Of course, the drug companies have developed and distribute medications that are helpful, even life-saving if properly administered to patients. But abuse runs rampant in the system, especially in pain clinics. This abuse is especially prevalent in Pain Management where “Pill Mills” have popped up around the country. Doctors treat patients for pain. Most of the doctors and complaints are legitimate; people suffer maladies and injuries that only opiates can temper. The problem is that most doctors are not savvy about addiction. How often we have heard stories from drug-dependent patients who were advised by their primary physician that when they had finished running the course of Vicodin or Oxycontin or Percocet, the patient would be able to simply wean off these narcotics? But more often than not they cannot do this. Patients become dependent on these meds very quickly (often between three and four days) and stopping is simply not easy.

Many doctors, never having experienced withdrawal, are ill-informed, so patients are treated without an exit strategy. It’s a bit like our troops in Afghanistan: Once in, how do we get them out? Once in the patient’s system, once the brain’s chemistry has been changed, how do we get them out? How do we deal with the cravings for these drugs once addicted? Patients will commonly experience profound urges to take these medications for weeks or months after they have stopped taking them. The drugs will call to them, consume their thoughts. The urge becomes obsessive.

Common, too, is the patient abusing the quantities of the medication. They start at a given dosage level, but soon become dependent on the euphoric sensation. They take at first one pill more than ordered…then two, three, four at a time. The continued ability to reach the same euphoric levels become more difficult and it becomes necessary to take more and more. This is physical dependence in the making. Often, the doctor is forced to stop prescribing these medications. Then, typically, the patient goes doctor shopping until he finds another physician, unfamiliar with the patient’s treatment history, who will provide him with another prescription. The new doctor has no way of determining a patient’s real pain level. She can look at an MRI or X-ray and see the damage, but it gives the doctor no indication of how much it hurts. Some patients are treatment-savvy and build medical histories, knowing full well that their charts will enable doctors to readily supply them with the drugs they need to get high.

Any doctor who has her own practice is familiar with the “Drug Rep.” The Drug Rep (Representative) is a drop-dead gorgeous 22-year-old female decked out in a sharply cut, smart-looking pin-striped business suit. Two years ago, she was a popular sorority sister at the local university. She was recruited for her first job by a major pharmaceutical company to represent their “product” by carrying the message to doctors from office to office. The message is contained in a satchel filled with drug “samples.” Thirty years ago, she would have been snapped up out of Phi Delta Kappa to American Airlines or Pan Am. She would have worn a similar smart suit, but with wings on her collar instead of a “Phizer” name card. If the drug rep was wheeling her sample bag through an airport waiting room rather than a doctor’s waiting room, she would be virtually indistinguishable from yesteryear’s “Stew.”
Naturally, the drug rep has her counterpart in good-looking, hunky guys in pin-striped suits, GQ profiles, sporting pearl-white, Cheshire-Cat grins. They, too, carry drugs in their briefcases — samples of new product — for sleeplessness, anxiety, depression or pain. They will leave these gifts for the doctor to dispense freely to the patients. The thinking is that patients will try their wares and come back for more. First one’s free! Sound familiar?

Is this payola? You’re damn right it is. Pharmaceuticals are big business in the United States and around the world. They lobby Congress as they grease healthcare providers up and down the food chain.

And then we have the Internet — the revolution in technology that has changed the face of health care. Because the government does not require it and the drug companies and pharmacies do not insist on it, there is no way to track or enforce the sale of drugs on the Web. The benefits of the Internet are obvious: The flow and access to any kind of information imaginable is so vast and so immediate, it boggles the finite human mind. Travelers in cyberspace are privy not only to any and every kind of medical knowledge and direction to healthcare, but to the dark side of The Force as well. By simply filling out a brief medical history which, more importantly than anything else includes a credit card number, and pressing the send button, any man, woman or child can be prescribed sleeping medication, erectile dysfunction drugs or opiates (most commonly Vicodin) “legally” by an unseen “doctor.” This doctor (who does not ask to see his patients and may reside in South Africa or Sri Lanka) has all the information he needs to Fed-Ex the applicant a month’s supply of his or her drug of choice. Often these drugs are resold to others in need at inflated prices.

Why isn’t our government regulating the flow of these drugs into our homes, our communities? Drug lobbyists see that Congress makes cheap prescription medications from Canada difficult, if not impossible to get. The barrier is set up to protect our home-grown pharmaceutical companies who have a financial strangle-hold on Americans in need (especially the elderly) of legitimate drugs. Much is made today of the illegal alien problem. But our borders are porous in many ways. What comes and goes is always dictated by the almighty dollar rather than the needs of the individual. Free trade is neither free nor trade as we understood it, but rather a cyber black market in goods and services that shock the imagination.
The greatest attraction for online drug shoppers is anonymity: no one knows. A prominent attorney will steal upstairs to his home office while his wife and children are sleeping and order a month’s supply of Hydrocodone. The wife is surprised to find her husband home early the following day. When the doorbell rings, he races to intercept the Fed-Ex or UPS package before disappearing with it behind locked doors. Yes, no one knows…or so he thinks. True, his wife and neighbors, children and business colleagues do not see him consume 12 pills throughout the course of the day. But they do notice when he slurs his words in the office. His wife notices when he smokes endless packs of cigarettes and has trouble keeping his eyes open at 9 p.m. He may hang around the house over the weekend, but when his kids need him, Daddy just isn’t there anymore. Yes, he’s anonymous, but he’s also a zombie. To learn more, visit www.recoveryadvocatesusa.com for more information.

Gray areas in the field of addictions contain soft addictions. On the surface, these soft addictions may appear as a bad habit, and they often do begin as such. However, the motivation and the continuation of engaging in these bad habits can foster an environment where addiction can manifest. The following are a few activities that can start as a bad habit and move into the realm of addiction.

•    Emailing
•    Chatting Online
•    Texting
•    Talking On the Phone
•    Caffeine
•    Nail-Biting
•    Hair-Pulling
•    Watching T.V.
•    Gossiping
•    Procrastination
•    Shopping
•    Smart Phones

Any of these activities is harmless in moderation. Many of these activities are a common occurrence in the day-to-day activities of a large portion of the population. None of these activities are illegal, but dependence on these items can lead to an addiction.

When Casual Use Turns To Abuse
The world we live in creates an environment where bad habits are easily formed. Individuals find themselves with not enough hours in the day and not enough money in the bank. Habits are formed when the behavior creates a reaction that the individual finds pleasing. Once a person feels that he or she is relaxed, numb, preoccupied or that their problem has been fixed by an activity, that person will continue to engage in that behavior. For example, if someone feels stressed or that his or her life is out of control, the escape of chatting online with the virtual aspect of another human being creates a sense of comfort. Thus, the individual will start to turn toward chatting online to alleviate any pain and discomfort they experience.

While chatting online may seem harmless on the surface, the motivation behind the behavior is where the danger exists. The motivation behind any action is entwined with the person’s “why”: Why are they developing a bad habit? Are the consequences of the bad habit being ignored? Is more time spent thinking about the habit? This pre-occupation is taking time away from activities that should be a higher priority. The individuals engaging in the bad habit are avoiding pain and swallowing their fear. By avoiding the core issue that is causing discomfort, they are not in a position to work on their issues. This avoidance leads down a slippery slope toward being dependant on the bad habit.

When Abuse Turns to Dependence
Abuse of a substance or an activity can turn into mental and physical dependence. When that line is crossed, the behavior is leading toward addiction. The crucial differences between abuse and dependence can include the following qualities:

•    More time spent on the habit and less time spent on important activities (food, sleep, work, school).
•    Tolerance: The body becomes tolerant of the amount of a substance or the length of time spent engaging in an activity. As the body grows accustomed, more and more is needed to attempt to achieve a desired result.
•    Withdrawal: The mind and body begin to experience extreme signs of discomfort if the person doesn’t engage in their habit.
•    Emotional and Physical Effects: This can include extreme mood changes, drastic changes in sleeping habits and physical discomfort when the habit is stopped.

