The Choice to “End it All.”

Suicide Definition Graphic

Written by Steven Barto, B.S., Psy.

IT WAS FOUR IN the afternoon. I was driving along the river in my home town. It was the fourth decade of my struggle with active addiction. Overwhelmed with thoughts of utter failure, rabid hypocrisy and complete hopelessness, I started ruminating about the idea of suicide. Why not? It made sense. I was in bondage to drugs and had grown tired of living a life so out of touch with my Christian upbringing. Seems I could not stop lying, cheating, stealing. Doing whatever it took to keep getting high. Duplicity was the word that most described my existence. I’d grown weary of living on the down-low. I was defeated, exhausted and tired of failing.

I turned into an area boat launch and stopped about fifty yards from the edge of the water. I closed my eyes and took my foot off the brake. I’d barely touched the accelerator when I heard an audible voice. It filled the cabin of my car: Don’t. I jammed the brake pedal to the floor and gripped the steering wheel in a panic. I must be losing my mind! There was no one else in the car. The radio was off. Yet, somehow, I heard a voice that seemed to fill the interior of my car. I could feel the voice, insistent but not loud. No sense of anger or disappointment. It was simply an audible, gentle, compassionate insistence.

Don’t end your life!

It’s been said that suicide is a permanent solution to a temporary problem. Perhaps if some in-between state existed—some alternative to death—many suicidal people would take it. One question every surviving family member has asked without exception, that they ache to have answered more than any other, is simple: Why? Why did their friend, child, parent, spouse, or sibling take their own life? Even when a note is left behind, it still never makes sense. Yes, they felt enough despair to want to take their own life, but Why did they feel that way? Alex Lickerman, MD said, “People who’ve survived suicide attempts have reported wanting not so much to die as to stop living, a strange dichotomy, but a valid one nevertheless” (1).

A friend of mine took his own life in 1996. We met a few years earlier as co-workers at a Philadelphia law firm. We were both on staff as litigation  paralegals. He had recently started a new career trading stocks. Apparently, he was under investigation by the SEC for insider trading. His wife kicked him out and filed for divorce. He moved in with his parents and had become quite depressed and withdrawn. He stayed home from work on a Tuesday. After his parents left the house, he took his father’s .357 handgun and drove to his wife’s place. When she answered his knock, he shot himself on the stoop in front of her. I always knew him to be outgoing, hilarious, and always up for a good time. His death made no sense to me.

Unfortunately, suicide without warning is common. Patrick J. Skerrett quoted Dr. Michael Miller, a psychiatrist at Harvard Medical School, in a recent article on suicide: “Many people who commit suicide do so without letting on they are thinking about it or planning it” (2). Currently, suicide is the tenth overall cause of death in the United States. In 2018 there were 48,334 suicide deaths in America. Had I not heard God’s voice that afternoon in 2018, the total would have been 48,335. There were an estimated 1.4 million suicide attempts in the U.S. in 2018. The rate of suicide is highest in middle-age white men in particular. It was the second leading cause of death among individuals between the ages of 10 and 34. On average, there are 132 suicides per day. In 2018, firearms accounted for 50.57% of all suicide deaths in America (3).

America’s suicide rate has increased for 13 years in a row.—The Economist

According to the National Vital Statistics Report, suicide was the second leading cause of death for age groups 10 to 24, or 19.2% of deaths, and 25 to 44, or 10.9%. This report presents final 2017 data on leading causes of death in the United States by age, sex, race, and Hispanic origin. These data accompany the release of final national mortality statistics for 2017 (4). In 2017, the 10 leading causes of death were, in rank order: heart disease; malignant neoplasms; accidents (unintentional injuries); chronic lower respiratory diseases; cerebrovascular diseases; Alzheimer disease; diabetes mellitus; influenza and pneumonia; nephritis, nephrotic syndrome and nephrosis; and intentional self-harm (suicide).

Suicidal Ideation and Social Media

Various social media platforms offer an unprecedented volume, velocity, and variety of social data to researchers. Among these, the most consistently studied is Twitter, a microblogging platform in which participants broadcast 140-character posts directly to one another or to the Twitter community simultaneously. Twitter’s sociological and psychological relevance for researchers and treatment providers is elevated due to ease of accessibility to data, the fact that most data collection activities can be undertaken at no cost to the researcher, and the ease of data management. For example, because Twitter limits individual posts to 140 characters, the information is more easily stored and reviewed than longer Facebook posts.

Facebook Suicide Prevention webpage can be found at www.facebook.com/help/594991777257121/ [use the search term “suicide” or “suicide prevention”].

As with a variety of social media platforms, Twitter has been a boon to suicide researchers, who can observe the behavior of individuals in a non-invasive manner, collecting “live” (time-sensitive) information that might not otherwise be shared because of the stigma of mental illness and suicide. One researcher was able to analyze 125 users who publicly announced they had attempted suicide. Analysis of these individuals’ posting history revealed distinct signals in previous posts that could have been used to predict their upcoming attempts and initiate an intervention (5). This is a relatively large sample that otherwise might have been overlooked.

Strong correlations have been discovered between suicidal expressions on Twitter and state-specified age-adjusted suicide rates. It is believed that posting suicide-related content on social media specifically identifies at-risk individuals. In fact, unique posting patterns have been posthumously discovered for Twitter members who died by suicide when compared to those who died of other causes (6). Such results demonstrate the value of verbal content people post on social media sites—providing unique insight into suicidal behavior.

Twitter’s Best Practices in Dealing With Self-Harm and Suicide at https://support.twitter.com [use the search term “suicide,” “self-harm,” or “suicide prevention”].

Psychologists and sociologists have begun to analyze social media data—correlating the content of social media posts regarding the topic of suicide with eventual suicides or attempts. Analysis has proven most useful in this regard. It must be determined whether suicidal behavior can be correlated to online comments among peers beyond one degree of social separation. Also, it must be determined whether that correlation persists after excluding innocuous commentary regarding mood and attitude. In other words, if mood is held to a constant in the analysis, will the observed association in suicide-related behavior still be higher than chance? Recent research has determined that comments on social media relative to suicidal expressions can be studied and correlated  up to three degrees of separation between peers, but no further. 

N.A. Christakis and J.H. Fowler (7) noted that correlation held between suicidal remarks and suicidal actions even when accounting for the distribution of mood among participants in the social media network. They used the bootstrapping method (employing computer-intensive analysis of  variability within their data samples) to study real-time posting activity on Twitter. Their samples were comprised of two non-consecutive 28-day periods. Mechanical Turk (MTurk; Amazon, 2016) raters have compiled suicide-relatedness ratings for each of the 10,222 most common words in contemporary English for use in evaluating social media posts for occurrence of “suicidal conversation.” These words are correlated with a preexisting list of “sad” words (as they relate to the sad/happy continuum) used to infer the general mood of social media users. Collection and analysis was conducted via double-blind method for accuracy and to allow for detecting statistical variation and spurious correlation.

Some variants of “sad/happy” word expressions that may or may not be associated with suicidal ideation include “I’m so sad! I’m gonna kill myself!” “I’m the worst! LOL!” “My final day on earth…” “Just got in a fight…” “It’s a sad day.” “I love my life!” Analysis included placing “sad,” “happy,” and “suicidal” words into columns on a graph and quantifying the number of uses of such words or phrases. Also, degrees of separation (direct friend versus once, twice, thrice removed) were determined at one through six degrees: friend, friend of friend, friend of friend of friend, and so on. The Sad Column, Happy Column and statistically relevant variables were each plotted along the graph comparing “mood” and “suicide-relatedness” comments. Amazingly, this study may be the first of its kind, and involved collection and analysis of over 64 million post from over 17 million unique social media users in two nonconsecutive 28-day periods. Analysis of this real-time data helped predict (by an algorithm) the information collected, which typically has infinite possibilities of correlative meaning.

