Since I live in an area where wildfires have been devastating communities, this is some of what I’m hearing in therapy this week:
“I’m having trouble breathing.”
“Should I keep my child home from school or make them wear a face mask?”
“Three of my friends just lost their houses.”
“I can’t seem to focus.”
“I was just starting to get my head around the Las Vegas shooting and now this.”
“I don’t even know how to take care of myself right now.”
“Donating bags of supplies doesn’t seem like enough.”
“I’t’s just one disaster after another- I’m not sure I want to bring my children up in this world.”
These are from people living near the wildfires. Not the ones who directly lost their houses, schools, churches in the fire. So you can only imagine the trauma for those impacted even more directly.
A Little About Trauma:
What is trauma? According to the APA (American Psychological Association) trauma can be defined as:
“an emotional response to a terrible event like an accident, rape or natural disaster. Immediately after the event, shock and denial are typical. Longer term reactions include unpredictable emotions, flashbacks, strained relationships and… physical symptoms like headaches or nausea. While these feelings are normal, some people have difficulty moving on with their lives. Psychologists can help these individuals find constructive ways of managing their emotions.”
Secondary trauma can be defined as “the stress resulting from helping or wanting to help a traumatized or suffering person.” (Figley, C.R., Ed., 1995).
According to Secondarytrauma.org, some of the symptoms of secondary trauma include:
- intrusive thoughts
- chronic fatigue
- poor concentration
- second guessing
- emotional exhaustion
Many caregivers, therapists, nurses, firefighters, emergency providers, and what I call “senstives” or “empaths” experience secondary trauma. Secondary trauma can result from working directly with people who experienced trauma.
But what can we do about it?
If you are feeling the effects of trauma, here are some thoughts on self-care.
- Physical self-care
A friend of mine said recently, “I feel like a baby. I don’t even know how to take care of myself during this.” Actually, thinking of baby self-care is a good clue as to what you may need. Babies need physical care and tending. If you are able to, keep regular routines of sleep, meals/snacks, hygiene (showers and baths), and stay hydrated. Obviously, physical self-care also includes staying in a safe house or shelter. In the bay area, many hotels, air b and b’s, and nearby friends/family members/colleagues are offering shelter for those who have lost their house or residence due to the fires.
2. Emotional Self-Care
When thinking about a time when you have felt grounded, ask yourself what you were doing? It may have been journalling, meditating, or spending time with a dear friend. Although tempting to NOT do these things during times of crisis, it is actually even more important to do them. This is the directive of “put your own oxygen mask on first.” You cannot be of service to others of you are unable to breathe yourself.
3. Help others
Note this comes third on the list. After you make sure you are taken care of and resourced, then you can give, whether it be through providing housing, volunteering, donating supplies, or emotionally supporting people affected by the disaster.
If you are a parent:
Here’s a beautiful acronym/summary of ways to support your child during/after a disaster or emergency from Alberta Health Services:
Remove yourself and your loved ones from danger. During an emergency or disaster, finding shelter, water, and food is the first step. Staying safe and keeping calm is important in helping you and your child in an emergency.
Eat nutritious food and drink water.
Activity. Return to your normal routine as quickly and much as possible. Try to do what your family normally did before the event (e.g., eat meals together, walk together, play games, read).
Take care of yourself! One of the gifts of both recovery and of disasters is that it forces asking questions such as: What is most important? And what do I need to take care of myself right now? Here’s to living our way into those answers.
As always, this blog is not intended to provide or replace psychological treatment.
Mentis in Napa county is one of many mental health centers in the bay area providing mental health support at low fee currently for victims of the California wildfires. 707-255-0966 ext 132 http://mentisnapa.org/our-services/#mental
The National Center for PTSD is a good resource for information on trauma recovery: https://www.ptsd.va.gov
Some addiction counselors recommend getting a pet after going through treatment (for alcoholism, eating disorders, depression) before you start dating. The thought being that first you learn how to tend to an animal that has a body and feelings, isn’t ashamed of them, doesn’t abandon them, and lets you know when you do (abandon them). It’s a metaphor for self-care, responsibility, and tending: tending to recovery, tending to relationship, tending to health.
Plants are harder. They don’t bark at you, jump on you, or snuggle up to you. They don’t beg for food or scratch on the door. They just sit there, in their pot, very quietly, thriving. Or not thriving. For someone with a black thumb, it’s hard to tell.
This orchid plant has been in my office for two years. It has never bloomed until this past week.
At one point it had sticky gunk covering its leaves and I thought it might die. Orchids are particularly challenging. With orchids, there are long periods of just sitting there, mostly looking ok, but not blooming. For two years, I watered it. Just a little, because I have heard they don’t like being flooded. Sometimes I put it on the sunlit windowsill, but not for very long, as I have heard that they don’t like too much light, either. As one gardening site states:
“Insufficient light results in poor flowering. However, too much light can lead to leaf scorch.” *
Well, I don’t know what leaf scorch is, but I certainly don’t want that for my orchid! And I certainly don’t want my clients coming into an office with a leaf-scorched plant! That would not represent hopefulness or health in the recovery process!
Orchids are what some might call “high maintenance” plants. They require very specific conditions or they will not flourish. “High maintenance” is not always a description that is welcomed. I prefer sensitive. Like orchids, many recovering people have orchid-like temperaments: sensitive and requiring certain conditions to flourish. Without these conditions, they may “go dormant” (depression) or become sick (eating disordered, addicted) in order to survive.