Physical and mental dependence are the final stage before an individual becomes addicted.

When Abuse Turns to Addiction
Addiction is a combination of a physical and a mental need for a drug of choice. Soft addiction can result in dire consequences, which can be physical and financial. Spending the majority of one’s time engaging in an active addiction leaves little time for anything else – the addiction becomes the focal point. The addicted individual does very little except concentrate on his or her addiction, thinking about how to acquire and fund the addiction.

While all of an individual’s time and funds are used to support their addiction, everything else gets pushed to the wayside. Families can be left devastated, jobs can be lost and bills do not get paid. In extreme cases, this can lead toward being destitute. The road to these consequences may seem excessive, but they do occur. For instance, if an addict is spending all of his or her time, energy and money sitting at a computer chatting in chat rooms, that person is prevented from having a fulfilled life. However, with any type of addiction, recovery is possible.

How Are Soft Addictions Treated?
Soft addictions are treated in a similar fashion to hard addictions. The first step is being aware of it and desiring a change – this element of surrender is crucial. There are fellowships, 12-Step programs, therapists, counselors and recovery coaches who are trained to help. These professionals have the tools necessary to empower the addict to move toward sobriety and recovery.

In being aware and pro-active, if someone discovers that he or she is beginning to lean on bad habits to cope, he or she has the opportunity to deal with those issues head-on. This creates an environment of healing that is safe and productive. By frequently taking inventory of one’s life, many bad habits can be dealt with before extreme consequences can occur.

Soft addictions come in many forms, but they often begin as a bad habit that quickly becomes a crutch. The core issue that needs to be examined is the motivation behind the need for the habit. Fear, escape, denial, a false sense of control and a desire to numb emotional feelings can all fuel negative activities. Once the harmful issues are treated, the need for the bad habit will dissipate, but this is always a work in progress for the addict and the trained professional. These bad habits can be replaced with healthy habits, tools to cope and an increased self-awareness. This is the place where addiction can be bravely faced and recovery becomes possible.

Women may be just as vulnerable to sex addiction as men.

Sex addiction is a problem that involves any pattern of uncontrollable sexual behavior that is secretive, shaming, or abusive. Sexual addiction is characterized by the terrible messes the behavior creates — lost jobs, ended relationships, arrest, disease, and death. It is a pernicious disease that flourishes in secrecy. There are some general distinctions between the way sex addiction presents in men and women, however, the etiology behind addictions in both sexes is likely the same: early wounding, traumatic experiences, and negative core beliefs.

Negative core beliefs are the genesis and fuel for acting-out behavior. From these core beliefs come the cognitive distortions that allow addicts to justify and rationalize acting out. According to Patrick Carnes, the sexual addict’s core beliefs are:

1. “I am basically a bad, unworthy person.”
2. “No one would love me as I am.”
3. “My needs are never going to get met if I have to depend on others.”
4. “Sex is my most important need.”  (I)

With a commitment to getting help through therapy and the 12-step program, addicts will soon have experiences that counteract those beliefs. For example, by adhering to a sexual sobriety plan, addicts in recovery quickly report that they no longer feel bad or unworthy. Likewise, the 12-step program is a “come as you are” program, so the core belief that they are unlovable quickly diminishes. The third core belief, “My needs are never going to get met if I have to depend on others,” is eradicated by the inherent structure of the program, which involves people reaching out to others, making phone calls for support, and going to fellowship. Many addicts in 12-step programs report that for the first time they have the experience of getting their needs met by others. Finally, through a commitment to a period of planned celibacy, people realize that sex is not their most important need. In fact, they learn that they have other, more important dependency needs, such as comfort, validation, and friendship.

Kelly McDaniel, author of Ready to Heal, has adapted Carnes’ core beliefs to include the confusing cultural messages that are at the heart of women’s addictive and compulsive sexual behavior. These four cultural beliefs are:

1. I must be good to be worthy of love.
2. If I am sexual, I am bad.
3. I am not really a woman unless someone desires me sexually or romantically.
4. I must be sexual to be lovable.

These beliefs compel a woman to compromise her interests and values in the pursuit of sex and romance, which are the primary ways she knows to get love. She may not know how to communicate her wants and needs to another, or even know what they are in the first place. She may struggle with setting boundaries and find it difficult to say no, constantly taking on responsibilities to the point of exhaustion or resentment. Her compulsive need to be liked makes her avoid confrontation and direct expression of anger. Instead, she might resort to passive aggression as a way to regain some sense of power and to vent her bottled feelings. These patterns fit a term called codependency, which is a partner to addiction and a common struggle for many women. While common, codependent behaviors left unchallenged can devolve into more destructive patterns, especially if a person has suffered abuse or trauma in childhood.

In a study of male and female sexual addicts (Carnes 1991), Patrick Carnes found that addicted women tended toward “behaviors that distort power – either in gaining control over others or being a victim.” Many of these women gravitated toward stripping, prostitution, or sadomasochism. They might engage in relationships where the men were “one-down” or perceived to be beneath them. Or they might have sex with men who degraded or devalued them, reenacting the early trauma of childhood. The men in the study tended to “objectify their partners and require little emotional involvement.” Some examples of objectifying behaviors are anonymous sex, prostitution, pornography, exhibitionism, and frotteurism (II).  In both genders we see addicts inappropriately eroticizing unacknowledged rage. Sexual addicts are often victims of childhood sexual abuse, physical abuse, pathological, or benign neglect. As children they weren’t allowed to express their feelings about being mistreated, neglected, or were in a family where feelings weren’t talked about. Their sexual behavior was a way of self-soothing in the face of unimaginable pain or numbness. As adults they are stuck in the same maladaptive behaviors that, as children, helped them to survive. Because they never learned to voice their outrage, hurt, and sadness, they act out these feelings sexually.

While a cognitive-behavioral, task-centered approach is the standard of care for assisting people to get sexually sober, women and men have different treatment needs. Research shows that females have stronger empathy centers in the brain, are more verbal, and have stronger processing areas for facial expressions and gesture. One study shows that women tend to be empathizers, while men tend to be systemizers. Males and females have both of these capacities, which can be stronger from person to person depending on nature and nurture (Simon Baron-Cohen, 2005). Males tend to analyze the underlying rules of the 12-step program, so they seem to get their treatment underway quickly. They will often intuitively figure out how the system works and are happy to take direction toward the goal or result of their sexual sobriety. Females, however, will leave treatment if they don’t feel attuned to. Females seem to require a higher level of empathy from the therapist, which means that treatment should focus on paying keen attention to her emotions and thoughts and responding appropriately. It may take the female sex addict a while before she is willing to participate in a 12-step program or group therapy.

The old belief that sex addiction is a male problem is outdated, and clinicians need to be able to spot the signs in women and be aware of the different treatment needs of this population. Through effective treatment, a woman begins to feel good about her body, experience sexual pleasure for herself and self-love. A woman is ultimately seeking her personal power, and her capacity to love and be loved. The key to sexual healing for a woman is that she turns toward the pursuit of self-knowledge in order to find her strengths instead of losing herself to others. When a woman begins to integrate her sexuality with self-knowledge and personal power, she reports experiencing the force of love that leads to a whole and complete self.

References:

I.  Patrick J. Carnes

II.  Carnes, Patrick J. “Gender Differences in Normal and Sexually Addicted Populations”, Am J Preventive Psychiatry & Neurology, 3:1, Spring 1991, pp.16-27

This paper appeared in Phi Kappa Phi Forum 2005 (Special issue on the Human Brain)
The Essential Difference: the male and female brain By Simon Baron-Cohen, Cambridge University (page 1)

This article was based on material by the author that first appeared in Gregory, R, (ed) Oxford Companion to the Mind (2nd edition, 2004) Oxford University Press. The author
was supported by the MRC UK during the period of this work.