You might ask, But why is this important? What does it mean? How can it be utilized? Suppose a counselor is concerned with the suicide risk of students in a high school where a fellow student recently took her own life. To get the best data in the shortest amount of time, the counselor would do the following:

  1. Ask a teacher for a list of the decedent’s closest friends and screen them;
  2. Ask any friends on that list to name their closest friends and screen those friends;
  3. Ask any friends from the new group to name closest friend and screen them, and so on; and
  4. Once there are no more positives in a friend group, screen students at random until a positive is found and begin the procedure again until the resources run out (i.e., there are no more students in the population).

Although the above process will provide an  initial “hint” of an assortativity-informed treatment approach, additional research would be necessary before beginning any efficacious intervention. Researchers warn that no offline behavior was included in their study, and therefore was not available for comparison.

Co-occurring Issues and Suicide

Suicide is a major public health problem and a leading cause of death in the United States. Everyone who chooses to attempt suicide has an underlying reason for wanting to do so. Suicide does not discriminate—people of all genders, ages, religious faiths, and ethnic groups can be at risk. Most people at risk will not follow through. Still, assessing the risk for suicidal behavior is complicated. Researchers tell us that people who attempt suicide may do so in reaction to a particular event, thought, or emotion. These individuals make decisions differently than those who do not attempt suicide. Such factors for increased risk are depression, anxiety, personality disorders, psychosis, severe bullying, rape or trauma, and substance abuse. 

Suicidal acts may be connected to recent events or current conditions in a person’s life. Although such factors may not be the primary motivation for the suicide, they can precipitate it as underlying or co-morbid triggers. A major underlying cause of suicide has been combat stress and other related PTSD issues. People in this at-risk category do not necessarily have to experience the horrors of a war zone. Other types of immediate stress include natural disasters, terrorism at home, or catastrophic loss from such events as a structure fire or a serious motor vehicle accident.

People suffering from chronic pain, severe disability, or a major illness may attempt suicide, believing their suffering is too great or that their death is inevitable. Victims of an abusive or repressive environment from which they have little or no hope of escape sometimes commit suicide. Situations that fit this category may include torture, confinement, sexual assault, or persistent physical abuse. Also, occupational stress has been indicated in some suicides due to extreme tension, anxiety, disillusion or “burnout,” and job-related financial pressures.

Cyberbullying, Substance Use Disorder

In addition to the above precipitating factors, many suicide attempts are preceded by a severe change in mood that do not correlate to an underlying psychiatric diagnosis. Mood changes most likely to lead to suicide often include extreme sadness, unresolved anxiety, frustration, anger, or shame. Unfortunately, the number of teens and young adults who take their own lives has increased due to bullying at school or on social media sites. Nearly 1 in 5 students (21%) report being bullied during the school year, impacting over 5 million youth annually. See National Center for Education Statistics [NCES], 2018. 

There has been a spike in cyberbullying over the last couple of years. This is willful and repeated bullying behavior that takes place using electronic technology, including texting, comments during gaming, Internet sites, social media, emails, blogs, cell phones, and so on. Unlike traditional bullying it can happen anywhere at all hours of the day. Approximately 34% of students report experiencing cyberbullying during their lifetime. See Hinduja & Patchin, 2015. Students who experienced bullying are nearly 2 times more likely to attempt suicide. See Hinduja & Patchin, 2018.

Worldwide, more than 1 million people die by suicide every year. Self-harm deaths have been on the rise in nearly every state in America. In the U.S., suicide deaths (47,173) were almost equivalent to the number of deaths from opioid overdoses (47,600) in 2017. It is essential that suicide prevention practices be implemented and expanded wherever possible (8). Opioid Use Disorder (OUD) has a distinctly strong relationship with suicide as compared with other substance use disorders (9). Pain causes alterations in brain circuitry in the brain’s reward center (involving the ventral tegmental area, nucleus accumbens, and the amygdala), resulting in vulnerability to suicide and a higher risk of opioid addiction. This is supported by epidemiological data that have shown chronic-pain diagnoses are linked to suicide. These associations are only partially explained by co-occurring mental health conditions, which tend to further complicate morbidity.

Tolerance to THC can build quickly in cannabis users. Teens who seek help for cannabis-use problems often report withdrawal symptoms such as anxiety, insomnia, appetite disturbance and depression (Budney & Hughes, 2006). These symptoms are of sufficient severity to impair everyday functioning (Allsop et al., 2012) and they are markedly attenuated by doses of an oral cannabis extract (Sativex) that contains THC (Allsop et al., 2014). Bagge and Borges (2015) conducted a case-crossover study of 363 persons who had recently attempted suicide and were treated in a trauma hospital for a suicide attempt within the previous 24 hours in Mississippi. The researchers compared rates of cannabis use in the 24-hour period leading up to the individual’s suicide (case period) to individuals who used cannabis during the same time period but did not commit suicide (control period). They found that 10.2% of those who attempted suicide had used cannabis within 24 hours of their suicide.

Cannabis was involved in an estimated 6.5% of drug-related suicide attempts, and in 46% of attempts the person had also used alcohol. In the 23% of drug-related suicide attempts with toxicology reports, 16.8% tested positive for cannabis, although this cannabis use could have occurred days or even up to one week earlier. In general, 9.5% of all toxicology reports for deaths by suicide (Borges, Bagge & Orozco, 2016) show the presence of cannabis. There is preliminary evidence of higher detection of cannabis among suicide decedents that do not involve overdose (CDC, 2006) and higher detection among male suicide decedents using non-overdose methods than among females (Darke, Duflou & Torok, 2009; Shields et al., 2006).

So Now What?

The Centers for Disease Control and Prevention (CDC) released data on the ten leading causes of death in the United States recently. Tragically, suicide—too often a consequence of untreated mental illness and substance use disorders, and as such a preventable condition—remains on that list as the 10th leading cause of death for adults and the second-leading cause of death in our youth. Suicide rates increased from 29,199 deaths in 1996 to 47,173 deaths in 2017. Click here for more information.

What are the contributing factors to a state of mind that ends in a person taking his or her life? What can be done to intervene? How can we turn the numbers around? The increased number of suicides year after year say something about the conditions under which people live and die, and about our society at large. Our teens and young adults are deciding in record numbers that killing themselves is the best solution to what is usually a temporary situation. Citizens at the lower end of the socioeconomic scale are significantly more vulnerable due to negative views about life and an increased amount of psychological and social difficulties. Many of these conditions are not diagnosed in time or go untreated. Many are turning to substance abuse to cope, which often increases the risk of self-harm behavior. This speaks to an environment that can promote depression, anxiety, and elevation in substance use disorder. Some sociologists have referred to these suicides as “deaths of despair.”

There are a number of interventions we can apply to these dire circumstances:

  • Safety Planning. Personalized safety planning has been shown to help reduce suicidal thoughts and actions. Patients work with a caregiver to develop a plan that describes ways to limit access to lethal means such as firearms, pills, or poisons. The plan lists coping strategies and people and resources that can help in a crisis.
  • Follow-up phone calls. Research has shown that when at-risk individuals receive proper screening, implementation of a Safety Plan, and a series of supportive phone  calls, their risk of suicide goes down.
  • Cognitive Behavioral Therapy (CBT) can help people learn new ways of dealing with stressful experiences through training. CBT helps individuals recognize their thought pattersn and consider alternative actions when thoughts of suicide arise.
  • Dialectical Behavior Therapy (DBT) has been shown to reduce suicidal behavior in adolescents. DBT has also been effective in reducing the rate of suicide in adults with Borderline Personality Disorder or related personality disorders. These mental illnesses are typically characterized by an ongoing pattern of varying moods, self-image, harmful or risky behavior, and impulsive actions. A therapist trained in DBT helps a person recognize when his or her feelings or actions are disruptive or unhealthy, and teaches the skills needed to deal better with upsetting situations.