Many of my clients are what might be characterized as “orchids.” (No, not all of them, and everyone has some degree of orchid-ness and dandelion-ness in them). Orchids are a sensitive lot. They need just the right amount of light and water or they don’t bloom. They’re often the ones, as children, that stay on the edge of the playground until the conditions are exactly right for them to jump in and play. I often use this analogy with my clients: If you go to a playground and one person runs right to the slide to go down it, and one person pauses before deciding where they would most feel comfortable playing, who is better? They often either look at me puzzled, or give me an exasperated:
“Well obviously, neither, on the playground. But real life isn’t like that, Dr. Linda. I should be able to go right to the slide (share confidently in class, jump right into a leadership role at a new job, know whether I am going to marry this person on a first date, be Supermom the day after labor and delivery).”
When I ask “Why?,” the answer that comes is:
“Because other people do.”
To which I respond “Hmmm…who are these ‘other people’ and did you do any double-blind research studies before comparing and despairing?”
Orchids are sensitive to their conditions and often “slow to warm up” in temperament. Dandelions, however, bloom in many different kinds of environments. Dandelions go right to the playground slide. Or the swings. Or hang out with their orchid friend in the quiet zone of the playground. They can grow in soil full of organic compost or they can thrive in dirt under a concrete sidewalk. If you suggest:
“Let’s eat here (Pizza, Bar-on-the Corner, 5-Star Restaurant),”
a dandelion will say:
If you suggest:
“Let’s eat here (Pizza, Bar-on-the Corner, 5-Star Restaurant),”
an orchid will say:
“Do they have gluten-free or vegetarian options, how loud is it, have the chickens been free-ranging?” (Except usually they won’t say this because they are worried about being too “high maintenance,” so they’ll go to the pizza place and get a stomach/headache from the noise, inability to digest the food, and concern about if the chicken was ranging free.)
You might be thinking “But those ARE the high maintenance people. That’s Sally in When Harry Met Sally when she takes ten minutes to order a sandwich.”
To which I would reply:
No, those are the people who are going to be deeply affected by the food they ingest, the company they keep, and their external environment. Those are the canaries in the mineshaft. Coal miners they used to take a canary with them into the mine because, when the canary died, they knew the air was toxic and they needed to get out. The sensitivity of the canary was their awareness of their own mortality. Canaries (Orchids) can offer wisdom as to how to honor sensitivity and diversity.
IF you are an orchid, your work is to stop pathologizing your sensitivity. Get yourself to an environment where you can thrive. Surround yourself with people who embrace your sensitivity. Give yourself the right amount of water and sunlight. Visit nature. Make art, music, or write. If you are an introvert, create quiet introversion recovery time in your schedule. If you have learned how to tend to your own sensitivities, then be of service advocating for other orchids and educate the dandelions. Many (but not all) dandelions are open to helping support orchids. Many (but not all) orchids are open to helping support dandelions. They can thrive together in the right conditions.
If you are an orchid, take very good care of yourself, even when you don’t see immediate results. Remember it took my orchid two years before it trusted me enough to bloom. But, in the famous words of Anais Nin:
“the day came when the risk to remain tight in a bud was more painful than the risk it took to blossom.”
[i] I borrowed the metaphor of orchids and dandelions from an esteemed colleague, Vivette Glover, who is a British professor of Perinatal PsychoBiology at Imperial College of London. Dr. Glover cites the article below as one that explores the “Orchid/Dandelion hypothesis.” This hypothesis explores how twins with short 5-HTT (“orchid”) alleles have different environmental susceptibility to depression.
Conely, Dalton, Rauscher, Emily, and Siegal, Mark L., “Beyond orchids and dandelions: Testing the 5HTT ‘risky’ allele for evidence of phenotypic capacitance and frequency dependent selection” Biodemography Soc Biot. 2013; 59(1): 37-56.
[ii] Part of this post originally appeared on Recovery warriors blog https://www.recoverywarriors.com/lessons-recovery-life-little-one/ “Lessons About Recovery and Life I’ve Learned From My Little One,” November 8, 2016
I will love the light for it shows me the way, yet I will endure
the darkness for it shows me the stars.
We are in a dark time of the year. There is a reason why there has always been a light-in-the-darkness time, and not just for those needing light in recovering from depression. Historically, in an agricultural society, December was a time when the harvest was done and therefore it was a time to rest, turn inward and reflect. With the days being darker, and Winter Solstice being the shortest day of the year, bringing and celebrating light is a natural response to, well, not going mad in the darkness. We need light. Not only does the vitamin D literally stave off depression, but symbolically we need to know there is light in the dark.
One theory of the origins of December 25 as the date chosen for the birth of Jesus is that it was originally the pagan festival in Rome celebrating “the birth of the unconquered sun,” celebrating the sun-god and the solstice. Hanukkah is also known as “the Festival of Lights,” Kwanzaa ritual include lighting special candle holders called kinaras, and in the December Hindu festival Pancha Ganapati, a shrine with Ganesha (the Hindu elephant god who clears away obstacles) is lit. Shabe Yaldā or Shabe Chelle, held on the Winter solstice, isan Iranian festival celebrating the victory of light and goodness over darkness and evil, and Chahar Shanbeh Sure, the Iranian “festival of Fire” celebrates light over darkness on the last Tuesday night of the year.
“People are like stained-glass windows. They sparkle and shine when the sun is out, but when the darkness sets in, their true beauty is revealed only if there is a light from within.”
-Elizabeth Kubler Ross
For recovering people, this can be particularly challenging to remember the light: the light of hope, the light of “this too, shall pass,” the light of love. It can be difficult to remember you have an inner light to which you can listen.
There is a lot to be concerned with in the world right now. So much suffering. Holding the light of hope can be hard. So many religions and cultures have this light in the darkness in their symbolism for this very reason. It is a human need; an archetypal commonality we share. Remember that you are only responsible for your light, your candle in the darkness. Light your candle. Revisit, hold onto, re-light this light. In the words of Anne Frank,
“Look at how a single candle can both defy and define the darkness.”