This problem is easy to caricature. Ignore the multifactorial underpinnings in many patients with chronic pain. Find a simple biological explanation for the patient’s symptoms. If nothing turns up on a brief history or physical examination, do an MRI, which will reveal some sort of abnormality in almost everyone. If a simple treatment doesn’t work – preferably a procedure that pays well – keep doing it over and over and prescribe a lot of opiates and sedatives.

Certainly many patients with chronic pain do well with a simple biomedical perspective – spinal stenosis, hip or knee osteoarthritis, postherpetic neuralgia, and diabetic neuropathy are good examples. In a small percentage, a purely emotional cause is found. Every pain management practitioner can cite dramatic cures they’ve achieved in patients nobody else could help, using their unique therapeu¬tic approach. One must be diligent to rule out subtle metabolic causes of pain, such as osteomalacia, vitamin B12 deficiency, heavy metal poisoning, and polymyalgia rheumatica.

More often, physicians and patients alike become frustrated because no cause is apparent. What does one do when there is no clear diagnosis or identifiable treatment for the pain? As a rule, the pathology underlying the pain is either obvious (postherpetic neuralgia or diabetic neuropathy) or obscure. For example, “more than 85% of patients who present to primary care have low back pain that cannot reliably be attributed to a specific disease.”*

Instead, chronic pain is a system. One finds a complex interplay of injury, physical illness, emotions, behavioral style, preexisting emotional trauma, lifestyle, deconditioning, and maladaptive coping responses.

The following points illustrate chronic pain as a multidimensional issue:

• Workers compensation claims representatives and nurse case managers will tell you that the worker who sustains an injury typically had been a marginal employee who struggled to function on the job long before the injury occurred.
• Best estimates place the incidence of borderline personality disorder (BPD) at 50–60% among pain patients. BPD can be thought of as inability to cope with normal life stresses. Maladaptive coping responses create extreme emotional dysregulation, frequently to the point of the patient becoming overwhelmed. Borderline patients crave opiates and sedatives, which almost always worsen psychiatric symptoms. Primary addictive disorders are common.
• Estimates put the incidence of child physical or sexual abuse among chronic pain patients at 50–60%.
• Studies show that psychotherapy (i.e., simple talk therapy) is ineffective in most patients with chronic pain. But teaching patients effective coping strategies and self-soothing approaches has solid scientific support for efficacy.
• The most common maladaptive coping strategy is to fully retreat from the pain. Excessive rest due to fear of the inevitable flare-ups leads to deconditioning, which itself worsens pain.
• Loss of a productive role in the family and the sense nobody takes them seriously further aggravates suffering and social isolation. Major depression is common and frequently overlooked.
• Although most pain practitioners agree that true addiction is uncommon, prescription opiate addicts brag about how easy it is to trick doctors into prescribing controlled drugs. Opiate misuse short of addiction is common.

It can be difficult to distinguish a purely somatoform disorder – where behavioral factors are the sole cause of physical symptoms – from situations where emotions merely contribute to the development, expression, or resolution of a physical illness. For instance, while peptic ulcer was once thought of as being purely caused by stress, later research revealed that Helicobacter pylori caused 80% of ulcers. However, four out of five people infected with Helicobacter pylori do not develop ulcers. An expert panel convened by the Academy of Behavioral Medicine Research concluded that ulcers are not merely an infectious disease and that mental health factors do play a significant role. One possibility is that stress diverts energy away from the immune system; thereby stress promotes Helicobacter pylori.

Codependency is common among those who present with physical symptoms combined with behavioral issues. Once thought to be limited to spouses and relatives of alcoholics and addicts, codependency can in fact follow many forms of psychological trauma. Particularly if childhood abuse or neglect continued over a long period of time, sequelae can manifest both physically and psychologically.

Codependents define themselves through others. Relatives, friends, and external events dictate their identity, self-esteem, feeling safe in the world, and ability to be soothed when emotionally distressed. This “external locus of control” leads them to try to control others and to express neediness beyond the typical human desire for closeness and connection.
Other characteristics of codependency include denial, low self-esteem, over-compliance, and trying to control everything in their lives. Childhood traumas remain hidden from others due to the shame surrounding the traumatizing events or because the patient does not recognize the events as abnormal or extreme. Because they have such a well-developed denial system and their focus is always outside themselves, they are completely unaware of how their illness/pain relates to their emotional experience. The secondary gain of attention and nurturing in chronic pain/illness may be the only way in which these patients can get the emotional nourishment they desperately want but have no means of requesting in a straightforward manner. In addition, codependents characteristically find it difficult to say “no” to others; their personal boundaries are poorly developed at best. Illness or chronic pain thus comes to the rescue. It relieves them of their self-imposed burden by making it impossible to meet the needs of all the “others” for whom the codependent feels responsible.

In addition, alexithymia (literally the inability to find words to describe one’s emotions) often plays a role in chronic pain. Alexithymia encompasses a cluster of cognitive and affective characteristics, including difficulty identifying and communicating feelings, trouble distinguishing between feelings and somatic sensations of emotional arousal, an impoverished and restrictive imaginative life, and a concrete and reality-oriented thinking style. A lack of introspection is typical in this population. As a result, they believe that any uncomfortable experience is always caused by an external force that must be identified and eliminated.

How can a skilled physician take into account all these myriad perspectives? Why does Dr. Gagné arrive at a new diagnosis in two-thirds of his patients with chronic pain? A comprehensive evaluation is key to understanding the various systems involved:

• The history should start with how and when the symptoms began. What was the mechanism of injury, if any? What sort of diagnostic and therapeutic endeavors ensued, and what were their results?
• What sort of physical therapy has the patient had? Was it largely passive (heat, massage, ultrasound) or active (strengthening, stretching, endurance, and balance exercises)? Passive therapy is usually much less effective.
• What medications does the patient take now, and what have he or she tried in the past? What was the result of taking these drugs?
• Regarding current symptoms, how many different kinds of pain can the patient distinguish? More than three different types and locations of pain suggest an emotional overlay.
• For each type of pain, what are its location (using surface anatomy), severity, quality, and aggravating or relieving factors? How does it vary by time of day?
• The Present Illness should include reviews of rheumatologic and neurological symptoms, sleep pattern, and functional capacity.
• Psychiatric screening is critical, including questions about prior psychiatric hospitalization or serious illness, suicidality, self-injury including cutting, mood, eating disorders, and childhood abuse.
• Addiction screening must be more than “have you ever had a problem with drugs or alcohol?” One should ask about history of using each major category of drug and whether the patient has ever been treated for addiction or experienced consequences from using.
• Physical examination should include orthopedic and neurological function and muscle tenderness or “trigger points.” Lab tests should be sufficient to rule out common metabolic causes of pain.

The evaluation outlined above is lengthy but can be scheduled in two to three sessions, if needed.

Many physicians aren’t comfortable trying to assess psychological aspects of chronic pain. If a referral is made to a psychologist, a psychological evaluation and testing may provide essential information regarding the patient’s overall psychological functioning and emotional/behavioral factors affecting physical symptoms.

If a patient is referred for psychiatric or psychological intervention, it should be understood that traditional talk therapy might not be helpful beyond the comfort of supportive therapy. More useful are interventions that empower the patient, thus moving the locus of control from a strictly external position (believing I have no power or authority in my life) to a more balanced view of internal vs. external loci of control. These interventions are mostly ways to train patients in needed coping skills. Examples include assertiveness training, boundary development (self and others), and cognitive behavioral therapy to counteract catastrophizing and generally negative self-talk. Especially with borderline personality disorders, dialectical behavioral therapy helps enhance emotional regulation and reduce self-injurious behaviors such as cutting. In cases of prior abuse or neglect, trauma resolution therapy reduces dissociative episodes and symptoms of hyperarousal. Helpful education regarding the mind-body connection can be undertaken in therapy or by assigning appropriate reading. †

One must also consider using antidepressant or other psychiatric medications. Though pure serotonin reuptake inhibitors offer no added pain relief, serotonin-norepinephrine reuptake inhibitors can dramatically reduce pain symptoms. Benzodiazepines characteristically worsen emotional dysregulation, whereas in those with personality disorders, atypical neuroleptics may help patients regain emotional control.