If you are struggling with thoughts of suicide, please reach out to someone before the fog of desperation clouds your mind. If you have a friend or loved one who has expressed an intent to take their own life, do not dismiss it as a cry for attention—instead, it is a cry for help. If you are interested in becoming a volunteer or mental health professional and want to be a part of the solution for this national epidemic, please talk to a teacher, professor, mental health professional, pastor, or mentor to find out how to get started.

NATIONAL SUICIDE PREVENTION HOTLINE
1(800) 273-8255

Footnotes

(1) Alex Lickerman, M.D. (April 29, 2010). “The Six Reasons People Attempt Suicide.” Psychology Today. https://www.psychologytoday.com/us/blog/happiness-in-world/201004/the-six-reasons-people-attempt-suicide

(2) Patrick J. Skerrett (Sept. 24, 2012). “Suicide Often Not Preceded by Warnings.” Harvard Health Publishing.

(3) “Suicide Statistics.” American Foundation for Suicide Prevention. https://afsp.org/about-suicide/suicide-statistics/

(4) Melonie Heron, Ph.D., (June 24, 2018). “Deaths: Leading Causes for 2017.” National Vital Statistics Reports, Vol. 68, No. 6. https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_06-508.pdf

(5) Wood, A., Shiffman, J., Leary, R., and Coppersmith, G. (2016). “Language Signals Preceding Suicide Attempts.” CHI 2016 Computing and Mental Health, San Jose, CA.

(6) Bryan, C.J., Butner, J.E., Sinclair, S., et al. (2018). “Predictors of  Emerging Suicide Death Among Military Personnel on Social Media Networks.” Suicide and Life-Threatening Behavior, 48, 413-430. http://dx.doi.org/10.1111/sltb.12370

(7) Christakis, N.A., and Fowler, J.H. (2013). “Social Contagion Theory: Examining Dynamic Social Networks and Human Behavior.” Statistics in Medicine, 32, 556-577. http://dx.doi.org/10.1002/sim.5408

(8) https://doi.org/10.1016/j.jcjq.2019.10.001

(9) Bohnert KM, Ilgen MA, Louzon S, McCarthy JF, Katz IR. Substance use disorders and the risk of suicide mortality among men and women in the U.S. Veterans Health Administration. Addiction 2017; 112:11931201.

 

 

Mental Health and Addiction

The first section of this post is taken from the blog of Sophia Majlessi,
National Council for Behavioral Health
Released January 8, 2020

Voters More Likely to Support a Candidate Who Promises to Address Mental Health and Addiction, According to New Polling from the National Council for Behavioral Health Released Ahead of December 16 New Hampshire 2020 Presidential Candidate Forum

WASHINGTON, D.C. (December 11, 2019)—New polling released today by the National Council for Behavioral Health shows strong bipartisan agreement among registered voters in New Hampshire that the federal government is not doing enough to address mental health (84% of Democrats and 72% of Republicans) and addiction (77% of Democrats and 53% of Republicans) in America. The National Council released the new polling in advance of the Unite for Mental Health: New Hampshire Town Hall, a public forum for 2020 presidential candidates to discuss mental health and addiction policies. The National Council for Behavioral Health, Mental Health for US and the NH Community Behavioral Health Association will host Unite for Mental Health: New Hampshire Town Hall on December 16 at the Dana Center at Saint Anselm College in Manchester, N.H.

“The message is clear: candidates who want to win New Hampshire need to tell voters they have a plan to address the mental health and addiction crisis, one of the most important health issues facing the nation,” said Chuck Ingoglia, president and CEO of the National Council for Behavioral Health. “The Unite for Mental Health: New Hampshire Town Hall will provide an important opportunity for presidential candidates to engage with New Hampshire families, mental health professionals and local policymakers to discuss the issues and share solutions voters—and the nationare eager to support.”

This statewide poll comes on the heels of new national data from the U.S. Centers for Disease Control and Prevention (CDC) confirming that suicide is the second leading cause of death among teenagers in the U.S. The suicide rate among people ages 10 to 24 years old climbed 56% from 2007 to 2017, according to the CDC report. These findings, compared with high rates of death nationwide from drug overdose, are leading to calls for the 2020 presidential candidates to engage communities across the country in order to better meet the needs of millions of Americans.

“Mental health and addiction continuously poll as key issues for many Americans, yet our leaders rarely prioritize prevention, treatment, and recovery strategies,” said former U.S. Rep. Patrick J. Kennedy, founder of The Kennedy Forum and Mental Health for US co-chair. “This new polling data from New Hampshire is the catalyst we need for change. The Mental Health for US coalition is proud to stand with the National Council and the NH Community Behavioral Health Association as we call on policymakers and candidates to walk the walk for the those with mental health and addiction challenges.” “The results of this poll are compelling. The need to invest in caring for those with mental illness is clear, and the voters want to see candidates for public office at all levels address these important issues,” said Roland Lamy, executive director of the NH Community Behavioral Health Association.

Results from the full survey have a margin of error of +/-6%. Click here for full polling results.

My Thoughts

The struggle to break free from active addiction is among the hardest undertakings a person can face in his or her lifetime. Putting the drug down is more difficult depending on the substance, amount used, and duration of use. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association, has sequestered substance abuse under the new heading Substance Use Disorder (SUD). The substance-related disorders encompass 10 separate classes of drugs: alcohol; caffeine; cannabis; hallucinogens; inhalants; cocaine (powder or rock); opioids; sedatives and hypnotics; stimulants (amphetamine-type, cocaine, and other stimulants; tobacco; and other (or unknown) substances. It is important to note that all drugs (when taken in excess) have a common direct activation of the brain reward system, typically leading to dependency and addiction.

Mental health issues can become a complicating factor; this is often referred to as dual-diagnosis, or, in the vernacular, “double-trouble.” Moreover, individuals with poor self-control may be particularly vulnerable to substance abuse. Accordingly, the roots of substance abuse for some individuals can be seen in behaviors long before the onset of actual substance use itself. It is also important to note that substance-related disorders are divided into two groups: substance use disorders and substance-induced disorders. These secondary issues can include intoxication, withdrawal, psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive-compulsive and related disorders, sleep disorders, sexual dysfunctions, delirium, and neurocognitive disorders.

Features of substance use disorders include a rather important element: change in brain circuits that may persist beyond detoxification, particularly in individuals with severe disorders. The behavioral results of such changes may manifest in repeated relapses and intense craving for the individual’s favorite drug. This craving is often set in motion through a mere drug-related stimuli, which is referred to in the addictions field as a trigger. Typically, the longer an addict remains clean the easier it is to recognize and defeat such cravings. A craving is likely rooted in classical conditioning, and is associated with activation of specific reward structures in the brain. These structures are rather individualized; not every addict is triggered by the same thought or stimulus. Instead, triggers are established by what the individual is agitated or distressed by, and inversely related to the ability to properly handle such stimuli.

Not surprisingly, treating co-occurring substance abuse and mental illness calls for simultaneously addressing two critical and sometimes confounding problems. In fact, double-trouble can often complicate differential diagnosis—the comparison of symptoms from multiple likely mental or physical conditions. From a personal perspective, it was quite difficult for me to clearly determine what was “wrong” with me. Severe anxiety, constant ruminations, insomia, and underlying depression crippled me for decades. In addition, I felt powerless and helpless, unable to relax or sleep. This is likely what initially led to my substance abuse. I started drinking alcohol and smoking marijuana the summer following my high school graduation. My use was extensive from the beginning, but I was able to calm down, stop my thoughts from racing, and finally get some sleep. Unfortunately, I was not “sleeping” as much as I was passing out. It did not take long for my substance use to become excessive, leading to a decades-long season of poor choices and serious consequences.

Reasons for drug and alcohol abuse by individuals with mental illness varies by individual. Substance abuse could be primary or secondary to psychiatric issues, or may even in some cases be independent of mental illness. The association between mental disorders and substance abuse is complex. The relationship of substance abuse to onset, course, and severity of mental issues, and problems in the evaluation of dual-diagnosis patients, is often complex. Adding to this difficulty is the likelihood that the individual often engages in self-medication to alleviate troublesome symptoms for which they have no explanation. This psychodynamic perspective must also include neurochemical considerations. Affective disorders (those impacting mood, often including depression, bipolar disorder, anxiety disorder) are particularly difficult to manage. I found welcome relief through drug and alcohol us—albeit only temporarily.