Light your candle. The world needs it. The world needs you.
The holidays can be hard. They can be especially difficult for people recovering from disordered eating, alcoholism, depression, or anxiety. The intention of this blog is to help you be a bit more fierce with your own self-care and a bit more compassionate with yourself and others. This is not a list to use to beat up on yourself for not doing enough or being imperfect! May it be helpful, useful, and ease some of your suffering during this time.
Try not to let yourself get too Hungry, Angry, Lonely, or Tired. Getting too tired, hungry/hypoglycemic, resentful, or isolating is a recipe for addictive behaviors and/or depression. Imagine yourself to be a little one (this will not be hard for you parents to imagine) who needs regular meals and snacks, regular emotional understanding, and regular sleep. If little ones get too tired/hungry/emotionally not heard, there will be meltdowns. Be a kind parent to yourself. Pack a self-care bag with protein snacks, water, get to bed on time, make plans with friends and/or providers that “get” you so you can feel nourished and grounded. Practice what a friend of mine calls “aggressive self-care.”
2. Keep 1 Thing Constant
Choose one thing – morning meditation, weekly support group, your meal plan, sobriety, journaling, daily inspirational reading… To read more, go to EDBlogs
Just as a reminder, the intention here is to help you be a bit more fierce with your own self-care and a bit more compassionate with yourself and others… not to beat up on yourself for not doing enough or being imperfect.
Stay tuned for part two next week!
Sometimes S’mores are Dinner and You Have to Let the Bad Feelings Out Before the Good Feelings Can Come in
Like many mothers, one of my fears is that my child will eat only sugar and therefore not grow (have deficits in attention, develop an eating disorder, etc.). When moms have this fear, what do they do? Often, they swoop in and try to control. Here’s what it has looked like in our house:
Me: “Eat your broccoli.”
Little one: “No.”
Me: “Eat your broccoli or no dessert.” (Yes, I am ashamed to admit I have resorted to this in my not-so-enlightened moments as RecoveryMama)
Little one: Takes tiny bite of broccoli floret- like half of a child’s pinky fingernail size- runs around making a horrible face as if being tortured while chewing, swallows, says “Done. Where’s my dessert?”
So, as you can see, my child now loves eating vegetables and we are living happily-ever-after on an organic broccoli farm. The End.
(Just kidding. This is the beginning. The rest is guest blog on on RecoveryWarriors, a fabulous eating disorder recovery resource. Click Here to continue reading)
Have you ever had a song come on the radio that suddenly transported you somewhere? A recovering alcoholic friend of mine takes it as a “sign” whenever she hears the song from the movie Frozen “Let it Go,” reminding her that she is not in control and that is a good thing. Another woman I know listened to “I Gotta Feeling” by the Black Eyed Peas every day when she was recovering from Postpartum Depression. It was the thread she held onto when she had forgotten what joy felt like. For those four minutes and fifty-one seconds, she could remember. Music enters the nervous system through the brainstem, which neuroscientists suggest may be the “seat of sentience..(To read full article go here, to Psyched in San Francisco, a San Francisco therapy site, where I am guest blogging. Then come back here for the list below!)
Dr. Linda Shanti’s Brief List of Music for Different Life categories
For Recovery, Patience, and Affirmation:
Let it Go (Indina Menzel)
Love After Love (Jami Sieber and Kim Rosen)
Good Day (Nappy Roots)
In My Car (I’ll Be the Driver) (Shanaya Twain)
One Day At A Time (Elton John)
Butterfly, Next Right Step, or Sing, Love, Dance (Jana Stanfield)
Have A Little Faith in Me (John Hiatt)
I Am Loved, Gentle With Myself, Prosperity Chant (Karen Drucker)
Just Let Go (Thin White Duke Remix)
HOPE Let My Love Open the Door (Pete Townshend)
Dream Machine (Downtempo Mix) Hotel Costes
I’ve Gotta Feeling By Urban Beats (Black Eyed Peas)
A Little Bit Of Riddim (Michael Franti & Spearhead)
Golden Bowls of Compassion (Karma Moffett)
Inspiration or Vision (Dr. Jeffrey Thompson)
The Empty Sky (Anugama)
Gaia (Michael Brant DeMaria)
Returning (Jennifer Berezan)
For Romantic Love:
The Way I Am and Giving Up (Ingrid Michaelson)
Can’t Help Falling in Love (Twenty One Pilots or Haley Reinhart)
I’m Gonna Be (The Proclaimers)
All My Days (Alexi Murdoch)
Breaking Up (the Bitter and Recovery Stages):
Gives you Hell (All American Rejects)
Send My Love To Your New Lover (Adele)
Breakable (Ingrid Michaelson)
Love After Love (Jami Sieber and Kim Rosen)
Get Your Booty Out of Bed, Song in Your Heart, or Peanut Butter and JAM, (Charity and the Jam Band)
We’re Going to Be Friends and The Sharing Song (Jack Johnson)
Crazy ABS’s or Food Party (Barenaked Ladies)
Itsy Bitsy Spider (This version: Party Like A Preschooler)
For the Earth and its People:
Keep A Green Tree in Your Heart (Charity and the Jam Band)
With My Own Two Hands (Jack Johnson)
Down to the River (Alison Krauss & Union Station)
Creating a Dream (Xavier Rudd)
Imagine (John Lennon)
Dreamy Music For Sleep (Dr. Jeffrey Thompson)
(I’m Guest blogging for a San Francisco therapist’s site! Here is the beginning of the article, then click on the link below to continue reading)
Last weekend I went to the movies with my preschooler. It was a special theater adventure into which we snuck in a large purse full of popcorn. As the lights dimmed and the light-up crocks flashed, we heard lots of excited children exclaiming “It’s starting!!!” and some not-so-happy babies sharing in their preverbal-but-very-easily-interpreted sounds.
