"On Healing" October 2003

Posted on Mon, Oct. 20, 2003
First treat alcoholism, then anxiety
By Dan Gottlieb

Dear Dr. Dan, My adult brother has a serious anxiety disorder. He lives alone and, although he still has a job, he only reports to it sporadically. The thought of being at work, or for that matter around people, causes panic attacks. He has turned to alcohol and has been hospitalized for this several times.

He has sought psychological assistance in the past but has rejected it, claiming it doesn't help. He seems to have convinced himself that his problems are physical. Now he complains that his liver hurts!

In an attempt to help alleviate some of his distress, my husband and I allowed him to live with us and taxied him back and forth from his job for a few weeks. We thought this might provide some inducement to attend work and have an alcohol-free environment in the evenings, but this too failed. He returned to his home on the weekend, binged, and ended up back in the hospital.

While in the hospital, he was recommended to an in-patient psychological program but refused it. He's now back home, left to his own devices.

What else can we do for him? Leaving him alone simply doesn't feel right. We are at our wits' end and are looking for any advice, either to help him or us.

Your brother does not sound like a man who wants to go downhill. He sounds like a man who is trying to manage his life, but in all the wrong ways.

Of course, no one can make a diagnosis based on a letter, but it sounds like his problems begin with an anxiety disorder and the alcohol abuse is, in part, an attempt to manage that anxiety. Nevertheless, the addiction must be addressed first because treatment for anxiety disorders will not work if someone is drinking or taking drugs.

John Grayson agrees. He is the director of the Anxiety and Agoraphobia Treatment Center in Bala Cynwyd, and author of Freedom From Obsessive-Compulsive Disorder. "Although it sounds like the anxiety is primary," Grayson says, "we cannot work with someone who is not sober, and my guess is he will have a great deal of difficulty not giving in to the urge to drink. So hospitalization and detoxification would be a good start, but in many respects, the hard work would begin after he got out."

The fact that therapy has not worked in the past is not of great concern as we know that traditional talk therapy is usually not helpful with anxiety disorders, and that a specific behavioral therapy usually gets results.

Grayson said that "therapy begins with understanding the fear and what it means. For example, if this man's anxiety about people is about wondering what people are thinking about him, through cognitive techniques we could help him understand the distortion in his thinking and that it is unlikely that everyone will dislike him nor is it likely that everyone will like him."

Grayson continues, "Often people with anxiety disorders get pretty rigid ideas of what situations they cannot tolerate. So they engage in behaviors that inevitably make the anxiety worse. Part of that treatment is to help them understand that whatever they feel they cannot live with, they probably can.

"The long-term prognosis of people with anxiety disorders is hopeful. Treatment is not easy and involves facing anxiety, but those we work with must understand that no matter how difficult treatment is, what they've lived with every day is worse."

Although the alcohol abuse may have begun as an effort to control his anxiety, it sounds like he may have an addiction which needs its own treatment. So, in addition to his therapy for anxiety, he should be attending several Alcoholics Anonymous meetings a week. Although he may find this quite burdensome at first, a commitment to this kind of treatment could be especially helpful to your brother, as he will find himself surrounded with people who accept him for who he is.

As you read all of this, you are probably thinking: "Sounds great, but remember he won't do anything for himself."

So what can you do?

Stop enabling him; do not make it easy for him to be an unemployed substance abuser. If you want to keep him in your home, keep him there with rules. Insist that he go to both AA and therapy while he lives there. If you catch him high or drunk, he is out. Make it impossible for him to stay there if he is anything but clean and sober.

The other option is to have an intervention. This is where your brother would be surrounded by everyone who cares and is concerned about him, including his employer, and talks about his behavior and their concern. Often this kind of loving confrontation breaks down defenses and helps get someone into an initial detoxification.

As for you, I strongly suggest you and your husband go to Al-Anon, a program for family and friends of substance abusers. This program will give you both the guidance and support you need to get through this. It will also surround you with kindred spirits.