Unfortunately, chronic substance abuse can also lead to the development of organic conditions, such as psychosis, mania, and mental confusion. Other disorders can include chronic apathy and dysphoria, and personality disorders such as Antisocial Personality Disorder and Borderline Personality Disorder. Again, there is often confusion regarding co-morbity. For example, addicts quite frequently use, abuse, manipulate, and disrespect friends, family, and other acquaintances in order to get what they need, whether it be money, shelter, or (at times) the drug itself. These traits are also typical of several key personality disorders.

As these traits become routine, the addict often slides down the slippery slope to criminal behavior—theft, embezzlement, forgery, kiting checks, burglary, armed robbery. A serious, unfortunate end-result for the dually-diagnosed addict can lead to suicide. I have personally considered taking my own life on many occasions during active addiction. I would become remorseful for the way I treated family and friends. The disconnect between my Christian worldview and my behavior haunted me. It seemed suicide was the only option. As my uncle once told me, I was unable to see the horizon. Truly, I have not faced a more difficult situation in my life than suffering from mental illness while in active addiction.

In my review of the diagnostic criteria for Borderline Personality Disorder, I determined I’ve displayed eight of the nine criteria for making such a diagnosis. I’ve demonstrated a pervasive pattern of instability in my interpersonal relationships, self-image, affect (mood swings), impulsivity (sexual behavior, drug and alcohol abuse, risk-taking, excessive impulse spending, reckless driving), recurring thoughts of suicide, chronic feelings of emptiness, and recurrent anger. Thankfully, I have seen a vast improvement in the lion’s share of these symptoms. However, I still deal with poor self-image at times, tend to “sanitize” the truth, occasionally manipulate others, and remain rather impulsive in areas such as impulsive spending.

Given the pervasive nature of dual-diagnosis, it is critical to identify when you are suffering from mental or emotional symptoms, and more importantly to recognize if you are using or abusing drugs or alcohol to dampen or defeat uncomfortable thoughts or feelings. Depression, anxiety, and insomnia tend to “respond” initially to substance use. However, the need for one’s drug of choice to “treat” these types of symptoms increases as use leads to abuse; abuse leads to tolerance; and tolerance leads to dependency. Consequently, self-medication of emotional or psychiatric difficulties by consuming drugs or alcohol is doomed to fail—often with quite devastating results. If you, or someone you know, is caught in the vicious cycle of addiction (with or without a co- occurring mental condition), it is vitally important to seek professional intervention.

It is impossible to “go it alone” and achieve anything like helpful results. In fact, it is likely your situation will deteriorate. I was told years ago by an addictions counselor that because I had an underlying mental illness, treating my addiction without addressing my psychiatric problem is like having two broken legs but only putting a cast on one of them.

If you or someone you know is struggling with substance use disorder and want more information or help quitting, please contact your local AA or NA chapter, or click here to visit the National Institute on Drug Abuse official website. You can also scroll back to the top of this post and click on the COMMENT bar to open an dialog with me. I will be glad to speak with you any time.

References

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th edition (Washington, DC: American Psychiatric Publishing), 2013.

 

“Is My Life Worth Living?”

“The purpose in a man’s mind is like deep water, but a man of understanding will draw it out” (Proverbs 20:5, RSV).

“We know that in everything God works for good with those who love him, who are called according to his purpose” (Romans 8:28, RSV).

IT IS OBVIOUS THAT purpose can guide life decisions, influence behavior, shape goals, offer a sense of direction, and create meaning. For some, meaning is defined by what they do—doctor, lawyer, construction worker, teacher, welder, chef. Others seek meaning through spirituality or religious beliefs. Unfortunately, some never find meaning for their lives. I cannot think of a more sad state than existing without knowing why you exist, or where you’re going.

A Matter of Worldview

We are talking about worldview. Everyone holds a worldview, which Phillips, Brown and Stonestreet (2008) define as “the framework of our most basic beliefs that shapes our view of and for the world and is the basis of our decisions and actions.” Sire (2015) says a worldview is a set of presuppositions (assumptions which may be true, partially true or entirely false) which we hold (consciously or unconsciously, consistently or inconsistently) about the basic makeup of our world. [Italics added.]

I agree with Phillips, Brown and Stonestreet (2008) that truth is absolute; if not, then nothing is true. They consider (p. 64), “If a worldview is true, we can expect to find at least some external corroborating evidence to support it. This does not mean that something is true because there is evidence for it, but rather evidence will be available because something is true.” [Italics added.] It is critical to note that evidence is always subject to interpretation, and interpretation also can be subject to bias. As it’s been said many times, worldviews function somewhat like a pair of eyeglasses. When you begin wearing glasses, the rims can be quite distracting. In a short while, however, you lose your awareness of the rims and even the lenses. You forget you’re wearing glasses.

Accordingly, we can lose perspective on our assumptions, presuppositions and biases, especially with the passage of time. Entwistle (2015) warns us that assumptions and biases affect data interpretation. He said, “…what we see depends, to some degree, on what we expect and are predisposed to see.” (p. 93) Our ability to know is both dependent upon and limited by the assumptions of our worldview. In my Christian worldview, I recognize God as the unique source of all truth, and that this truth is absolute. In other words, it is not relative, but it is universal and unchanging. Truth is not absolute on its own merits; rather, it derives ultimately from God. I do not believe, however, that the Bible contains all that we need to know: e.g., we don’t consult the Bible to understand how to change a tire or perform brain surgery. Scripture does contain everything we need to know regarding God, the spiritual life, and morality.

We begin developing our worldview as young children, first through interactions within our family, then in social settings such as school and church, and from our companions and life experiences. Increasingly, our media culture is playing a key role in shaping worldview. We are a culture saturated with powerful media images in movies, television, commercials, music, gaming, and social media. What we watch, listen to, and read, impacts the way we think.

The lack of a sound basis for the meaning of life can cause a gnawing sense of being unfulfilled. This perception underlies everything we do. For example, we can be “busy” with many things, yet wonder if what we’re doing makes any real difference. Life, by its very nature, presents itself one day at a time: a random and unconnected series of activities and events over which we seem to have little or no control. If a sentiment of disconnectedness develops in our everyday existence, boredom sets in deep within our soul. To be “bored” does not mean we have nothing to do; it means that we question the value of the things we are so busy doing. Here is the great paradox of life: Many of us are busy and bored at the same time!

Symptoms of a Lack of Purpose

Interestingly, boredom might be rooted in resentment. If we run around all day like a crazy person, doing this and that, yet wonder if our busyness means anything to anyone, we easily feel used, manipulated, or exploited. Is this not often how a parent feels when he or she is constantly doing for their children, but the children appreciate nothing? In this state of mind, we begin to see ourselves as victims pushed around and made to do things by people who do not acknowledge us or take our contributions seriously. An inner anger starts to well up inside us—an anger that eventually settles into our hearts. Left unresolved, this anger leads to resentment, which has an effect on us much like a poison.

Perhaps the most damaging expression of our looming sense of unfulfillment is depression. When we start to believe our life has little or no effect on those around us, we can easily fall prey to sadness, depression, and regret. This can morph into guilt. It must be our fault that no one appreciates us, right? Perhaps we don’t do enough. Maybe we did the wrong thing. We begin to think it’s all our fault. This guilt is not always connected to just one event; sometimes it is connected with life itself. We feel guilty just for being alive. The realization that the world might be better without us becomes a sort-of “sub plot” to our life. We look in the mirror and, “Is my life worth living?”