I have to say I think I enjoyed the movie much more than my child. The Psychologist part of me was impressed with the ways they imaged memory consolidation in the brain and characterized feelings. Here are a couple of things that stood out as ways to practice emotional understanding either as a parent to your inner child, your external child/ren, or both.
1. Externalizing and characterizing parts of the self makes them less scary
The other night I lost it with my preschooler after 9,003 (ok it cold have been 9,002) attempts to get teeth brushed before bed and yelled “BRUSH YOUR TEETH RIGHT NOW!” (I do not recommend this). After taking a deep breath, I was able to soften my own guilt for yelling and make it less scary/ more able to be released for my child by stating,
We then talked about “the angry flame-guy” and how sometimes t is helpful to shoot out flames (like when you are trying to get the window open for your friends joy and sadness) and sometimes it is not helpful to shoot out flames (like when you are trying to get your child to brush their teeth) but it’s just the angry flame-guy, and we all have an angry flame-guy part of our self. We also all have a sad, crumpled-on-the-floor-have-to-drag-me-around part, a green, disdainful-condescending-mean-girl part, a pixie fly-around-in-joy-reframing-everything-as-a-growth-opportunity part, etc. They are just parts of the self, not ALL of the self. When we remember that, we can stay an integrated whole Self. And when we forget, that, we become dis-integrated, overwhelmed self.
A controversial article by Gabriel Glasner came out last month in the Atlantic titled “The Irrationality of Alcoholics Anonymous” . As a Psychologist who has witnessed the power of 12-step Programs transform lives, I wanted to share my perspective.
AA is not evidence-based treatment. It is a peer-led support system.
In her article, Glasner states, “Nowhere in the field of medicine is treatment less grounded in modern science.”
12 step meetings are a community-based support group. AA is not a treatment program, nor is it evidenced-based research. AA or any other 12-step program is not therapy or medicine. It is a group of people assisting each other to stay sober or free from other addictive behaviors and learn new tools to manage their emotions. There is no double blind research going on during meetings. There are no medical professionals such as Psychiatrists, Social workers, or Medical Doctors facilitating the meetings and collaborating on the care of patients attending meetings. AA is a peer-led support group. As one member of AA said to me ironically “it’s not named “Well-Persons’ Anonymous.” By its very definition, AA is made up of sick people becoming well helping other sick people become well. The Preamble to AA and Tradition 3 of the twelve steps and twelve traditions both state:
“The only requirement for A.A. membership is a desire to stop drinking… A.A. is really saying to every serious drinker, ‘you are an A.A. member if you say so. You can declare yourself in; nobody can keep you out.’” 
The history of AA is a fascinating story of two alcoholics, Bill and Bob, discovering experientially that the only thing effective in keeping them sober was supporting and being of service to another alcoholic struggling to be and stay sober.
AA and other 12-step programs complement treatment
This peer support can lend itself to complementing treatment such as individual cognitive behavioral therapy, family systems therapy, psycho-education, and/or medication. Many addictions/addictive behaviors (including but not limited to alcohol use, disordered eating, compulsive spending, sexual addiction) are medicating underlying mood disorders such as anxiety or depression. In terms of evidence-based treatment, cognitive behavioral therapy (CBT) has been found to be the most effective treatment for recovering from mood disorders such as anxiety or depression. CBT in combination with pharmacotherapy is often found to be the best treatment. 
Common to addictive behaviors, as well as the underlying anxiety and depression, are “cognitive distortions” and “automatic negative thoughts.” Cognitive behavioral therapy uses a collaborative approach to challenging these thoughts by asking the client to look for evidence in their life to see if they actually true. Some cognitive distortion categories and examples are:
“If there’s something wrong here, it must be my fault”
Jumping to conclusions and Mind Reading:
“I know she hates me because she just frowned. She is thinking I’m a bad Mom,”
“I really shouldn’t be feeling this way. I should pull myself up by my bootstraps and be happy already”
“I feel stupid, boring, and ugly, therefore it must be true.” 
Cognitive distortions are not limited to those suffering with addictive behavior or drinking problems. We all have cognitive distortions. However, these distortions become magnified and appear to be the truth in the mind of someone suffering with anxiety or depression, often triggering them to drink. Alcohol, however, is a depressant, and therefore often leads them further into the very cognitive distortions from which they are trying to escape. In AA, group members will often state things like “My best thinking got me here,” or “I am working on my stinkin thinkin.” In therapy, an environment of collaborative empiricism (“Is it really true that she is thinking you’re a bad mom? Is there any evidence to support that thought?”) can help decrease the negative power that cognitive distortions hold over someone. Often these cognitive distortions grow and get reinforced from family systems with parents with alcoholism or mood disorders. (Children don’t have the executive functioning developed yet to reason things out without personalizing and so “it must be my fault” as a child’s interpretation grows into an adult thinking “it must be my fault” when someone else gets angry or depressed or their boss blames them for doing an imperfect job.)
12 Step Programs help break isolation and provide frequent and accessible support.
For someone suffering from anxiety or depression, isolation can be one of the worst triggers to worsen the symptoms. And, as many clients can attest to, the symptoms for anxiety and depression are often at the peak during hours most therapists are unavailable for support. AA and other 12 step programs are available 24/7. If you look up AA meetings in your area, you will most likely find them meeting on the hour, every hour, often more than one! I looked up AA meetings for Sunday in San Francisco: there are 71 meetings available to attend (not including the bilingual ones). Smart Recovery (which I also am in favor of as a compliment to treatment) offers 3 meetings per week in San Francisco. In 12-step fellowship, people often share their phone numbers and provide sponsorship mentoring, which is guidance from someone further along in the recovery journey. This fellowship is available during weekends, evenings and other “triggering” times during which someone struggling with the desire to drink cannot call or will not reach their therapist for support.
