning, being able to learn from past mistakes, having empathy for people around you, and how your actions affect other people those are really kind of sophisticated human concepts. The frontal cortex is responsible for those functions and begins to sort of shut down during active substance use or active substance abuse. So when somebody starts to get sober not only is their brain screaming at them you've got to get dopamine back in your system, figure out a way to do it quickly they don't even have access to the part of the brain that is going to guide them to healthy ways to get that dopamine. It really becomes a setup for failure. I should say a setup for a lot of hardship and that becomes the hurdle that they're trying to stay sober because the consequences have gotten so big but their brain in almost every way is working against them and telling them you've got to go get that substance.
M: Let's go back to the continuum again because you've referenced substitutes disorder a number of times and just for our folks to know what are some basic criteria just so people have a frame of reference around that.
G: That's a great point. We're looking at 11 criteria for substance use disorder and a lot of them interestingly are subjective and we're not looking at a blood test you know not taking a blood test to see if we have a problem with substances. It's really based on how our life is unfolding and what the global impact of substance use has been on our life. Most of the criteria it is looking at consequences and our continued use in spite of consequences so it's saying things like “my use of substances has caused a problem in my relationships and yet I continue to use anyways”, “my use of substances is causing me health problems and yet I continue to use anyways”, “my use of substances is causing problems to my career or my schooling or my productivity and yet I continue to use substances”. So many of the criteria is looking at consequences and then there's also some physiological criteria where we're looking at things like my tolerance has increased. I now experience physical withdrawals if I don't have the substance. We're just kind of seeing the upping of the ante it's sort of like how many little areas of my life has this substance woven its little fingers into. It's kind of like the BLOB.
M: It's just kind of surrounding my life in more and more ways and so if we could go back to that continuum again and what you were talking about around the hurdles around staying clean and sober and how it can be different for somebody who meets that criteria and for somebody maybe abusing a substance but it hasn't gotten to that quite yet. Because again, I feel like this is personal for me. As you mentioned, you're stopping the drinking or you're stopping the use of of a drug and there's a loss one feels. I've experienced this kind of believing where it sort of forces you to look within in ways that you know maybe the substance that kind of masked that or allowed you to not have to look at it. Would you talk a little bit more about that and sort of that journey that you help people through?
G: Absolutely. I think that there's a saying in recovery that says recovery is easy all you have to do is change absolutely everything (laughing). Oh my God what does that even mean you know and I think that it's a process for people to understand what that means now how dramatically you have to change everything obviously is going to vary from case to case. If somebody has been 100% dysfunctional unable to work, unable to manage their finances you know overdosing multiple times and you know that's going to look very different than somebody who has remained high functioning throughout their substance use. And of course I work with people all across that spectrum but you know getting sober usually means you gotta face stuff that's uncomfortable. There's a lot of great quotes in recovery. Another one is if recovery feels comfortable you're probably doing it wrong. I like that one as well so you know people who experience problematic substance use not always but often have a trauma history and you know one of the things that we need to do, which takes a tremendous amount of courage is be willing to sort of look at where all this started and if it didn't start with a specific trauma history because some people sort of say you know gosh I feel like there was supposed to be some major childhood traumatic event that happened to me and there wasn't. And that's certainly OK! You don't need to conjure one up that didn't exist but you know we want to look at what the need is that we've been trying to meet. What have we been trying to run from because there's some reason that we began getting into disordered substance use whether it's a self- esteem issue or sort of negative thoughts that we've never really been able to tackle or address effectively. It could be sort of the lens in which we view the world you know whether it's one of resentment or self pity but you know the substances have begun serving a purpose in our life and it's sort of given us this ability to artificially manipulate feelings that have been uncomfortable for us or to enhance feelings that felt really good to us. Sometimes people say I didn't use because I felt bad I used because I felt good and I wanted to feel better. Even in those cases the deeper that somebody dives into their own emotional intelligence and understands themselves better. I usually find that the reason they want to feel better is because there are you know sort of some negative stuff going on in their psyche that makes them feel icky when they're sober most of the time. They really want to capitalize on the time that they do get to feel good right?
M: I'm sort of in the middle of that kind of sort of the existential piece of this you know where you're doing this exploration learning more about yourself or things that maybe you forgot about yourself. There was this whole element of from a personal perspective but then there was also the social aspect, which all of a sudden you realize how much time was caught up in drinking or using whatever it is. And for me, it's now this process of trying to figure out more about who am I? What are some things that I like to do and I found that to be hard. Is that a pretty common experience?
