From Alcoholic Enmeshment to Rational Recovery

Todd came to see me at the encouragement of his mother. He "talked the right talk" about leaving his drugs and alcohol behind, although he had a long track record of failed attempts. Todd had been in and out of residential treatment programs without success. This young man looked to me and rational recovery as his last chance to live a lifestyle free of the ravages of addiction.

I pushed Todd to explain to me, in every conceivable manner, how "this time" things would be different from all of his other failed attempts at sobriety. In a straightforward, yet probing way, I took him apart in the process of working to hold him accountable for his wasted life. Fortunately, he didn't run away from therapy.

Todd came to see me every week as we combined my cognitive-behavioral treatment with a local outpatient rational recovery program. Since the efficacy of inpatient substance abuse treatment programs is marginal, I felt that this would be a more effective treatment approach. This two-pronged strategy appeared to be the perfect mix. Naltrexone, a medication employed to stop the urges and cravings of alcohol was used with my patient. The goal of treatment was to focus on his lifestyle of excessive drinking and to rationally, reconfigure patterns of behavior that were consistent with a lifestyle of sobriety.

Todd began drinking when he was eight years old. His father would take him on camping trips and would provide him with hard liquor during their journey. Todd recalled his father handing him small, open alcohol bottles for consumption which had been purchased from the airlines. Todd reminisced about how he would eventually end up vomiting during stops along the way to the camping sites. According to Todd, his father was too "wasted" to be of any assistance to him.

This father and son drinking dynamic went on throughout Todd's adolescence. Todd began being admitted to residential treatment programs by the time he was thirteen years old. Each time Todd was placed in a rehab program for drugs and alcohol, Todd's father would make a special effort to visit him during recovery. Ironically, he would wish his son well and then would depart. On one occasion, Todd remembered his father drinking and smoking pot with him in their car just prior to his being admitted.

I found it fascinating that Todd never thought about the peculiar, symbiotic, outrageous abusive nature of his father/son relationship until we began exploring it. Even then, Todd deflected the experience through anxious laughter. As I "turned up the heat" on the emotional impact of what he experienced, Todd's vision of his past became clearer. He began to understand the betrayal, shame and humiliation foisted upon him by his father’s alcoholic enmeshment. It was painful for Todd to learn to hold his father responsible for the hurt, disappointment and destructive behavior he created.

As we moved through therapy, Todd was afraid of his anger and where it would lead him. We addressed that fear along with ways of coping with his enfeebled, alcoholic father in the present. Todd set more appropriate boundaries related to any contact with his father, and on several occasions broached the subject of his father's past behavior to no effect.

Todd learned to accept the fact that his father would never change, and that he would need to grieve and release a history filled with horrible memories. Todd's rational recovery, based upon cognitive-behavioral therapy, is working. He has a positive support system, medication for his urges and cravings, and takes full responsibility for his recovery. Every day is a choice about whether to allow his father to continue to have power over his life or to choose to forgo a pattern of drinking that started many years ago during his father/son camping trips.


{Note: This narrative is a composite. It has been deliberately altered in order to protect an individual’s right to confidentiality and privacy.}

Cognitive Therapy and Sleeplessness

It appears that "as the world turns" many are having a difficult time falling asleep and/or staying asleep. Our fast-paced lifestyle can leave one feeling fatigued, apathetic and restless as a result of a cycle of sleep deprivation. Some turn to sleep medications as a way of rectifying the problem of insomnia. Others look for naturopathic remedies to provide respite from a sleepless night.

Certain chronic insomniac conditions that result from pain-related problems may warrant the use of sedating medications. Other cases, however, may respond to various non-medicinal treatments, including the use of cognitive-behavioral therapy.

Cognitive-behavioral therapy is at the forefront of treatment for various disorders, including depression, anxiety, pain management issues and insomnia. Insomnia may be caused by life stressors, physical illness, emotional discomfort, environmental factors, self-medicating or disruption in one's sleep pattern due to work-shift changes or jet lag.

CBT seeks to work with insomniacs through their thought processes, ways of viewing the world and underlying beliefs about sleep. Many adults become anxious about their lack of sleep. They may ruminate about the horrible things that they believe will happen to them if they fail to promptly fall asleep. I often tell patients, "Where is the evidence that not sleeping tonight will cause you undue harm? What's the worst thing that will happen?" Frequently, it is the anxiousness about not sleeping that sets up a self-defeating dynamic of frustration and restlessness.

CBT uses paradoxical intervention strategies for dealing with sleeplessness. I recommend that patients who experience insomnia stay awake as long as possible prior to going to bed. Individuals should be sufficiently fatigued and drowsy before lying down. The bed should always be used for sleep purposes and never used for reading, relaxing or ruminating. If the patient's sleep is interrupted, the sufferer should get out of bed and read, watch television, until sufficiently tired enough to resume sleep.

Often, people do not realize that the human body will automatically self-regulate. If one only gets three hours of sleep on a given night, the body will automatically compensate, eventually providing appropriate rest. It is the fear of not sleeping that sets up a negative dynamic for the insomniac. Individuals may set up a self-defeating cycle by remaining in bed as they ruminate about sleeplessness. Ironically, this process only compounds the problem by leading to further restlessness.

Learning to relax the body and mind is important to getting quality sleep. Learning mindfulness meditation helps the insomniac to calm the sympathetic nervous system, setting the stage for restful sleep.

What people do with their time prior to going to sleep is important. Playing stimulating music, working at the computer and using alcohol will negatively affect one's ability to sleep. Learning to let go of work-related stressors is imperative. Individuals who are "pusher-drivers" are more likely to carry their workday into the night.

Patients, who experience insomnia, generally suffer from the following self-defeating thoughts and assumptions:

• "If I don't sleep, something awful will happen to me."
• "I must sleep or else I won't be able to function anymore."
• "I'm afraid to go to sleep because something might happen to me."
• "If I don't fall asleep promptly, there must be a problem."
• "I have so much work to do that I don't have time to sleep."
• "I must stay in bed until I fall asleep."
• "Worrying about things helps me to control my life."
• "I must complete everything on my list, especially work tasks."
• "Being alone at night is a scary thing."

Assisting patients to reframe negative thinking is essential to treatment for insomnia. Anticipatory anxiety in the form of negative self-statements must be replaced with more adaptive ways of thinking about sleep. By employing strategies that emphasize the “reverse-effort” of not trying to fall asleep, patients learn to relax their bodies through passive volition and secure needed rest.