Brain chemistry, Neuroscience and Medication
Neuroscientists and researchers are discovering more and more about how alcohol affects the brain. Functional Magnetic Resonance Imaging (fMRI) is allowing researchers to “see” blood flow to particular regions of the brain and identify which ones are active. This is allowing them to track not only how alcohol affects brain function but also how it changes as alcohol dependence develops. There are many medications used to treat alcohol withdrawal, to prevent consumption, or to reduce cravings, Naltrexone being the one that Glasner focuses on in her article. There are also many medications used to treat the anxiety and/or depression that cause many people to “self-medicate” with drinking. As a Psychologist, my opinion on medications is that they are useful as a tool, just as therapy is useful as a tool; just as support groups are useful as a tool. They all help in the healing process. However, using one alone can risk being not enough and miss an important aspect of the healing process. I would never recommend to a client to take naltrexone (For the record I am a Psychologist so it is not in my scope to prescribe medication) alone for recovering from alcohol use disorder. It would be like offering a pill to my sick child and then sending them off to the playground. The pill, should it be the right kind of medication for the sickness, would certainly help, but the pill alone without the essential rest and human kindness would be missing the mark on healing an entire person. Alcoholics and addicts are particular susceptible to the cognitive distortion that “if you take a pill, you will feel emotionally better and it will all go away.” Even in the information pamphlet for naltrexone, it states:
Naltrexone is only one component of a program of treatment for alcoholism including counseling; help with associated psychological and social problems and participation in self-help groups. In both studies where naltrexone was shown to be effective, it was combined with treatment from professional psychotherapists.
There is no contradiction between participation in AA and taking naltrexone. Naltrexone is not addictive and does not produce any “high” or pleasant effects. It can contribute to achievement of an abstinence goal by reducing the craving or compulsion to drink, particularly during early phases of recovery. It is most likely to be effective when the patient’s goal is to stop drinking altogether. 
In other words, naltrexone can be helpful for treatment and is not contraindicated with peer-led support, such as AA.
What are Alcoholism, Problem Drinking, and Alcohol Use Disorder?
Glasner seems intent on distinguishing between “alcoholism” and “problem drinking” in order to determine for whom abstinence would benefit and who can realistically continue drinking in moderation. The thought being that some people (“problem drinkers” but not “alcoholics”) can learn to drink in moderation without it interfering in their life (or needing to attend Alcoholics Anonymous). Alcoholism and problem drinking are layperson terms distinguishing between severities of alcohol use.
However, I have administered the Michigan Alcohol Screening Test (MAST) to a client who scored a 3 and absolutely identifies herself as an alcoholic. The MAST is a 22 question screening tool that clinicians often use to determine the severity of someone’s drinking problem. A total score of six or more indicates “hazardous drinking” or “alcohol dependence.” The woman who scored a 3 is a high-functioning working mom who has been sober and attended AA meetings for the past eight years (some details changed to protect confidentiality) in order to “be a better mom and stay connected in my marriage without drinking to stuff and avoid anxiety.” I have also administered this test to a client who scored a 7 and still looked me straight in the eye and stated, “I don’t have a problem with my drinking.” This was someone who had missed work weekly due to hangovers, blacked out frequently, and lost relationships due to her drinking. (She later discovered that she does in fact have a problem with alcohol and is not drinking. She does not attend AA, but attends therapy, women’s groups, and has started painting instead of drinking. Again, details changed to protect confidentiality.)
Clinically, the Diagnostic and Statistical Manuel (DSM-IV) used to distinguish between alcohol abuse and alcohol dependence, the latter being more severe. It required that a person have three symptoms during a 12-month period from a list including such criteria as:
- Need for markedly increased amounts of alcohol to achieve intoxication or desired effect; or markedly diminished effect with continued use of the same amount of alcohol
- The characteristic withdrawal syndrome for alcohol; or drinking (or using a closely related substance) to relieve or avoid withdrawal symptoms
- Drinking in larger amounts or over a longer period than intended.
- Persistent desire or one or more unsuccessful efforts to cut down or control drinking
- Important social, occupational, or recreational activities given up or reduced because of drinking
- A great deal of time spent in activities necessary to obtain, to use, or to recover from the effects of drinking
- Continued drinking despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to be caused or exacerbated by drinking. 
In the most recent manual, DSM–V, anyone meeting any two of the 11 criteria during the same 12-month period would receive a diagnosis of Alcohol Use Disorder (AUD). The severity of an AUD—mild, moderate, or severe—is based on the number of criteria met. DSM–5 eliminates legal problems as a criterion, and adds craving as a criterion for an AUD diagnosis. 
Research is not what heals. Relationships heal.
When Glasner states that AA is not supported by research (the subtext implying that therefore it is therefore not effective in healing from alcohol use disorder), I’m not that impressed. Research absolutely has its place. Research is necessary. I needed to do research to earn my doctorate in psychology. Research keeps the fields of psychology and medicine growing, as well as help track what is and is not working in all kinds of treatment. Research has even discovered the following in terms of what is most helpful in the therapeutic process and healing:
- The therapy relationship makes substantial and consistent contributions to patient success in all types of psychotherapy studied (for example, psychodynamic, humanistic, cognitive, behavioral, systemic).
- The therapy relationship accounts for why clients improve (or fail to improve) as much as the particular treatment method.
- Efforts to promulgate best practices or evidence-based practices (EBPs) without including the relationship are incomplete and potentially misleading. 
In other words, it does not matter what modality the therapist is trained in if their bedside manner is crap. In clinical practice, I have discovered my clients generally want to know three things:
1) Do I care? Do I truly care about them and their process?