Boredom, resentment, and depression are all symptoms of our sense of being disconnected. We cannot help but see life as a broken connectedness. We feel as though we don’t belong. Not surprisingly, this often leads to loneliness. This is what is meant by being in a room full of people at a gathering but feeling all alone. We experience this  because we don’t really feel like we’re part of the community. And it is this paralyzing sense of separation from others that establishes the core of much suffering in the world. When in this state of feeling cut off from the community, we quickly lose heart. Ultimately, if we don’t address this sentiment, we see ourselves as passive bystanders. We tend to live life “on the bench.”

Americans Increasingly Turn to Suicide

There is now a potential for us to believe our past, even our present, no longer carries us to the future. Instead, we go through life worried, cut off, without any promise that things will improve. Perhaps this is at the crux of one’s decision to commit suicide. According to the Centers for Disease Control (CDC), suicide was the tenth-largest cause of death in America in 2017, claiming the lives of more than 47,000 people. Suicide was the second leading cause of death among individuals between the ages of 10 and 34, and the fourth leading cause of death among individuals between the ages of 35 and 54. There were more than twice as many suicides (47,173) in the United States in 2017 as there were homicides (19,510).

No Sense of Roots

Henri Nouwen wrote, “Most of us have an address but cannot be found there. We know where we belong, but we keep being pulled away in many directions, as if we were still homeless.” I had a t-shirt years ago that had a rather interesting quip written on it: I Have Gone to Find Myself; If I Return Before I Get Back Keep Me Here. Does this not address the very struggle we all face when attempting to define the meaning of our existence. This “rudderless” life leads to our being tossed to and fro on the ocean in search of a port—any port—in the storm. For me, this pervasive sense of meaninglessness and loneliness led to some rather damaging behavior—infidelity, job hopping, geographic changes, and addiction. I learned that when we feel an inescapable sense of disconnectedness we will being to lie to ourselves. Not only about what the meaning of life is (or should be), but about the serious damage our addictive behaviors and activities of distraction are causing—both to us and to those around us.

What is the Answer?

If you are familiar with Scripture, you will likely remember that Jesus does not respond to our worry-filled way of living by saying that we should not be busy with everyday activities. Instead, His response is quite different. He asks us to shift the point of our focus—to essentially relocate the “center” of our attention, to change our priorities. Jesus wants us to stop focusing on “many things,” and instead focus on the “one necessary thing.” He does not preach of a change in activities as a means of finding a meaningful life. That would be akin to putting a temporary bandage on a bleeding wound. When we ignore critical wounds in the flesh, we risk developing a puss-filled infection that can spread to our bloodstream, thereby causing a “systemic” infection.

Instead, Jesus speaks of a change of heart. This change is what’s needed to make everything different even while everything appears to remain the way it was. Let me be clear: Many of us are living lives that are in need of drastic change. That’s a given. When we focus on the one necessary thing, we begin to tap into the resources needed to realize an effective change in our direction. This is what Jesus meant by His comment to the disciples, “Therefore I tell you, do not be anxious about your life, what you shall eat or what you shall drink, nor about your body, what you shall put on. Is not life more than food, and the body more than clothing? …do not be anxious, saying, ‘What shall we eat?’ or ‘What shall we drink?’ or ‘What shall we wear?’ But seek first his kingdom and his righteousness, and all these things shall be yours as well” (Matthew 6:25, 31, 33, RSV).

I believe it is only when we understand the importance of Jesus’s urgent instructions to make God the center of our lives that we can better see what is at stake. We will understand who we are, why we are here, and why things happen the way we do. This cannot be achieve through our human wisdom or understanding. We can’t grasp the things of the Spirit while focusing on the flesh. A heart set first on the Father’s kingdom is also a heart that is properly oriented toward the spiritual life. Thankfully, Jesus provided an exemplar for us to follow when refocusing our attention in this manner.

We see that Jesus was not merely a zealot who ran around the Holy Land espousing some “new wave” approach to life. He was not interested in seeking a “self-fulfilled” life. Rather, everything we know from Scripture is that Jesus was concerned with only one thing: To do the will of the Father. From His very first public utterance in the Temple, He made this abundantly clear. “‘Why were you searching for me?’” he asked. “’Didn’t you know I had to be in my Father’s house?'” (Luke 2:49, NIV). The footnote provided for this verse at blueletterbible.org says, “be about my Father’s business.” Jesus was quick to tell his disciples, “Truly, truly, I say to you, the Son can do nothing of his own accord, but only what he sees the Father doing; for whatever he does, that the Son does likewise” (John 5:19, RSV). In other words, Jesus wants us to understand that without God nothing is possible. Moreover, with God nothing is impossible.

Consider this thought: Jesus is not our Savior simply because of what He said to us or did for us of His own accord. He is our Savior because what He said and did was said and done in obedience to the Father. Paul expressed this in Romans 5:19: “For as by one man’s disobedience many were made sinners, so by one man’s obedience many will be made righteous” (Romans 5:19, RSV). This speaks of an all-embracing love—for the Father and for us. We cannot understand the impact of the richness of Jesus’s ministry until we see how everything He did was rooted in one thing: Listening to the Father and obeying out of the power of a perfect and unconditional love.

When Jesus said He is the way, the truth and the life, He was not merely stating that everything He said was true. It was, of course, but He meant something much deeper. He was not speaking of an idea, concept, or doctrine, but He was talking about true relationship. I believe that’s why we cannot quash the nagging sense of meaningless alone; rather, it must be understood through relationship with Jesus and with the Father. It is only by first loving God, then loving our neighbor as ourselves, that we can hope to find the connectedness many of us are desperately searching for day after day. When our lives become a continuation of Jesus’s life and ministry, we begin to see the paramount importance of being connected with Him and the Father in order to experience connectedness to our “selves” and others.

Concluding Remarks

It is in and through the Father’s kingdom that we find the Holy Spirit, who will guide us, heal us, challenge us, and convict us. This is the very mechanism for renewal. Moreover, this is not merely hitting the “heavenly lottery.” The words, “all other things will be given you as well” express that God’s love and care extends to our whole being. When we set our sights on Him. we come to understand how God keeps us in the palm of His hand. We learn not to worry, project, or become hopeless. We avoid the trap of emotional upset, including anxiety and depression. We become lifted up into God’s unconditional love and care. A change in our hearts leads to a change in our perspective, and this is the very meaning of developing a Christian worldview.

References

Entwistle, D. (2015). Integrative Approaches to Psychology and Christianity, 3rd Ed. Eugene, OR: Cascade Books

Phillips, W., Brown, W., and Stonestreet, J. (2008) Making Sense of Your World: A Biblical Worldview, 2nd Ed. Salem, WI: Sheffield Publishing.

Sire, J. (2015) Naming the Elephant: Worldview as a Concept, 2nd Ed. Downers Grove, IL: Inter Varsity Press.

“I’ll Quit Tomorrow!”

Hung Over.jpeg

It is mind boggling how alcoholism impacts people from all cultures, races, socioeconomic class, gender, religion, profession, and academic background. Interestingly, all alcoholics are ultimately alike. The disease itself swallows up differences and creates a universal alcoholic profile. The personality changes that go with alcoholism are predictable and virtually inevitable.  Alcohol can precipitate the onset of a disease with a predictable, inexorable course. It can ultimately destroy the physical, emotional, spiritual, and mental life of the sufferer. Alcoholism is typified by a progressive mental “mismanagement” and an increasing emotional distress that can reach suicidal proportions.

Hidden costs of alcoholism are not small. Alcohol-related expenses cost federal, state and local governments $223.5 billion. Of that amount, tax payers are footing the bill for $92.4 billion.

Drinking Was Fun, Once Upon a Time

drinkers

Early drinking is a mood-swinger, typically in a positive direction. It gives the drinker a warm, good feeling, that may lead to giddiness. When the effects wear off, the drinker feels normal. It does not take long to learn how to set the amount and select the mood. As the typical social drinker gets deeper into the booze, getting drunk begins to have a very different effect. Heavy drinking creates a sort of undertow that drags the drinker back beyond normal and into pain. This might be the point where euphoria is reached at a big cost—if it’s achieved at all. Now the booze is consumed in order to feel no pain. In other words, to get back to some degree of normal. This is the beginning of harmful alcohol dependence.