In patients on chronic opiates and sedatives who are not doing well, discontinuing controlled drugs is often astonishingly helpful – and weeds out those seeking secondary gains from controlled drugs. Opiates and sedatives are especially problematic in patients with psychiatric disorders, because they worsen psychiatric symptoms. Buprenorphine can be extremely helpful in reducing opiate misuse, and sometimes it can eliminate opiate hyperalgesia and dramatically improve physical and psychiatric distress.

In the past few years, inpatient chemical dependency programs skilled in treating dual addiction and psychiatric disorders have found that their approach has proved extremely helpful in those with chronic pain. These programs combine a structured milieu, physical rehabilitation, expert medication management, and heavy emphasis on skills training. (By contrast, programs offering a strict 12-step approach usually have little to offer those whose primary concern is pain.)

If you’re treating patients whose diagnosis is unclear, who have not responded to straightforward measures, such as switching to appropriate medications, and who have failed active physical therapy, what can you do? Several steps might be helpful:

1. A conservative neurologist or rheumatologist can help rule out occult illness.
2. Consider psychiatric or psychological evaluation by a practitioner skilled in chronic pain.
3. A well-trained psychologist can teach effective coping skills as outlined above.
4. One of the more effective treatments is “functional restoration”: aggressive physical therapy that ignores pain and addresses loss of function and physical fitness. But the therapist works within the patient’s limitations and helps them pace activities and minimize flare-ups.
5. If the patient is especially challenging and has sufficient financial resources, consider one of the comprehensive inpatient programs to further evaluate and treat the pain syndrome.

A brief clinical vignette illustrates the benefit of a comprehensive approach.

Bill was a police officer injured on the job. Despite equivocal evidence of lumbar disc bulging or herniation, he underwent multiple procedures without benefit and wound up on high-dose opiates. Pain migrated all over his back. Evaluation revealed myofascial pain without evidence of underlying pathology. Six weeks of treatment at the Canyon at Peace Park (where Dr. Gagné is affiliated) addressed medication and emotional issues, and his pain completely resolved.

* Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007, 147:478–491. Also, see the superb review of the diagnosis and treatment of central-processing pain disorders: Clauw DJ. Fibromyalgia: an overview. Am J Med 2009, 122:S3–S13

† The following resources present a detailed discussion of this topic: The Body Bears the Burden by Robert C. Scaer, M.D., Healing Back Pain: the mind-body connection by John Sarno, M.D.

Clearly, her daughter is pulling away, which can be one of the hallmarks of addiction, depression, or an adolescent trying to form an identity. When you think of addiction, you think of drugs, alcohol, or even an eating disorder. But what about the newest addiction affecting teenagers: Celebrity Addiction? This phenomenon has nabbed one-third of Americans and is linked to depression, anxiety, body-image problems, and addiction.

In no way is this author comparing the ravages of substance abuse to celebrity worship, but it is important to look at today’s teenagers with a different set of eyes. According to recent studies, many adolescents believe that emulating the lifestyle of their favorite celebrity is one of the only ways to form an identity and if they don’t reach the same level of stardom, they will become “nobody.”

There is also a dramatic shift in the way teenagers perceive success. In fact, research reveals that teenagers would rather surround themselves with celebrities or become one, rather than becoming a more intelligent human being. In addition, it is showing that having these fantasy relationships with a celebrity stimulates the production of opioids, chemicals in our brain that make us feel better. It is no wonder we are raising a generation of adolescents, for example, who would rather become a famous actress like Paris Hilton rather than a presidential nominee like Hillary Clinton.

This type of value system was seen at the Grammy Awards a few years ago. You have to wonder what it means when musician Amy Whitehouse is singing “no, no, no”, refusing to go to rehab to deal with a drug addiction and becomes a huge Grammy winner. What does this tell our teenagers? It sends out the message that it is appealing to be in the throes of a drug addiction. Or what about Lindsay Lohan being the first story on the Today Show with regard to her jail sentencing for several probation violations related to her issues with alcohol? Does she deserve to be the first story on a major television network?

Teens not only mimic the clothes, jewelry, and cosmetics celebrities use, but now increasingly see addiction as glamorous. Joanne Barron, National Outreach Director for Insight Treatment Center for adolescents says, “Unfortunately, too often what we see or hear about celebrities has to do with a lifestyle of excess — smoking, drinking or drug use, constant parties, and sexually acting out.”

This is not necessarily new in popular culture. Many musicians and actors have died tragic deaths from addiction, and many more will die in the continuing drug epidemic. Musician Janis Joplin glamorized drugs in the 1960s and died at age 27 of a drug overdose. And what about Timothy Leary and his famous quote, “Turn on, tune in, drop out”? Last year we viewed a barrage of specials portraying the very disturbing life of Michael Jackson and Corey Haim. Their lives were viewed more times than true news-worthy stories.

Adolescence is often a time of soul searching and finding an identity. It can also be a very vulnerable and impressionable time. However, today’s identity formation has crossed the line. Teen idolization is even turning into a medical issue. Teens are undergoing surgery to have lips like Angelina Jolie and carving dimples in their chins to look like John Travolta. Has the media gone too far?

“Whether we like it or not, celebrities are role models for teens. For many years, we have seen the influence of pop culture on our youth. Ever since television and movies became mainstream in America, teens have tried to emulate the speech, dress, and behavior of their favorite celebrities,” says Barron.

Scientists have found a correlation with celebrity worship and depression and anxiety. Which comes first, the proverbial chicken or the egg, or does it matter? Does depression lead to addiction or does addiction lead to depression? The bottom line is there has been an epidemic of teenagers who believe they are entitled to become famous and will become famous during the course of their lives. Maybe mimicking the drug addictive behavior of celebrities is the closest thing they will ever come to being a celebrity or knowing one.

Of course, there are numerous causes of addiction, such as trauma, a genetic predisposition, peer pressure, or a divorce or significant loss in a loved one’s family. However, the media normalizing celebrity addiction by sensationalizing where the latest actor is going to rehab does not help in reducing the problem; it only reinforces it.

One of the other difficulties many adolescents face today is eating disorders. Television, Hollywood, magazines, and the Internet portray slender women much more often than the majority of women with normal body types. They then develop distorted images of what a body should be based on what the celebrities portray. “Once these idolized perceptions are accepted as truth, thought distortions may develop, which can lead adolescent girls into self-destructive behaviors, such as eating disorders, self-injurious behaviors, excessive exercising, and other destructive behaviors,” reports Buck Runyan, the COO of the Center for Discovery, an eating disorder treatment program.

How can we prevent our teens from idolizing these tragic figures of fantasy and deception? How can we reduce substance abuse and eating disorders among teens? Self-esteem is one of the buzz words of this century. Lack of self-esteem can increase the odds that your teen will look for numbing-out methods to suppress their discomfort, pain, and frustration during this time. When children are comfortable in their own skin, they can reach inward for well-being and strength, rather than becoming reliant on outside sources to dull their senses. Having an open dialogue with your teen without judgment or criticism allows your teen to feel more comfortable sharing issues, such as substance abuse, peer pressure, and sex with you. They will feel heard and understood, which will allow them to trust you with their deepest demons. Otherwise, they look for validation somewhere else, potentially joining groups or gangs where drugs and alcohol is the norm.

Another solution to this growing epidemic might be getting to know our neighbors more closely to feel part of a community, rather than having to look outside our neighborhoods for a sense of belonging. Creating deeper bonds within our own circles might alleviate the need to search outside for validation. Perhaps reducing the number of reality television shows on the air might diminish the problem. Reality television reinforces the idea that it is easy to become famous, and that we are entitled to this fame and fortune. Teens believe becoming famous is a cure-all for life’s challenges.

This pandemic of celebrity addiction is on the rise and needs to be squashed. Our society is in the midst of raising a generation of narcissists whose only sense of self is around entitlement and becoming famous. Healthy relationships will be replaced with illusory celebrity relationships that lack intimacy and real connections to others, and teens will continue to seek temporary relief from substance abuse and celebrity worship to ward off the pain that normal adolescence brings.