2) Do I know what I am talking about when I offer feedback and suggestions?
3) As they trust me, can they learn to trust themselves in this healing process?
Never have I had a client say to me: “But what did your doctoral research findings state?”
12 Step Meetings are Low cost and therefore available to everyone, regardless of whether they have insurance or the ability to pay for treatment or therapy.
I won’t be popular stating this as a therapist, but let’s be honest: therapy is expensive. 12 step meetings are not. The preamble of any 12-step meeting includes: “There are no dues or fees for membership. We are self-supporting through our own contributions.” What this looks like in practice is that if it is your first 12-step meeting, you are invited to attend for free. If you are an ongoing member, you are invited to make a small donation to cover the cost of renting the meeting room and contributing to the 12-step world service organization, which is largely run by volunteers. The current standard donation amount is about $2 per meeting. Group therapy costs in the bay area are currently $60 per group session. A 24-hour stay at a private treatment facility is $1,000- $1,500 per day.
12 Step Programs help teach humility and service to narcissists in ways that other treatment modalities fail
Because AA was developed by two male alcoholics and strongly influenced by the Oxford group teachings (more on this later), there is a strong focus on ego deflation, service to others, and dependence on God (a Power Greater than ones’ self). Back in my pre-doc experience working as a substance abuse counselor, I found that one of the few psychological interventions that worked with narcissists (who are notoriously impervious to interventions reflecting on the need or desire to change themselves) was another narcissist effectively challenging them. If the “challenger” was intent on sobriety and recovery, than this would often land in an open-ness toward his peer’s desire for recovery. They could hear it from each other. They weren’t very interested in hearing it from the doctor or the facilitator, unless the doctor or facilitator “had what they wanted.” This would often need to be a strong male figure that had recovered himself and was radiating a sense of power and confidence. As a newbie woman therapist, I didn’t have much of what they wanted other than perhaps a date, with which I was a) not interested and b) had professional boundaries.
Where therapy failed with the great Dr. Carl Jung and the spirituality of the twelve steps worked
One of the first members of Alcoholics Anonymous was a gentleman named Rowland. Rowland spent a year under the care of Dr. Carl Jung due to his despair over the inability to control his drinking. After this year, thinking he had been cured, he left and promptly became intoxicated:
Sometime in 1931…a young, talented, and wealthy financial wizard, had found himself on the verge of despair over his inability to control his drinking. Having attempted virtually every other “cure,” he turned to one of the greatest medical and psychiatric talents of the time, traveling to Zurich, Switzerland, to … Dr. Carl Gustav Jung. For close to a year, Rowland H. worked with Jung, finally leaving treatment with boundless admiration for the physician and almost as much confidence in his new self.
To his consternation, Rowland soon relapsed into intoxication. Certain that Jung was his last resort, he returned to Zurich and the psychiatrist’s care. There followed, in Bill Wilson’s words written to Dr. Jung in 1961, “the conversation between you [and Rowland] that was to become the first link in the chain of events that led to the founding of Alcoholics Anonymous.” That conversation, in Wilson and Jung’s later memory, had made two points. “First of all, you frankly told him of his hopelessness, so far as any further medical or psychiatric treatment might be concerned.” Second, in response to Rowland’s frantic query whether there might be any other hope, Jung had spoken of “a spiritual or religious experience — in short, a genuine conversion.”
“You see, ‘alcohol’ in Latin is ‘spiritus’ and you use the same word for the highest religious experience as well as for the most depraving poison. The helpful formula therefore is: spiritus contra spiritum.”
This metaphorical understanding of what Rowland was truly seeking in turning to alcohol deeply influenced the spiritual underpinnings of AA. He wasn’t looking for alcohol- he was looking to have a spiritual experience. In the twelve steps, there are two kinds of spiritual experiences: the “lightning bolt” kind (the Aha’s! that are inspirational, sudden, and life changing) and the “educational variety,” that develop slowly over time.
I often work with clients with both of these kinds of experiences. The challenging part is often that many want the “Aha!” but not the “slow educational variety.” Let’s be honest, it is much more enticing to have a sudden experience of seeing God or of completely understanding in a flash why there is suffering in the world. It is not as pleasant to learn, slowly over time, such things as how parking meters apply to you, and needing to still wash the dishes. As the author and meditation master Jack Kornfield so aptly put it “after the ecstasy, the laundry.”  Healing and growth occur slowly, over time, with both sustained effort and surrender. Attending 12 step meetings regularly, doing a spiritual practice such as prayer or meditation, and having a support system of trusted peers giving you feedback on your blind spots can help create and sustain this healing and growth. As they say in 12-step “you can’t kiss your own ear.” Having people you trust, both peers and a therapist, give you feedback on where to turn toward/lean in and where to turn away/detach can be invaluable to growth.
What about women?
It is often suggested that women recovering from alcoholism attend women-only AA meetings. Sexism can still exist in ways such as having men called on to speak more frequently and “the old boys network” of calling on your friends to speak in AA meetings often keeps women feeling even more shame and silence. In addition, many women have the unwelcome experience being “hit on” for dates in a place where they are seeking emotional safety during a vulnerable time of healing.
In women-only meetings, there can be an atmosphere of camaraderie, compassion, and encouragement that can be harder to find in co-ed meetings. The language of 12 step and its “bible” (The “Big Book of Alcoholics Anonymous”) is masculine and this can be a barrier for many women, especially those who are recovering from trauma in their past, whether it be religious, sexual, physical, or emotional. Recovering a sense of internal and/or feminine (instead of external and/or masculine) can be an important piece of the recovery process for some women. Stephanie Covington’s work discusses many of these issues. As shame is such a silent epidemic among women, particularly those struggling with any form of addiction or disordered eating, finding safe spaces to break the isolation of this toxicity is essential to unveil and transform it. For many women using alcohol or process addictions such as codependency or disordered eating, the “ego deflation” process developed through the early AA members is not helpful because they have a weak, underdeveloped ego. This weak sense of self needs bolstering, not deflation.