G: Very very common. I think that question of identity is one that you know I would say also grows with how advanced the disease is. Let me let me speak to the more extreme versions of that and then I'll pull back maybe to some of the more moderate stuff that I think you're talking about. The more extreme version of that is that if somebody's been using most of their adult life, I should say a lot of people started abusing substances at 13, 14, 15 years old. What we know is that emotional growth and identity growth tends to sort of slow down or stop around that time. So let's say you sort of wake up in your 40s and consequences have now gotten huge and it's time to get sober and it's undeniable you've kind of fallen to your knees and surrendered - I can't do this anymore. That's amazing but it's just the beginning of the work because now you have to kind of like go backwards to age 14 or 15 and figure out who the heck am I. I had this one client describe it to me so beautifully and so vulnerably a guy that's in his late 30s. He got out of prison and entered recovery a couple of years ago when his life had just completely fallen apart. A lovely guy and he said, “I tried dating when I first got sober and it took me a couple of years to realize that I was faking it. I was pretending to be a guy who was 36, 37 to a woman. It was 36, 37 but inside I'm a 17 year old faking it.” And it's true. I don't know how to cope with life, I don't know how to manage my finances. You know I think a lot of people with advanced stages of substances when we talk about hurdles they have devastating hurdles that they have to overcome while simultaneously having to kind of hide that from society because society doesn't really understand that inside you feel 15/16/17 years old. I can tell you personally my entire 20s was like this major adulting learning curve and I messed up a lot. My executive functioning skills were a disaster and I was irresponsible. I was selfish, I was all those things but we're going to have a lot less empathy for a 40 year old or a 50 year old who's those things who can't get their life together, they can't get their kids to appointments, they can't figure out how to manage their finances, they're coping poorly with stress and that's really what early recovery looks like for people that are getting sober. The more you understand about that journey I think the easier it is to empathize with and almost admire and say, “wow that's incredible that you have the courage to begin this journey with so many odds stacked against you”. I find my recovering clients to be some of my most inspiring but I'll pull back and talk a little bit about more of that average moderate range that I think you're talking about. I do an exercise with a lot of my clients called the balance star and I have them start with a visual of a star with five points and it doesn't have to be 5 it can be six or four or whatever it doesn't matter. I want them to think about the different components of who they are and so I use myself as an example and I'm a little bit generic right now because I'm a mom with young kids and I'm married, I'm right in the middle of my career so mine's not that creative you know but the points on my star are being a mom, being a wife, being a therapist or having a professional career, being a girlfriend to my girls and then self. My identity as a self right? And it's not that being a mom doesn't sing the word. I want to be a mom and I have three young kids but saying that doesn't necessarily explain what it means to me to feel fulfilled in that role. So I ask people to really flesh out that role so when you say mom what does that mean? How does that feel fulfilling to you? And I'll think about what that means to me or I'll go over to the career wing of my star and say well what does that mean? Well, for me, to feel fulfilled I want to do something that is meaningful and helps other people. I want to do things that scare me and challenge me like standing on the stage as a keynote speaker I mean if you think that's not scary that's crazy right?! I want to challenge myself. I want to do things that scare me that really push me out of my comfort zone and if I can flesh out more information and understand what those different wings mean then I can start doing some problem solving about what's missing and how to start filling in those pieces. I have people come in and they're like, “Oh my God I can see the problem! 4 out of my five wings are deflated. I'm not doing anything in those other areas.” I'm a mom and all I'm doing is that. I have no identity that's my own or you know “Oh my God all I do is work I see why you know all my other all the other points are just falling apart here”. So I can tell you personally I have never balanced out that star perfectly it's a constant juggling act but I do keep all five of those points in mind and I realize that if I start to neglect more than two of those points at any given time, if I'm too wrapped up in work, or too wrapped up in Momville and I'm not spending time with my girlfriends or not cultivating my marriage, not working on my personal identity and doing things that I really love that's when I'm going to start feeling more depressed and anxious. That's when I'm going to be more inclined to want to drink a few extra glasses of wine that sort of thing. I think in the world of recovery, when all of those points are in balance, we call that being spiritually fit. Now if you're more of a secular person you don't have to use that language of course but being spiritually fit means that you're feeling balanced in all the different areas there's no place that's leaving a strong want or a strong need or a strong emptiness for you.
M: Karen I've heard you talk about people and their superpowers when it's related to the recovery process. Would you tell me a bit about that?
G: I'm sort of a rare breed in the sense. I work actively as a therapist in the field of substance use disorder and I work with both families and people in recovery themselves. It's not lost on me that many people have negative stigmas around substance using individuals. It's not a population we typically empathize with a tremendous amount and the reason I understand that is that I felt the same way when I first got into the field that I did not choose this population in Graduate School. I was stuck in an internship that I wasn't at all interested in doing and I immediately fell in love with this population immediately and I was just sold I was like I don't know why these are my people but they are my people and something that I have learned is that people that identify as being in recovery from substance use disorder or what we've know historically as addiction or alcoholism - in order to choose recovery they've had to do some serious soul searching and they've had to overcome some hurdles that probably most of society could never even fathom. There's a resiliency that is built into being a recovering person just from the get go. As a person gets sober and they do the work, whether it's through 12 step work or therapy or other modalities that get them sober there's sort of a process of enlightenment that almost happens because you've kind of been to hell and back and you've had to really learn yourself to crawl out of this hole that you're in. When I'm walking around in society I come across different people seeing how they cope with life what I'm I'm really thinking is recovering people are some of the most evolved people walking around on the planet. Maybe they started off as some of the most dysfunctional people walking around on the planet but they have, in order to get where they are, they have had to do emotional work they've had to do spiritual work, they've had to do skill development work so you know I think next time you see a recovering person maybe consider where there's tremendous room for admiration that they may have something that you want or could use yourself. Maybe we all sort of need to do this work and they're just the ones who have spearheaded it