The work your brother has to do is difficult and will require a commitment to his own welfare. The work you have to do can be just as difficult and may require the same commitment. You will have to wrestle with your helplessness in the face of what could be a life-threatening illness for your brother. Mostly, you will have to deal with your own confusion, guilt and fear. Once all these difficult feelings are faced, you and your husband might be surprised that you can find peace and even happiness regardless of your brother's behavior.

Posted on Mon, Oct. 06, 2003
Security, without and within
By Dan Gottlieb

I recently visited a new casino in Atlantic City with a friend, and we passed a large, imposing door labeled "Security."

I told my friend I wanted to go in.

"Why?" he asked.

"Well, see that attractive woman sitting by herself? I would love to ask her to have a drink with me, but I'm feeling a little insecure. So I wonder if the people in the security office could help me!"

I really would've loved to have done it, just to see the expression on their faces. I didn't because, well, I was feeling a bit insecure, remember?

"Security" has become the holy grail of our times. In our quest, we seek both the kind of security offered by the security office - protection from external threats - and the kind of security I really wanted - protection from internal anxiety.

Our pursuit of external security began well before 9/11. In Behind the Gates, environmental psychologist Setha Low says that over the last 20 years, gated communities have become the fastest-growing housing type in the nation.

But gated communities are only a small part of our pursuit of security. We have just created a massive bureaucracy in Washington dedicated exclusively to homeland security. The Patriot Act is about security. So are burglar alarms and most gun purchases. So is insurance. For my security, I carry homeowner's insurance, car insurance, malpractice insurance, health insurance, and life insurance. I even have umbrella insurance, which insures me in case my insurance doesn't insure me enough!

Think of what we do for and to our children in the name of their future security - security from poverty, from violence, from worry. We make great sacrifices to live in the right communities with the right schools to enable them to get into the right colleges so that they can be secure.

Since the '50s and white flight to the suburbs, many home purchases have been influenced by this quest for security. Now, even our choice of cars is driven by security. Think about all of the enormous vehicles on the road whose owners say: "I know it's a gas-guzzler, but I just feel more secure in my SUV."

Security is like happiness. The more fervently we pursue it, the more elusive it becomes.

Parents are pursuing the right schools, and children are pursuing that same dream, yet we are feeling less secure than ever. Depression is up in the suburbs, substance abuse has not diminished, we are buying more guns, building more walls, and becoming more isolated - all symptoms of insecurity.

As Setha Low discovered in her research, the vigilance it takes to maintain security in gated communities actually heightens residents' anxiety and insecurity. Why, despite this great investment of time and money, is our insecurity getting worse?

Now, before you start drafting your angry e-mail about my softheaded naivete, I understand there are real threats in our world and that we have to do everything we can within reason to protect ourselves. There are people who are desperate or impaired or so blinded by dogma or desperation that they could do us great harm. I also understand it is our evolutionary imperative to care for the well-being of our children.

Often, we pursue security on the outside when what we really want is security on the inside.

It is our nature as human beings to seek safety. Babies who don't have a safe and secure environment in their early years often grow up to have psychological and physical problems.

As we grow, the pursuit of security continues. It is fairly typical for adolescents to feel insecure. They begin to realize that they are not quite like their parents, or like their friends. Their bodies are changing, as is their thinking.

For adolescents, insecurity is almost inevitable. The critical question is how they cope with it. Some talk about their feelings, some use the insecurity for motivation, and some use drugs and sex to cope with those feelings.

Like our teens, we, too, are insecure. So how do we cope? First, we must understand that insecurity can never be eliminated. And sometimes insecurity can lead to good things. Whenever a person looks another in the eye and says "I am frightened" or "I feel insecure," tension seems to evaporate.

The kind of security I playfully talked about in the casino is the kind of security we feel when we are comfortable inside our skin. When we feel we are with people who understand and care about us. The kind of security we want frequently comes from human contact. But our efforts to eliminate our insecurity don't work because they increasingly isolate us. Isolation leads to anxiety, not safety.

I'm not suggesting we drive unsafe cars or cancel our insurance policies or cast our fate to the winds. But like it or not, insecurity can never be eliminated. Insecurity is an emotion that feels intolerable. If we look behind the walls, guns, burglar alarms and SUVs, we might discover insecurity is one of the things we all have in common.

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