Limitations of 12 step Programs
Spirituality and Moderation:
As mentioned earlier, AA historically grew out of the Oxford group, which was a religious group focused on dependence on God, service to others, spiritual experience, continuous change for growth, and fellowship. These are tenets that continue to be strongly held in 12 step philosophy and practice and do not work for everyone. Not everyone wanting or needing to recover from alcohol or any other substance/process addiction wants or needs to find recovery through spirituality. And as already mentioned, for those that do, the masculine or Christian language can be a barrier, re-traumatizing shame. Spirituality is not for everyone, nor is abstinence-based recovery. For those wanting to recover without using spiritual terminology or explore how to drink in moderation while using different tools to manage life skills, there are alternatives approaches such as: Harm Reduction, Rational Recovery, LifeRing, and Secular Organizations for Sobriety.
Eating Disorders and Process Addictions
As a Psychologist currently in private practice, I specialize in working with women recovering from disorder eating, body image distress, and perinatal mood disorders. With eating disorder recovery, there obviously can’t be an “abstinence-based” (abstinence from food) recovery. You need to eat to live. Food related 12-step programs take a variety of positions on this very issue: some have a suggested plan of eating that is considered abstinent for recovery for everyone, some suggest determining what your recovery food plan is with your sponsor and healthcare professional(s), and some
“endorse sound nutrition and discourage any form of rigidity around food. Balance not abstinence is our goal.” 
Philosophically, I align most with EDA, as “it is not about the food” and recovery is about learning other emotion regulation tools to cope with life. I do not often recommend clients attend Food Addicts Anonymous (FAA), as it can feel triggering and shaming for someone who has been alternating between dieting and bingeing for much of their life to be given yet another food plan that resembles a restrictive diet as a solution to a life problem. Some meetings actually do not allow members to speak if they have not followed this food plan for 30 days, which can feel quite shaming and re-traumatizing for someone who is already struggling with food, finding one’s authentic voice, allowing imperfection, and being less rigidly black and
Other process (as opposed to substance) addictions such as gambling, spending/debting, and sex/relationship/codependent addictions also have 12-step programs for people to abstain from what they identify as their addictive behavior in order to develop other tools to cope with life, on life’s terms. Again, these are not for everyone. However, AA paved the way to make available low-cost, readily available, peer-based support for many people struggling with many kinds of issues.
12-step Programs are certainly not for everyone. And I work with many therapy clients who attend 12-step meetings and many clients who do not. All of them are on their own healing path. However, I would ask Ms. Glasner to not throw out the baby with the bath water or simplify the recovery process by simply replacing AA with Naltrexone. Recovery is a multifaceted and individualized journey in which many people may actually benefit from both AA and Naltrexone or neither of these. And without AA, without the inspiration of two men simply trying to stay sober, 1 day at a time over 60 years ago, there would be no other 12-step programs in the world today. Twelve step programs help millions of people every day all across the world. Let’s not spend our time criticizing what works quite well for some, advocate what works for each person in their own journey of healing, and by all means invest time and money researching what can work even better in the future.
Why AA “declined to talk”
One of the traditions, tradition 11, of 12-step program is anonymity. It states that “Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio, and films.” And so the Glasner article leaves a big void for members of AA to challenge if they are to remain true to the very program that has helped them. As a Psychologist who has seen 12 step programs transform lives, I wanted to speak up in service of the miracles I have seen 12-step programs facilitate in the people with whom I work.
Dr. Linda Shanti McCabe is a Licensed Clinical Psychologist practicing in San Francisco. She has worked in residential, partial hospitalization, and outpatient treatment for alcohol and substance use as well as eating disorders. She currently specializes in assisting women recover from disordered eating, body image struggles, anxiety, and perinatal mood disorders. To read more about her work, visit www.DrLindaShanti.com or her Mommy blog at www.Recoverymama.com
 Glasner, Gabrielle, “The Irrationality of Alcoholics Anonymous” The Atlantic, April 2015
 “Cognitive Behavioral Therapy for Depression and Anxiety Disorders,” Systematic Review, National Registry of Evidence-based Programs and Practices, Substance Abuse and Mental health Services Administration, a branch of the US Dept. of Health and Human Services http://www.nrepp.samhsa.gov/cbt.aspx
 Beck, A. T. (1976). Cognitive therapies and emotional disorders. New York: New American Library.
Burns, D. D. (1980). Feeling good: The new mood therapy. New York: New American Library.
 Nagel, B.J., and Kroenke, C.D. “The use of magnetic resonance spectroscopy and magnetic resonance imaging in alcohol research,” Alcohol Research & Health 31(3): 243–246, 2008.
 Rounsaville, Bruce J., M.D., O’Malley, Stephanie, Ph.D., and O’Connor, Patrick, M.D., “Guidelines for the Use of Naltrexone in the Treatment of Alcoholism,”, The APT Foundation, 904 Howard Avenue, New Haven, CT 06519, 1995.
 Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC: APA, 2000.
 As stated by Bill W at THE IMPACT OF ALCOHOLISM HEARINGS BEFORE THE SPECIAL SUBCOMMITTEE ON ALCOHOLISM AND NARCOTICS OF THE COMMITTEE ON LABOR AND PUBLIC WELFARE, UNITED STATES SENATE NINETY-FIRST CONGRESS, FIRST SESSION ON EXAMINATION OF THE IMPACT OF ALCOHOLISM
JULY 23, 24, AND 25, 1969 and printed in the original “AA Grapevine” newsletter of Alcoholics Anonymous.