Sanctuary: A place of refuge, safety, protection and asylum; a holy, consecrated spot

The notion of sanctuary dates back to ancient times. Many civilizations provided the persecuted with impunity if they reached a recognized sanctuary. Western culture later adopted this concept where during times of battle, troops could retreat to the nearest church where they’d be free from harm.

Intimacy: The feeling of being in close personal association and belonging together. Genuine intimacy in human relationships requires dialogue, transparency, vulnerability and reciprocity. Also means ‘to state or make known’

The Intimacy vs. Isolation conflict is articulated by Erik Erikson as one of eight stages of human development. According to Erikson, each stage builds on the successful completion of the stage before it.

Over 40 years this author has found — whether working with sex addicts, veterans, rapists, rape victims, domestic violence victims or substance abusers — the level of sanctuary directly affects outcome. True sanctuary creates an emotional climate where the intimate disclosure that precedes healing can occur. A sanctuary environment allows authentic ‘meeting’. Do we actively develop our vocabulary of sanctuary with the same fervor that we pursue techniques, software and the continuing educational hours to maintain our licenses? Or do we unwittingly degrade sanctuary because we ourselves are uncomfortable, fearful of hearing truth from different perspectives and paralyzed in the commonly established roles and paradigms of our field?
 
What are the sanctuary elements needed for people to name, claim, integrate and use their experiences?

How do we construct sanctuary? 

• For veterans to tell of their nightmares, the eyes of the dead, the dismembered child, being two seconds too late to save a friend…
• For the small child to recount his mother’s rape as he helplessly watched…
• For the minister addicted to Internet porn, discovered by the teenage son of the women with whom he is having an affair…
• For the women held hostage and gang-raped in a field for 14 hours…who went to the county jail flaunting her drugs so she would be arrested and “safe” but couldn’t say what really happened…
• For the women raped by her father since childhood, but he is a police officer so…who could she tell?
• For the university president arrested for obscene phone calls to teenagers, himself a victim of childhood sexual abuse…
• For the woman prostituting, stabbed and left to bleed out in the alley by her pimp — her blood stained his white suit so he refused to call an ambulance…
• For the little boy, every morning he knows what kind of beating it is going to be by what kind of belt his mom hangs on the door knob… ( He grows up to be a rapist) 
• For the ‘good husband’, a family man with a secret life of prostitutes who one night going down the stroll in a strange city honks for the hooker — and as she turns, he realizes it is his own daughter, supposedly in college, who is prostituting… 
• For the woman raped by the priest in childhood, the priest who a few years later presided over the burial of her father, her marriage and baptizing her children…
• For the man serving a life sentence for murder. It’s his 33rd birthday, his fifteenth year in and he’s never told the truth to anyone. He tries to figure out how to have dignity — sees kids just like he was going in and out; he would like to help but doesn’t know where to start…

These are real stories; some found sanctuary and built a life. Some didn’t and killed themselves. Why is it safe for some to pick up the phone and make that call…and for others to literally die instead? As helping professionals, it’s our responsibility to improve our processes so that more people feel safe enough to ask for help.

The Need for Sanctuary

It might be argued that in today’s world — with war, genocide and millions incarcerated — we are in dire need of those who have crossed the bridge of degradation to dignity, number to name, changed their paradigms and traveled emotional distances with the courage to tell their story, making it safe for those who follow. It might be argued that we need more consciousness, authentic friendships and a generation of emotionally literate young people with the heart to create sanctuary for those from different backgrounds. If more sanctuary existed and emotional intelligence was developed in the young, might there be less addiction? Many are needed with the courage to engage in community-building and peacemaking — not only for self and family, but for community and planet.

Working in the field of restoration, reconciliation and recovery, the ability to build and expand our vocabulary of sanctuary for ourselves, co-workers and those whom we serve may well be one of the most overlooked ‘non-negotiables’. Despite the plethora of tests, instruments, indexes, motivational interviewing techniques, NIDA studies, focus groups, 12-Step gatherings and conferences, do clinicians regularly ask “what makes you feel safe?” “When have you experienced sanctuary and acceptance?” It is different for everyone.

Sanctuary: Yesterday and Today

Cultures throughout the ages have had spaces, places and ceremonies that represent sanctuary. Establishing sanctuary was a prerequisite for healing, vision, celebration and transition. Sanctuary was present from the dreamtime of the Australian aboriginal people, to Asclepius’ Temenos in Epidaurus; from the dances of the bushman of the Kalahari; to the soul-catching, sweat lodge and rites of passage of the American Natives. All created space for the sanctuary that preceded acknowledgement and transformation of the spiritual and psychological. We cross the centuries to industrialized, ‘civilized’ nations where thousands of us seek relief from addictions, therapy for anxiety disorders and elevated blood pressure. We study meditation…we practice yoga. Our global ‘progress’ has decimated and degraded sanctuary and ceremony, and that degradation contributes to the wounded feeling function of our time.

Sanctuary is not space without boundaries. It is psychological space supported by a physical environment where boundaries are created with the intent of repelling that which is lowest in our nature, and inviting that which is sacred and authentic to enter. With entry of the sacred, comes consciousness and transformation.
 
Developing Sanctuary

Do we not have an obligation as helping professionals, regardless of our specialty, to aid as much of the whole person as possible? To develop a vocabulary of sanctuary, we must start with ourselves. What constituted sanctuary when we were five, 10, 20 years old? What constitutes sanctuary for us today? What are the elements that we need to feel safe, to be able to say anything? Who are we comfortable saying anything to in our own lives? How do we create the emotional climate that is needed for the suffering, to present an astounding contrast from the world in which they’ve lived?

The emotional climate of sanctuary starts with the faculty. It’s easier to stop smoking in a smokeless environment. It’s easier to establish sanctuary in an environment where adults have established authentic friendships and rigorously protect and develop those relationships.

Retention is always positively impacted when faculty do not indulge in gossip, have unfinished business with each other or harbor resentments. Bad habits on the part of the faculty typically create a low emotional ceiling, easily intuited by those seeking help. This is particularly true in correctional environments where projects to reduce recidivism often succeed or fail based on the authenticity faculty are able to build with each other.

Typically, authenticity creates buy-in to the project by incarcerated people. “Free world” staff members provide the most interesting soap opera in town — and every detail is noted by the incarcerated. Those in prison are typically described as having authority problems; in fact, the problem is typically with vested authority rather than personal authority, a distinction made by Stanley Milgram in his landmark book, Obedience to Authority.

Gangs, criminal organizations, street crews, mafia, cartels, numbers men and enforcers all were adept at forming and maintaining organizations on personal rather than vested authority. Interestingly, many who initially joined such organizations report that they joined seeking sanctuary in some form — personal, family or neighborhood protection. To create a sanctuary environment for transformation, it is useful to understand that many sanctuary experiences were on the wrong side of the law.

By asking hundreds of people in need about their experience with sanctuary, this author has experimented with a multitude of interventions and strategies. A few include:

1. Having the environment represent those served, inclusive of art, posters, books and customs.
2. Development of curricula that are inclusive of multi-cultural role models. These curriculums are gender-accountable as opposed to gender-responsive, reinforcing emotional literacy and emotional responsibility for both men and women. (www.extensionsllc.com)
3. Inclusion of ceremonies/holidays that represent the global village.
4. Changing the vernacular at residential sites to “students” and “faculty” rather than “counselors” and “clients”.
5. Discussing, in initial interviews, when and where the prospect felt safe — physically, psychologically, spiritually and emotionally
6. Having “sex workers” in recovery participate in screening new hires served as an effective filter for hiring.
7. Structured focus groups between sex workers and sex purchasers articulating their personal experiences from a feeling perspective.
8. Development of a quality assurance system whereby those served give daily feedback on their teachers in a non-threatening and productive way.
9. Creating a culture where no faculty member teaches any curriculum without having personally gone through it themselves.
10. Development of a process of “reciprocity partnerships” whereby an agency’s faculty is assigned a partner (not their supervisor) whose task it is to discover each other’s strengths and foster integration.
11. Developing curriculum for women to de-role from rape and objectification; inclusive of a presentation for men regarding their experiences.
12. Developing a multitude of teaching tools that move treatment away from didactic sessions, allowing rotating leadership and settings with multiple roles so that no one is left behind — and all involved can have a strength-based, growth-oriented experience.