In addition to dependency, this phase also involves a rising emotional cost. We we see a significant and progressive deterioration of the personality of the alcoholic, and (eventually) a visible physical deterioration. Ultimately, the alcoholic’s whole emotional environment is torn to pieces and destroyed. Of course, most active alcoholics are in complete denial of the impending bottom.

There is now a progressive emotional cost for every single drink. The carefree days are gone, but the alcoholic is dimly aware of this fact at best. The rising cost is willingly paid. This is proof that dependency has become truly harmful. Of course, the drinker fails to comprehend the increasingly clear signs of destruction by alcohol. Frankly, at this point the alcoholic is learning to depend more and more on rationalization. Intellect begins to blindly defend against reason—indeed, against intervention. Eventually, the alcoholic will be completely out of touch with emotions. Internal dialog will become the soundtrack of an increasingly impenetrable defense system.

Denial is Not Just a River in Egypt

The tragedy is that rationalization actually works! This form of defense—which I employed constantly during my active addiction—continues to operate as the disease progresses. The alcoholic’s behavior will become increasingly bizarre, and the innate and unconscious ability to rationalize will be practiced to the point of perfection. The drinker finds it increasingly difficult to accept blame. Time passes, and the alcoholic condition worsens. Over a period of months and years the alcoholic’s self-image continues to wane. Ego strength ebbs. Feelings of self-worth sink low, and excessive drinking continues, producing painful and bizarre behavior. Eventually, emotional distress becomes a chronic condition. The drinker feels distress unconsciously even when not drinking.

Unfortunately, rationalization works. The tragedy is that this form of defense will continue to operate as the illness progresses.

Now, “mood swings” or personality changes are evidenced while drinking. The kind person becomes angry or hostile; the happy person becomes sad or morose; the gentle person becomes violent. Alcohol causes one’s guard to drop, and chronic unconscious negative feelings are laid bare. The drinker becomes truly self-destructive. All this drinking and emotional distress may lead to a vague but poignant feeling, I just might have a drinking problem. There is a general malaise so strong felt that desperate measures to escape are actually attempted. Geographical cure, a new job, divorce.

The Pathology of Alcohol Dependence

The final stages of alcoholism are close at hand. Continued excessive drinking and accompanying behavior bring on chronic suicidal feelings. I remember thinking many times, I should just go jump in the Susquehanna River! If the course of the disease is not interrupted, the end of all this is suicide—either slowly by continued drinking or in a direct manner. This is because as emotional distress mounts, and deterioration of the personality accelerates, these negative feelings are not clearly discernible. Quite the opposite is true: They are more effectively hidden.

A pathological use of alcohol can be measured by how the individual answers the following questions:

  • Have you ever drank early or first thing in the morning?
  • Have you ever drank alone?
  • Have you ever drank an entire fifth of alcohol in a day?
  • Have you ever felt remorse after drinking?
  • Is there a growing anticipation of the welcome effects of alcohol?
  • Has the anticipation moved into the realm of preoccupation?
  • Do you hide your booze in unusual places?
  • Are you unable to be honest about how much alcohol you consume?
  • Do you suffer blackouts or experience an inability to remember chunks of time?
  • Are you having difficulty with personal relationships, work, or the law due to drinking?

Counselors gather a history of the behavior patterns by questioning those who spend meaningful or extended time around the alcoholic. Here, the basic goal is to discover whether there has been a changing lifestyle secondary to the use of alcohol, which would indicate a growing dependence.

Drug and alcohol counselors often explore this changing lifestyle by asking probing questions. Has there been a growing tolerance to alcohol? Does it take more booze for the drinker to get the desired effect? Does the alcoholic start drinking in the kitchen before bringing drinks for guests into the living room? (I often drank secretly before drinking in front of guests or family.) To what lengths is the alcoholic willing to go to get the amount of alcohol needed? The degree of ingenuity used to get more booze becomes the scale for determining how far dependency has progressed. All instances of harmful dependency that show up in alcoholic behavior patterns indicate a maladaptation of the lifestyle to (a) growing anticipation of the welcome effects of drinking, (b) an increasingly rigid expected time of use, and (c) a progressive cunning in obtaining larger amounts of alcohol.

Rational defenses and projection take hold. Why is it that the alcoholic cannot see what is happening? Simple. They have lost the ability to see it at all. The reason alcoholics are unable to perceive what is happening to them is actually understandable. As the condition develops, self-image continues to deteriorate. Ego strength grows increasingly weaker. For many reasons, they are progressively unable to keep track of their own behavior and begin to lose contact with their emotions. Their defense systems continue to grow, so that they can survive in the face of their mounting problems. The greater the pain, the higher and more rigid the defenses become—and this whole process is unconscious. Alcoholics do not comprehend what is happening. Quite literally, they are victims of their own stinkin’ thinkin’.

stinkin-thinkin

As the emotional turmoil grows in chemically-dependent people, rational defense activity turns into real mental mismanagement. The drinker erects a wall around him or her. The end result is that the alcoholic is cut off from increasingly negative feelings about themselves. They are unaware of the presence of such destructive emotions.

Not only is the drinker unaware of the powerful, highly developed defense systems, they are also unaware of the intense feelings of self-hate buried inside them. Moreover, the problem is being compounded by the fact that these defenses have now created a mass of free-floating anxiety, guilt, shame and remorse, which becomes chronic. In other words, the alcoholic no longer drinks from a “normal” point, experiencing an upswing in mood to feeling great or euphoric; rather, they must start from where they feel depressed or pained and drink to feel normal again.

Drink Takes a Man

Alcoholics drink because they drink. A Chinese proverb says, “First the man takes a drink, then the drink takes a drink, then the drink takes the man.” The drinking pattern becomes thoroughly unpredictable or compulsive. The alcoholic quits, then resumes, and does not know why he or she is drinking again. And whenever they do start again, the resumption is at the level of chronic emotional deterioration. Conditions worsen with each new episode, trapping the drinker in a deadly downward spiral.

Depression and low self-esteem become so great, the alcoholic begins to employ projection—a defense mechanism in which unwanted feelings are displaced onto another person, where they then appear as a threat from the external world rather than from within. The alcoholic does not know this is happening. The more hateful alcoholics see themselves, the more they will come to find themselves surrounded by hateful people. Depending on the personality of the drinker, such projection can present itself in ways ranging from gentle complaining to outright aggression. It is obvious the easier targets are those people typically spending time with the alcoholic, including the most meaningful. Although alcoholics tend to hate themselves, their projection works so well that they actually believe they are attacking hateful people.

People who live and exist around the active alcoholic have predictable experiences that are also psychologically damaging. As they meet failure after failure, their feelings of fear, shame, frustration, inadequacy, guilt, resentment, self-pity and anger mount. So also do their defense mechanisms. They too use rationalization as a defense against these feelings. The chemically-dependent—and those around them—all have impaired judgment; they differ only in the degree of impairment.

People who are chemically-dependent on alcohol have such a highly-developed defense system that they become seriously self-deluded. The rigid defenses that have risen spontaneously around their negative feelings about themselves, and therefore around their behaviors that caused these feelings, would be quite enough, were they the only deluding factors, to draw these people progressively and thoroughly out of touch with reality. Not only do these defense mechanisms become more rigid, but such individuals develop a growing rigidity in their very lifestyle. They are less able to adapt to unexpected change. They eventually reach a point where even schedules are burdensome. This is primarily because, paradoxically, they are less likely to plan ahead. Or, when they do plan something, they tend to feel trapped as the moment closes in.

To Make Matters Worse

Chemically-dependent people have two factors progressively working together to draw them out of touch with reality: Their defense mechanisms and distortions of memory. Consider euphoric recall, which is the tendency for an alcoholic to remember their drinking escapades euphorically or happily—in only the best light—with gross distortion of the truth. They believe they remember everything in vivid and accurate detail, thinking that all was “just fine.” Of course, this will only serve to bury the drinker’s antisocial or destructive behavior. There is a destructive distortion of perception itself. There is a lack of ability to see and appreciate reality. No recognition or acceptance that they are on a downward spiral, fast approaching rock bottom.