 Kurtz, Ernest, Not-God: A History of Alcoholics Anonymous, Center City: Hazelden, 1979
 As quoted by William James in Appendix II, “Spiritual Experience,” Alcoholics Anonymous, New York: Alcoholics Anonymous World Service, 1994.
 Kornfield, Jack, After the ecstasy the laundry: How the heart grows wise on the spiritual path, New York: Bantam Books, 2000.
 Covington, Stephanie, A Woman’s way through the 12 Steps, Center City: Hazelton, 1994.
 Eating Disorders Anonymous, FAQ’s
 Anonymous, Alcoholics, Twelve Steps and Twelve Traditions of Alcoholics Anonymous, Alcoholics Anonymous World Service Inc, Copyright 1952, 2004.
I recently had the privilege of sitting on a doctoral candidate’s dissertation committee.• She was researching maternal intuitive eating and how this can prevent children from developing obesity. One title she considered was “You are what your mother eats,” which, though catchy, we decided was just too reinforcing of the already all-too-prevelant “mother guilt.” If you are a mother, you know what I am talking about: you worry about what your child eats, doesn’t eat, how much, in what way, whether it is packaged in BPA free packaging, whether their daily sugar intake is setting them up for future alcoholism…(OK, I may be getting a bit too far into neurosis here, but the point is that moms worry about their kids, and specifically, what their kids eat). So we decided to change the title.
You are (and are not) what your mother eats.
OK, so now that we have put the guilt aside, her research was fascinating! In many ways, it confirmed much of what has already been discovered about intuitive eating. Intuitive eating (1) can be summarized by the following factors:
- relying on internal cues for hunger and satiety
- eating for physiological rather than emotional reasons
- no dietary restrictions/unconditional permission to eat
- body size acceptance
It has been discovered and empirically validated that infants and toddlers have the capacity to self regulate their eating (2), given the right conditions. The right conditions being: provide a wide variety of nutrient dense food, while allowing the child autonomy to choose which of these foods to eat and when they are hungry.
Ellyn Satter’s work summarizes how parents can think about and put into practice modeling/trusting intuitive eating with children, while surrendering battles for control over two-year-olds refusing to eat broccoli in the following way:
The Division of Responsibility for infants:
- The parent is responsible for what.
- The child is responsible for how much (and everything else).
The Division of Responsibility for toddlers through adolescents
- The parent is responsible for what, when, where.
- The child is responsible for how much and whether.
More on Ellyn Satter (and down loadable handouts) here: http://ellynsatterinstitute.org
Two of the most fascinating clinical implications of this candidate’s research were:
- Mothers can learn about how they can indirectly influence their child’s self-regulation via body acceptance messages.
- Body appreciation is a predictor of intuitive eating and Body acceptance messages from mothers predict awareness of the internal feelings and function of the body.
In other words, the more YOU as a mother listen to YOUR OWN body, hunger cues, appreciate and do not criticize your own body, the more this translates to your child(ren).
She found that “controlling feeding practices” such as:
- Pressuring your child to eat,
- Restricting access to certain foods, as a means to decrease the amount of “unhealthy” foods a child consumes, and
- Monitoring food intake, as a means to track the amount of “unhealthy” foods a child consumes. (4)
all have a negative correlation with developing intuitive eating and do not support body appreciation.
Yep, that means NOT saying “you can have dessert if you eat your vegetables,” not pressuring your child to finish what’s on their plate, and stop micromanaging how much sugar your child eats at various birthday parties. I know, it’s hard! I’m on the journey with you, Mama, trusting that at SOME point in his lifetime my child will eat broccoli…or not! And I can model that it is ok either way.
*Congratulations Dr. Rosanna Franklin, PsyD, California School of Professional Psychology, Alliant International University, 2014.
1. Intuitive Eating: A Revolutionary Program That Works, by Evelyn Tribole and Elyses Resch, 1995
2. Birch and Deysher 1985; Matheny, Birch, and Picciano, 1990.
3. Augustus-Horvath & Tylka, 2011; Avalos & Tylka, 2006.
4. Birch et al., 2001.
Yep, we’re talking about our chests this week. All that you wish that was different and the reality of your chest being exactly the way it is supposed to be. I can’t tell you how many times I hear large chested women say they wish their chests were smaller and small chested women say they wish their chests were bigger! What would it be like to accept and maybe even bring a tiny bit of love to your body the way it IS?
Being a mom during pregnancy, postpartum and/or breastfeeding brings whole other facets to breasts and chests! I remember during my pregnancy and breastfeeding days being amazed and awed at how my body changed. And then joking at how my chest “deflated” again after no longer breast feeding. Becoming a mom, however, actually made me fiercer about loving my body and its capacities. I remember one time breastfeeding my baby at a restaurant and the waiter looking at me strangely. I looked back at him and clearly stated “He’s already ordered.” I had had enough with the controversy over breast feeding in public. I needed to get that “off of my chest.” Heaven knows breasts have been seen publicly in many other contexts and not always respectfully or being utilized to feed a baby!
Some moms judges their chests because one side is larger/smaller than the other or in breastfeeding, one breast produces more or less milk than the other. Instead of saying “You should be producing more milk!”, what would it be like to thank your breasts for making milk, doing the best they can?
What do you need to get off of your chest? How can you love and or accept your chest? I invite you to comment below.
* For the record: As a Mom and Psychologist, I support moms is ALL of their choices in breastfeeding, not breastfeeding, breast feeding in the way they feel comfortable, partially breastfeeding, etc! There are many personal and medical reasons both to breastfeed and not to breastfeed. And there is no 1 right answer.