Objectification and Misanthropy

Objectification: An attitude that regards treating another person merely as an instrument, object or commodity with insufficient regard for a person’s personality.

Misanthropy: The hatred of humanity; from the Greek word misos or hatred. Parallel to misogyny: the contempt or hatred of women, as well as misandry: the contempt or hatred of boys.

It has been said that evil prevails when good people do nothing. Are helping professionals actively contributing to the larger story that is needed in our world?

Those coming to us come to us for help, live in today’s world in which desensitization to humanity is frequently the norm. Even Craigslist has been the site of sex sales of teenage girls. We are bombarded with examples of objectification, misogyny and violence. Ours is a time with arguments about what constitutes torture (water boarding) or genocide (Rwanda). Newspaper articles abound with labels: convicts, felons, sex workers, illegal aliens, prostitutes, veterans, inmates, victims, abusers, predators, addicts, refugees, insurgents, detainees, collateral damage… By 2008, the United Nations counted 42 million refugees worldwide. The U.S. Department of Defense reports that more U.S. military personnel have taken their own lives than have died in action in Iraq and Afghanistan combined. Finian Cunningham of Global Research interestingly refers to this phenomenon as “Empire Pathology”.
 
Newsweek reports the advent of “war porn”, where actual footage depicting the death of enemy soldiers has “taken the Internet by storm.” Interestingly, one of these sites started when a sexual porn site Webmaster experienced problems with credit card payments from soldiers in war zones. His solution was to swap war footage for access to sex sites. Within two years, there were 30,000 members. One wonders about the Iraqi child who will someday see footage of her father being eaten by a dog…collateral damage?

Historically, labeling and prejudgment have traveled together, yet the rate at which we are objectifying, creating and naming others as enemy is unparalleled with the advent of the Internet. Different groups routinely argue that sexual abuse may not be on the rise; rather, it’s more frequently reported. These arguments include clergy, workplace and most recently the military, where sexual abuse now has its own acronym: MSA, or Military Sexual Abuse.

Women veterans are nine times more likely to suffer Post Traumatic Stress if they’ve suffered MSA. In our political world, objectification is increasingly common, arguably allowing violations of civil rights considered unacceptable a decade ago — Arizona’s Senate Bill 1070, allowing officers to stop people on the basis of “reasonable suspicion”, being a prime example. Suddenly, the renowned surgeon, who happens to be Latino, driving a BMW with his assistants in hospital attire, is a possible illegal alien and is stopped and harassed.

Are we alert to objectification and misanthropy in our own workplace? Are we conscious of the veterans, the Muslims, the elderly and the youth? Are we ensuring that our agencies are good places for women to work? Do we have childcare provisions?

In a world where women still earn less on the dollar than men, are we ensuring parity? Do women replacing men in our agencies routinely earn less? Do men tend to be labeled “directors” and women “administrators?” Do men and women end up with the same benefits, computer equipment, cell phones and offices?

Remembering Meaning

Sir Laurens Van Der Post — Carl Jung’s closest friend, student of the African bushmen, survivor of a Japanese prisoner of war camp — frequently re-told one of the oldest stories of the Kalahari:

“The Bushman in the Kalahari Desert talk about two ‘hungers.’
There is the Great Hunger and there is the Little Hunger.
The Little Hunger wants food for the belly; but the Great Hunger,
the greatest hunger of all, is the hunger for meaning…
There’s ultimately only one thing that makes human beings deeply and profoundly bitter,
and that is to have thrust upon them a life without meaning…
There is nothing wrong in searching for happiness…
But of far more comfort to the soul…is something greater than happiness
or unhappiness, and that is meaning. Because meaning transfigures all…
Once what you are doing has for you meaning, it is irrelevant whether you’re happy
or unhappy. You are content — you are not alone in your Spirit — you belong… The worst form of human suffering is to hide behind a life without meaning…and one will hide behind all sorts of indulgences and violence if one is thrust into such a life.”

Might we consider expanding the horizons of our work and create more sanctuary tomorrow than we did yesterday.

Let us help people remember, collecting dismembered pieces of their lives so they might rediscover meaning. Let us not slide into the twilight of indifference as objectification and misanthropy grows around us. In reference to adulthood, e.e. cummings once said, “and down they forgot as up they grew.”

A nine-year-old boy wrote a poem after the bombing of the World Trade Center towers — at nine he grasped the importance of a life with meaning — of feeding the Great Hunger. May we do as well:

Remember the twins the towers
Cloaked in the smoke of hatred
Swallowed up in the fires of hell
Soon there is nothing left but the ashes of sadness
I wish there was peace on this kithless globe
And let it begin with me

Given the popularity of the Internet, accurate diagnosis of Internet addiction is often difficult, because its legitimate business and home use often masks addictive behavior. Internet addiction is characterized as an impulse-control disorder that does not involve an intoxicant; of all the diagnoses referenced in the DSM-IV it is viewed as most akin to Pathological Gambling. By using Pathological Gambling as a model, symptoms of compulsive online use are outlined as follows:

1. Do you feel preoccupied with the Internet (think about previous online activity or anticipate next online session)?
2. Do you feel the need to use the Internet with increasing amounts of time in order to achieve satisfaction?
3. Have you repeatedly made unsuccessful efforts to control, cut back or stop Internet use?
4. Do you feel restless, moody, depressed or irritable when attempting to cut down or stop Internet use?
5. Do you stay online longer than originally intended?
6. Have you jeopardized or risked the loss of significant relationship, job, educational or career opportunity because of the Internet?
7. Have you lied to family members, a therapist or others to conceal the extent of involvement with the Internet?
8. Do you use the Internet as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)?

Clients are considered dependent users when answering yes to five or more of the questions, and when their behavior cannot be better accounted for by a Manic Episode. Only non-essential computer/Internet usage (i.e., non-business or academically related use) should be assessed.

While time is not a direct function in diagnosing Internet addiction, addicts generally are excessive about their online usage, spending upward of 40 to 80 hours per week online. Sleep patterns are disrupted due to late-night log-ins, and addicts generally stay up surfing until two, three or four in the morning, with the reality of having to wake up early for work or school. In extreme cases, caffeine pills are used to facilitate longer Internet sessions. Such sleep deprivation causes excessive fatigue, which impairs academic or occupational performance and may decrease the immune system, leaving the addict vulnerable to disease. Furthermore, sitting at the computer for such prolonged periods also means that addicts aren’t getting the proper exercise, sometimes leaving addicts at increased risk for carpal tunnel syndrome.

Treating Internet Addiction

Treatment for Internet addiction is similar to those methods used for compulsive behaviors, such as pathological gambling or compulsive overeating. Traditionally, clinicians who specialized in the treatment of addictions integrate individual, group (treatment and support) and family counseling, with a heavy emphasis on abstinence. Abstinence is frequently included in the treatment plans for individuals suffering from alcoholism, drug addiction and compulsive gambling. However, individuals experiencing process addictions, such as compulsive overeating or compulsive spending, must learn moderation and not total abstinence.

Internet addiction falls into this same category if the computer is used as part of the client’s work or educational setting. In such cases, teaching clients how to set limits, balance activities and schedule time without complete abstinence can be successful. For example, like a compulsive overeater who sets limits by committing to abstinence from particular trigger foods (sweets, butter, potato chips), an Internet addict may decide to abstain from visiting particular chat rooms, Web sites or gaming sites.