Rock Bottom Became the Foundation

Either of these defense mechanisms seriously impair judgment. The time inevitably comes when it is plain that alcoholics cannot see they are sick. Yet they are acutely ill with a condition that will ultimately lead to death and destruction, and which will seriously impair their constitution emotionally, mentally, and spiritually during the final months of year of their active addiction. Accordingly, treatment for acute alcoholism cannot concern itself merely with putting the drink down. It also has to do with restoration of adequate ego strength to enable the alcoholic once again to cope with life.

The Best Approach

Therapy for acute alcoholics must address the whole person. The alcoholic suffers emotionally, mentally, physically, and spiritually. Treatment often involves physicians, psychiatrists, sociologists, psychologists, pathologists, and clergy. If the whole person is not treated simultaneously, relapse is simply… inevitable. If, for example, the emotional disorder alone is addressed, the alcoholic may believe he or she feels “so good” now that they can handle the drink. When treatment is short-sighted or limited, friends and family of the alcoholic may be heard commenting, “He was easier to live with when he was drinking!” This is akin to being a dry drunk. As this “dry” condition worsens, mental gains erode away and the alcoholic inevitably reverts to drinking to feel normal.

A description of despair by Søren Kierkegaard found in his book The Sickness Unto Death. Human despair is found at three distinct levels. First is the despair that expresses itself in sentences such as, “Oh what a miserable wretch I am! Oh, how unbearable it is to be me!” Second is the despair  that expresses itself by crying out, “Oh, if only I were not what I am. If only I could be like that person!” This is deeper despair because it considers self to be so worthless as to want to abandon it completely. But the third, deepest, despair of all is despair that does not believe one is a self at all. In other words, “I used to be… but not I am not.”

Physical complications, mental mismanagement, and emotional disorder are accompanied by a similarly progressive spiritual deterioration. Guilt, shame, and remorse exact their inevitable and immobilizing toll as time goes on. Feelings of self-worth begin to decline. As meaningful relationships wither on the vine, the growing estrangements lead to spiritual collapse. At the end, these feelings produce suicidal moods, ideation, and, unfortunately, suicidal attempt and/or death. If asked, “Can’t you see you’re drinking yourself to death?” the alcoholic replies, “So what? Who cares?”

Concluding Remarks

When asked how alcoholism is treated, people commonly think of either the 12-step program of Alcoholics Anonymous (AA) or inpatient drug and alcohol rehabilitation. There are, however, a variety of treatment modalities currently available. Today’s treatment for alcoholism naturally rests upon decades of research. AA was founded by Bill Wilson (“Bill W.”) and Bob Smith (“Dr. Bob”) in Akron, Ohio in 1935. AA’s program of spiritual and character development is based on the premise that turning one’s life and will over to a “personally meaningful higher power” is the key to recovery. It is, in fact, referred to as the key of willingness. Another central idea is that sobriety or recovery depends on the admission of powerlessness with respect to alcohol or other substances.

Treatment for alcoholism has made significant advances in the last 20 years. Researchers are constantly seeking novel approaches for improving the effectiveness, accessibility, quality, and cost-effectiveness of treatment. Alcoholism is a treatable disease. Regardless of how someone is diagnosed as alcohol-dependent, or how they came to realize they have a drinking problem, the first step to treatment is a sincere desire to get help. Overcoming an alcohol problem is an ongoing process that sadly might involve relapse. Granted, relapse is not a “requirement” for recovery—you don’t have to change your sobriety anniversary!—but it is merely a setback and not an indication that you will fail in your attempt to get sober.

 

A Fundamental Orientation of the Heart

Perhaps one of the hardest things we face is taking stock of whether our actions match what we claim to believe. Our worldview – that is, how we see the world and our place in it, or, if you prefer, our “philosophy of life” – should be obvious from our behavior. A worldview is not just a set of basic concepts but a fundamental orientation of the heart.

Since the events of 9/11, the term worldview is often used as a very general label for how people view the cultures with which their culture clashes. This is very important to note, as a worldview is a set of presuppositions (assumptions which may be true, partially true, or entirely false) which we hold (consciously or unconsciously, consistently or inconsistently) about the basic makeup of our world. A worldview is sometimes considered to be the fundamental perspective from which we address every issue of life.

From a Human Perspective

Imagine someone who thinks life has no true purpose. For that person, events are random. “I live, then I die.” A meaningless existence requires nothing from anyone. There is no need to check our bearings along the way to see of we’re “on track.” There is no need to justify our choices, values, or goals. There is a quiet desperation that drives humanity to think about the question, “Does life have meaning?” Even non-religious people understand that man has a burning desire to make sense of his life. Humanist Deane Starr writes, “Humans find their most complete fulfillment, whether real or imaginary, in some sort of intimacy with the Ultimate.” Our greatest and most difficult achievement is to find meaning in life. It is well known that many people lose their will to live because such meaning evades them.

What happens when someone fails to find a reason for living? Often they experience a spectrum of emotional and behavioral aberrations. Jay Asher published a book in 2007 titled Thirteen Reasons Why. Netflix has produced a mini-series based on Asher’s book, which has caused quite an uproar across the country. The story begins when Clay Jensen returns home from school to find a strange package with his name on it lying on his porch. Inside he discovers several cassette tapes recorded by Hannah Baker—his classmate and crush—who committed suicide two weeks earlier. Hannah’s voice tells him that there are thirteen reasons why she decided to end her life. Clay is one of them. If he listens, he’ll find out why.

Suicide is the third leading cause of death in the age group of 10 to 24 years. It is a critical problem in America. Educators and mental health professionals have mixed feelings about Thirteen Reasons Why. Dr. Nicole Quinlan, a pediatric psychologist at Geisinger Medical Center in Danville, PA, objects to the show’s graphic, gratuitous portrayal of Hanna Baker’s suicide. I watched the mini-series, and I was shocked and upset by the final scene. I didn’t expect to see Hanna Baker drag a razor blade up both of her arms while sitting in a bathtub of warm water. It was, indeed, horrific.

Hanna Baker is a fictional character, but her plight is far from pretend. She was hounded by classmates, bullied online, and was labeled a “slut” after a football jock posted a random shot of her dress flying up when she came down a sliding board during her date with him. He intimated in his online post that Hanna was “easy.” Hanna’s problems worsened when she was raped by another member of the football team. On each side of the cassette tapes, she exposed one person (one “reason”) why she decided to end her life. Her thirteen excuses. Teenage angst is a very real and difficult emotion. Hanna, as are many teens, was trying to find meaning in what she felt was an already meaningless existence. Her worldview was that life was without purpose. The fault of the story depicted in Thirteen Reasons Why is its lack of providing meaning, hope, or the option of seeking treatment.

From a Biblical Perspective

Developing a biblical worldview involves both a mindset and a willset. First, how does the Bible explain and interpret my life and the world around me? Once this question is answered and accepted, the next aspect of a biblical worldview presents the challenge of putting this view into practice. A worldview is the framework of our most basic beliefs that shapes our view of and for the world, and is the basis for our decisions and actions. Worldview leads to values, which lead to actions. Beliefs clearly shape our behavior.

Man’s attempts to explain his existence are just that: man’s attempts. Within the world, man’s experience and perceptions of the infinite universe are limited and inadequate. We need help from the “outside.” This is what a biblical worldview is. Help from the outside. More fundamental than any worldview that can be delineated by ideas and propositions is the religious or faith orientation of the heart. There are only two basic commitments, leading to two basic conditions of life: “man converted to God,” and “man averted from God.” The commitment one makes is decisive for all life and thoughts. From a Christian perspective,  worldview is not so much a matter of theoretical thought expressed in propositions, but is a deeply rooted commitment of the heart. Theory and practice are a product of the will, not the intellect; of the heart, not the head.

How Would My Life be Different if I Lived Out my Convictions?

I have spent most of my life manipulating others. For reasons best understood by reading my testimony, https://theaccidentalpoet.net/about/, I felt the need to hide, run away, or escape. I had a difficult time telling the truth, and, because of a victim mentality, I was able to rationalize my behavior. I became a born-again Christian at age 13, but never fully developed a relationship with, nor the mind of, Christ. When I began escaping through drugs and alcohol, I set off down a road that ultimately took me until August of last year to get off of and head in the right direction.

How could I act in such a callous and selfish manner if I was a Christian? I now understand the reason. One of my sponsors in Alcoholics Anonymous kept saying, “I hope you get God out of your head and into your heart.” Each time I heard that, I became defensive. Who are you to tell me I don’t have God in my heart? My former pastor said the same thing when he commented, “You don’t seem to have a heart for God.” What? I continued becoming defensive.  Several things happened over the past year that finally got through to me

First, I returned to the church of my youth where I accepted Christ. Within a few months, our church got a new pastor from New Jersey. Pastor Mike is exactly what I needed. He has a wealth of experience counseling Christians struggling with addiction. In our several one-on-one meetings, he has been able to help me restructure how I see my addiction and the many excuses I was holding on to as justification. He has also helped me take a different approach to my chronic back pain. He made an amazing statement: “Have you ever considered that your chronic pain gives you the opportunity to share in the sufferings of Christ?” Whoa!

Last August I made the ridiculous decision to “help myself” to some of my mother’s oxycodone. Unfortunately, this was not the first (or second, or third) time I’ve done so. The result was serious damage to my relationship with her and the rest of my family. Interestingly, this is something I feared would happen if I did not stop using drugs. Especially using mom’s medication! I remain estranged from the family, and can only continue on my road to recovery, turning my relationship with the family over to Christ. I know I am delivered from the bondage of addiction. I have to live that freedom all over again each day. One day at a time.

Luke 6:45 is a Scripture I meditate on daily. It is very convincing, and seems to confirm what my former pastor and a former sponsor said regarding my lack of having God in my heart. The verse states, “A good man out of the good treasure of his heart bringeth forth that which is good; and an evil man out of the evil treasure of his heart bringeth forth that which is evil: for of the abundance of the heart his mouth speaketh.” Proverbs 23:7 says, “As a man thinketh in his heart, so is he.” God is concerned about the hidden man of the heart, which is our inner life. Our inner life is what we think about. And like the Scriptures above indicate, how we live and who we are.

A Change of Behavior Requires a Change of Heart

It says in Jeremiah 17:9, “The heart is deceitful above all things, and desperately wicked: who can know it?” Why do we sin, do bad things, and make mistakes? Because of our heart, which the Bible says is desperately wicked. Why do so many people struggle with drugs and pornography, returning again and again to these sins and vices even though they know their lives are being ruined by them? Because our heart often leads us astray. We cannot live perfect lives, and we cannot save ourselves from the punishment that we deserve. Moreover, it is impossible to deny the flesh, resist temptation, and stop living a self-centered and sinful life without a true change of heart.

Can this explain my constant relapsing over nearly forty years? Can it account for my selfishness? The disrespect and dishonor I’ve shown toward my parents and siblings? Does it help explain how I can “believe” and “speak” about Christ and recovery while secretly using drugs? Worldview, as I mentioned at the beginning of this post, is how we think about the world and our place in it. This basic belief establishes our values, which directly control our actions.

O Lord, how heartily sorry I am for failing to establish the proper Christian worldview, and to hide your Word in my heart that I might not sin against Thee.

It is only through my embracing a true Christian perspective and asking Christ to take away my heart of stone and give me a heart of flesh that I can hope to act from a position of love and respect.

Opioid Use Disorders and Suicide

The following is a guest blog taken verbatim from the monthly blog post of Dr. Nora Volkow, director, National Institute of Drug Abuse published April 20, 2017.

“At a Congressional briefing on April 6, the President of the American Psychiatric Association, Dr. Maria Oquendo, presented startling data about the opioid overdose epidemic and the role suicide is playing in many of these deaths. I invited her to write a blog on this important topic. More research needs to be done on this hidden aspect of the crisis, including whether there may be a link between pain and suicide.” – Nora

In 2015, over 33,000 Americans died from opioids—either prescription drugs or heroin or, in many cases, more powerful synthetic opioids like Fentanyl. Hidden behind the terrible epidemic of opioid overdose deaths looms the fact that many of these deaths are far from accidental. They are suicides. Let me share with you some chilling data from three recent studies that have investigated the issue.

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In a study of nearly 5 million veterans recently published in Addiction, scientists reported that presence of a diagnosis of any substance use disorder and specifically diagnoses of opioid use disorders (OUD) led to increased risk of suicide for both males and females.  The risk for suicide death was over 2-fold for men with OUD.  For women, it was more than 8-fold.  Interestingly, when the researchers controlled the statistical analyses for other factors, including co-morbid psychiatric diagnoses, greater suicide risk for females with opioid use disorder remained quite elevated, still more than two times greater than that for unaffected women.  For men, it was 30 percent greater.  The researchers also calculated that the suicide rate among those with OUD was 86.9/100,000.  Compare that with already alarming rate of 14/100,000 in the general US population.

You may be tempted to think that these shocking findings about the effects of OUD on suicide risk are true for this very special population.  But that turns out not to be the case. 

Another US study, published last month in the Journal of Psychiatric Research, focused on 41,053 participants from the 2014 National Survey of Drug Use and Health.  This survey uses a sample specifically designed to be representative of the entire US population.  After controlling for overall health and psychiatric conditions, the researchers found that prescription opioid misuse was associated with anywhere between a 40 and 60 percent increased risk for suicidal ideation (thoughts of suicide).  Those reporting at least weekly opioid misuse were at much greater risk for suicide planning and attempts than those who used less often.  They were about 75 percent more likely to make plans for a suicide, and made suicide attempts at a rate 200 percent greater than those unaffected.

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Using a different strategy, a review of the literature in the journal Drug and Alcohol Dependence estimated standardized mortality ratios for suicide.  This is a way of comparing the risk of death in individuals with a given condition compared to individuals from the general population.  The researchers found that for people with OUD, the standardized mortality ratio was 1,351 and for injection drug use it was 1,373.  This means that compared to the general population, OUD and injection drug use are both associated with a more than 13-fold increased risk for suicide death. These are stunning numbers and should be a strong call to action.

Persons who suffer from OUD are highly stigmatized. They often talk about their experience that others view them as “not deserving” treatment or “not deserving” to be rescued if they overdose because they are perceived as a scourge on society.  The devastating impact of this brain disorder needs to be addressed.  People who could be productive members of society and contribute to their families, their communities, and the general economy deserve treatment and attention.

As a country, we desperately need to overcome stigmatizing attitudes and confront the problem. We need to understand what causes some individuals to become addicted when exposed to opioids and thus study the biological basis of the disease of opioid addiction. We desperately need to know what the best treatments are for a given individual, and for that too, we need research to identify biomarkers for treatment response. Given the fact that effective medications exist but are drastically underutilized, we need to overcome institutional and attitudinal barriers to these treatments and deliver them to the 24 million people who could benefit. It can prevent not only the suffering of addiction and the danger of unintentional overdose but also help prevent the tragic outcome of opioid-related suicide.

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Ronnie’s Leap

Dedicated to the memory of my friend, Ronnie Benner, who killed himself by jumping off  the Shikellamy State Park lookout.

I keep playing it over and over
In my mind; he leaps again and again.
He climbs over the fence
And steps to the edge of all his yesterdays,
The breeze making his hair dance.
He has become unable to remember pleasure,
Thinking only of pain;
He is smothered in a blanket heavy with malaise;
No one to talk to,
No chance for release.
He takes one last step,
Then he’s gone.