To achieve this goal, cognitive-behavioral therapy (CBT) is the primary treatment. The goal of CBT is for clients to disrupt their problematic computer use and reconstruct their routines with other activities. The goal of treatment is not to put an end to Internet use, but to reduce it to moderate and sensible use. Some basic guidelines in applying CBT with Internet-addicted clients are to set clear time limits on Internet use, identify triggers for abuse, abstain from problematic online applications and reintegrate offline activities.

Set clear time limits. Structured sessions should be programmed for the client by setting reasonable goals, perhaps 20 hours instead of a current 40. Then, schedule those 20 hours in specific time slots and write them onto a calendar or weekly planner. The client should keep the Internet sessions brief but frequent. This will help avoid cravings and withdrawal. As an example of a 20-hour schedule, the client might plan to use the Internet from 8 to 10 p.m. on weeknights and 1 to 6 p.m. on the weekends. Incorporating a tangible schedule of Internet use will give the client a sense of being in control and help avoid the potential risk of relapse.

Identify triggers for abuse. It is important to determine the Internet activities, situations and emotions that are most likely to trigger online binges. A particular chat room, a certain time of day or a client’s mood just before logging online may all serve as triggers that can lead to abuse. Recovery means relearning how to use the Internet in order to make better choices about time spent online and abstinence from problematic online applications. To pinpoint these triggers, have clients maintain a Daily Activity Log to keep track of when and how they use the computer. Keeping a log serves as a baseline of present activities, identifies high-risk situations that can lead to excessive online use and serves as a guide in future treatment planning. Thoroughly go through the client’s responses and determine if any patterns emerge. What time of day does the client usually log online? How long does the client stay on during a typical session? What applications are most problematic for the client and why? (Be specific: which sites, chat rooms, games.) What types of feelings or situations precede online use for the client? Does stress trigger a client’s need to go online? How does the client feel when he or she logs off? Like a craving for a cigarette or a desire to have a drink, emotions such as stress, depression, loneliness, anxiety or burnout can lead to a client’s need to go online, which serves as a temporary distraction to fill an emotional void.

Abstinence from problematic online applications. Clients must develop more appropriate ways of coping with problems than turning to the Internet. Underlying problems contributing to the addictive behavior, such as relationship difficulties, job stress or untreated psychiatric conditions, must be addressed, along with helping clients achieve complete abstinence from problematic online applications. Filtering software, typically used by parents to block access to online sexual content from their children, can help clients to self-regulate Net use. The software can be programmed to automatically block a multitude of online applications, such as porn sites, chat rooms or gaming sites. For many, this stops the behavior immediately, and many describe the experience as a “cold shower” that breaks the trance associated with the addiction. With it, clients feel empowered to control the temptations that often lead to relapse.

Reintegration of offline activities. Simply being at the computer increases a client’s risk of falling back into old patterns. Therefore, to maintain a healthy balance of Internet use, work with the client to cultivate alternative activities that take them away from the computer and that help them rekindle their interest in old activities that have been replaced because of the Internet. It is helpful to take a personal inventory of what the client has cut down on, or cut out, because of time spent online. Perhaps the client spends less time hiking, golfing, fishing, camping or dating. Maybe the client has stopped going to ball games, visiting the zoo or volunteering. Perhaps it is an activity that the client has always put off trying, such as joining a fitness center. Encourage clients to find healthy ways to spend their time as they wean themselves from the computer. This also means that clients must take time out each day to avoid plugging into anything. Have clients avoid computers, laptops and any other technological device that habitually demands attention.  At those moments, encourage a client to get up, walk around the office, stretch, do breathing exercises or meditate. At the very least, take a short break from the computer.

Finally, in serious cases, twelve-step support groups can be part of treatment planning. Support groups improve the Internet addict’s real-life social support system, while providing an opportunity to build offline relationships. Such peer support offers comfort that decreases the reliance upon the Internet for companionship and serves as a safe place to reality-test interpersonal behavior that leads to personal growth.

For more information, visit www.netaddiction.com.

Mr. Woods’s misfortune may do for sexual addiction what Magic Johnson did for HIV, if only from the perspective of being a beloved public figure, whose personal tragedy is taking sexual addiction out of the closet. The news coverage, undoubtedly painful and intrusive to his family, portrayed the women with whom he was involved as glamorous. Interviews were coveted, head shots of the women appeared on the internet and in newsstands. One ambitious entrepreneur sold golf balls with the faces of these women — an act that begs interpretation regarding our culture’s acceptance of objectification. Mr. Woods, of course, is neither the typical representative of the rank-and-file sexual addict, nor are the women he is with. However, the media circus surrounding Mr. Woods may be an opportunity to look in the mirror at ourselves, our culture, pornography, sex addiction treatment and our ability to value or degrade each other.

What responsibility does the helping professions have to improve our ability to aid those who suffer?

What Is Sexual Addiction?
Dr. Mark Gold of PsychCentral.com describes it as “[a] progressive intimacy disorder, characterized by sexual thoughts and acts…Over time, the addict has to intensify the addictive behavior to achieve the same results.”

Womenshealth.com states, “Sexual addiction is not sexual desire, nor defined by the type of sexual act performed, or even by the frequency of sexual activity…a compulsive use of sex to address non-sexual emotional needs…frequently indicated by the willingness of an addict to suffer enormous consequences for engaging in sex.”

The literature suggests that sex addicts are typically cross-addicted, most commonly as workaholics, and secondarily as substance abusers. Given the size of the pornography industry — which rivals big oil, arms and illegal drugs — the increasing number of people needing treatment and the definitions above, one might surmise that we are collectively suffering from a pandemic of intimacy disorders and objectification.

Who Goes to Treatment, Who Doesn’t?
Those who enter treatment for sexual addition are primarily white professional men. Dr. Patrick Carnes, considered a leading expert in the field, stated in a 1999 Fortune Magazine article, “Most of my patients are CEOs, doctors, attorneys or priests — they are people with a great deal of power. We have corporate America’s leadership marching through here, and they are paying cash because they don’t want anybody to know…”

A sex addict/workaholic in a corporate environment, where power and control often reign over authenticity and information, creates the perfect conditions for the progression of an intimacy disorder. Sexual addiction has not just affected corporate America; it’s rampant in prison populations where creative men and women (inmates) make a living writing and selling porn to others. In inner cities, the sex-addicted workaholic might be focused on gang-building, drug-selling…even murder. These are people who lack $45,000 for treatment, and would probably not attend an all-white treatment center or 12-step meeting even if they were able to do so. Just as the age of first drug use dropped from the late teens to middle school, the age of first exposure to and use of pornographic materials has dropped, precipitated by a generation that uses the Internet as its parents used television.

Cyberspace Pornography: Porne Graphos
Cyberspace pornography addiction is reported as one of the most common manifestations of sexual addiction, as well as a gateway activity that fosters ramp-up to increased acting out. Adult channels are found in hotels, cable networks and cell phones. In l999, the Omni hotel chain announced that it would no longer offer adult movies in hotels or sell adult magazine in its gift shops, incurring a $1.8-million loss in revenues. Omni made the decision “in response to what it perceives as a growing need for corporate America to support pro-family issues.” For hotels that didn’t follow Omni’s footsteps, Frontline’s “American Porn” 2002 report claims that in-room adult movies generated more revenue than mini-bars.

The word pornography has its origins in the Greek word porne, meaning “whore or female captive” and graphos, which means “to write or tell about”. Erotica, on the other hand, comes from the name of the Greek god Eros. Gloria Steinem pointed this out in her essay, “Erotica vs. Pornography”, observing that what society needed was love, and what we got was pornography. Her observations were made before the explosion of the Internet and simultaneous explosion of easily accessible cyberspace pornography.

It is of note that prior to the Nazi invasion of Poland, the Nazis launched a campaign proliferating pornography, in the hopes of destroying community and promoting shame and isolation, hence making their conquest easier. The pornographic images of those exploited were Jewish women, adding to the mindset that Jews were “less than human.”

On today’s computer, a few clicks can progress from standard centerfold fare to child porn, teen porn, bestiality, pregnant women, incest, elderly women, chat rooms and web cam views in the heterosexual, homosexual and transsexual worlds. On “granny sites”, rape and bondage are particularly popular with women who appear to be between 60 and 85. Any user searching otherwise benign keywords in combination, such as boys, nubile, teen, legal, nasty, barely, zoo and girls enters a world where video trailers to lure viewers are full of daughters, sons, sisters, brothers, mothers, fathers, grandparents and grandchildren. The young girls — barely developed, pig-tailed and sometimes wearing braces — are asked “Are you really 18?” and answer, “Yes, I am really 18.” They then have ejaculate squirted onto their faces. The young boys staring doleful and naked from the computer screen, would seem better placed in a little league uniform, or eating cookies in their grandmother’s kitchen.

In ancient Japan, an unfaithful woman was humiliated by a practice known as Bukkake, tied and publicly held captive, while all the men in town would ejaculate on her face. Today, Bukkake porn is a niche group for straights, gays and lesbians. Men, women and children can be looked up by weight, strength, age, race, body parts, sexual preference and ability or activity. For those of us who know Black history, through another lens this is reminiscent of requests made at the auction block. Three decades ago, Susan Griffin’s heartfelt book, Silence and Pornography, was heralded by Sam Keen (one of our most thoughtful societal observers) as a book that “told me more about cruelty and tenderness, more about sadism and masochism (and) more about myself …”

Ms. Griffin observed:

“…pornography depicts acts of terrible violence to women’s bodies… is violent to a woman’s soul. In the wake of pornographic images, a woman ceases to know herself… Her experience is destroyed. Like men and women living in the institution of slavery, we have become talented at seeming to be what we are not…. the racist mind of the slave owner required that the men and women he enslaved resemble the image which he had of them. Because he imagined that blacks were stupid and slow, he required of his slaves that they appear to be stupid and slow. And because they wished to survive, men and women of quick intelligence learned to mime a slow and stupid manner. That this racist mind had a frantic need to believe its own invention…we can see in the slave owners’ injunction against the slave’s learning to read. One might ask, why would a law against learning to read be necessary for a people supposedly too dull to perform this skill? But, of course, the answer is that the people were not too dull… their masters had to be fooled, had to be deceived even against their own knowledge of black intelligence into a belief of black stupidity.”

To continue Ms. Griffin’s analogy, imagine a Fellini-type time-travel movie where plantation owners who beat, rape, exploit and sometimes kill slaves gather in self-help groups. They commit to recovery, discuss powerlessness, economic effects of their behavior, selfishness and loss of productivity at work. They participate with renewed fervor in church, have spiritual awakenings, take moral inventory, articulate the emotional effects on their family and thank each other for sharing. Associations are formed for spouses, social events are held. Slavery itself is never addressed, nor the reality of the slaves’ lives, who they are and the effect of slavery upon them. They remain nameless and faceless. The plight of the slave doesn’t occur in the mind of the owner…after all, they have housing, are cared for, they made “choices” and they are from a different class. The plantation owners, proud of their sobriety, honesty and community, establish a network of help and service, exclusively to address their own suffering.

What Is Missing?
Are the sincere efforts of those in the treatment field — many of whom are in recovery themselves — de facto promoting racism, classism and sexism? Sobering and notable by its absence in this sea of information and advice for sexual addiction is the voice representing the experience of those in the sex industry. What is their experience as they contribute to the multi-billion-dollar worldwide industry? Why are those who are objectified, raped, used, bartered, sold and exploited left out of the process? How does it feel to them, even if it is only “play acting”, to pretend to have sex with animals, enjoy being ejaculated on or fake orgasms before a camera for hours? How do they explain their jobs to children? Whether “play” or not, the fantasy life of the sex addict takes the performance seriously. The addict, like the slave owner, has a frantic need to believe the sex purchased — whether virtual or actual — is relished by the seller. In treatment, people walk the walk, talk the talk, suit up and show up to develop new roles for themselves — is the reverse not true? Does the field understand the culture of degradation? Do addicts think of the 16 year old — the age of their daughters and granddaughters — who works as an erotic dancer and does wall dancing for extra money? Do treatment professionals even know what wall dancing is?

In the plethora of the most commonly available self-help books, only Dr. Sbraga and Dr. O’Donohue in The Sex Addiction Workbook include sections directly addressing the sex industry and objectification. Yet, consistent in testimonials of partners of sex addicts is that they feel degraded because they cannot favorably compare with the pornographic images. Is the culture of treatment such that counselors ever illuminate to partners the reality of life in the sex industry?

Do faces on the screen, prostitutes from the street and the dancers in the club remain unnamed, forgotten, relegated to stay in their place, never dignified within the treatment process as real, feeling people, profoundly affected by their expendability? Is the rationale for those addicted similar to the group that could afford cocaine (and insurance for treatment) in the l970s? Many proclaimed that buying illegal drugs was a victimless crime; meanwhile caskets carrying murdered children from the streets of Bogotá, their organs hollowed and filled with cocaine, were one of the many ways drugs were delivered. Are these issues discussed or is it considered bad form? As part of training, do counselors learn about the actual (not virtual) life of the porn star, erotic dancer and prostitute? Or are sex industry workers dismissed as being “hooked on eroticized rage”? In the age of restorative justice and victims’ rights, do treatment centers offer education or group sessions between addicts and sex workers in recovery?

Susan’s mother turned her out when she was 12 because one of her tricks would not pay unless he could have sex with Susan. It was Detroit, early winter. Thrown outside after the act, Susan washed herself off with the garden hose; she found herself months later enmeshed in the sex industry.

Naked pictures of Juanito were taken at age 11 and circulated in juvenile hall after his first rape by the officers. For the next seven years, each time he returned, the officers who regularly raped the boys knew he had already been “broken in”, and it continued. Juanito found himself turning tricks to support his drug habit and participating in pornographic movies. Years later, he was found dead behind a dumpster, a victim of violence.

Maria, a victim of childhood sexual abuse, was strikingly beautiful. Prostituting before she was 20, she woke up one morning after passing out in a motel room; her trick had stuffed a syringe inside her vagina.

Do our treatment programs and support groups hear these stories? Do we ignore the suffering of those who are used, either in person or the subjects of fantasy and masturbation on the Internet?

In our prison system, people migrate from name to number; in sex clubs, pornography and prostitution, from name to object. Woe unto the nameless faceless people who have worked in the sex trade and end up incarcerated. Many do not realize that the women’s prison population in the United States is growing at a faster rate than that of men. This is where some percentage of sex workers ends up. Interestingly, two states with well-known centers to treat sexual addiction are mandatory minimum-sentencing states: Arizona and Mississippi. Do sex addicts in treatment understand that what gets them off often means long incarcerations for street workers after several arrests? Do high-end treatment agencies do service and outreach to the exploited who have no means to pay for treatment?

Ironically, the plight of those in the sex industry is largely hidden from the sex addict, who continues to rationalize behaviors. The professionals who do work with those in the sex industry are frequently admonished not to encourage people to explore experiences in detail, for fear of re-traumatization. But does that not help the sex addict to maintain the rationalization that the sex addict is the victim alone? In our recent history, the consciousness of the world was changed by the likes Fannie Lou Hamer, Victor Frankl and Elie Weisel — through their honest explication of the horrors they experienced. Bessel van der Kolk, dedicated his book Traumatic Stress to Nelson Mandela and “all those who, after having been hurt, work on transforming the trauma of others”. After studying trauma world-wide, van der Kolk states “that the spirit of squarely facing the facts as a prelude to healing should guide both our clinical and research work with victims of trauma and violence.” The treatment of sexual addiction is rife with trauma and violence, and all parties deserve the facts (not the images) squarely faced.

The words to John Newton’s hymn, Amazing Grace, are known to all. His transformation led him to leave the life of a slave trader and speak out about was arguably the greatest human rights issue of his time: the abolition of slavery. Might we not only sing his words, but also follow his example. Would that those with the resources to get help, and those who counsel them, actualize the grace that will lead to the service and healing of the most exploited.