Confronting the problem of addiction is almost always daunting and exhausting. The layers of complexities increase tenfold when the family system is also trying to preserve its stability and normal functioning despite the disruptions that addiction brings.
Family members are often exasperated that the usual admonishments of “how could you do this to…?”, “why can’t you see that you are hurting…?” or “how long do you think you can keep doing this…?” seem to bounce off the walls.No amount of shaming, guilt-laying or threats seems to wake the affected person up to see the realities of the wreckage that has been inflicted on the family.
According to the American Society of Addiction Medicine:
“Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviours that become compulsive and often continue despite harmful consequences.”
Addiction is a disease.As a family member, it is important to recognise that “you did not cause the disease, you cannot cure it and you cannot control the outcome of the disease”. The person affected needs to learn to manage their own recovery and family members need to learn effective responses towards the affected person to support the recovery of the family system.
Recovery is a life-long process that may and often include a series of relapses both on the part of the individual and on the family system.
How Does One Know When Addiction Strikes?
Symptoms of addiction are manifested by:
Compulsion – an absolute and overpowering urge towards substance use or behaviour.
Craving – an increase in usage and/or frequency to a point of necessity for survival.
Control – loss of ability to manage manner of use, to reduce or to stop.
Consequences – the use or behaviour continues despite relationship, work, school, legal and money problems.
The first step to bringing the affected person towards professional help can either motivate or unsettle the recovery process.
As professional therapists working in this field, we witnessed many instances where one of the first steps by family members would be to call the authorities.This is a painful first step that often inflicts hurt on both the affected person and the family member.The outcome could turn out to be a sharp wedge between family members which may take a long time for repair and reconciliation. Many a time, the affected person may attempt to run and hide, taking them even further away from the treatment help that they need.
The next most common first step is an intervention. This is a meeting convened to confront the person affected and interventionists may include family members, close friends and/or religious leaders.Each member shares with the person about their observations of specific negative behaviours and how these behaviours have affected them.The group then presents options to the target person and encourage the entry into rehab immediately.
An intervention is a double-edged sword. When done well, members expressed their love and care for the target person, while maintaining an uncompromising position about the person’s problem with addiction and need for treatment.When executed poorly, the target person receives a shock and feels a deep sense of betrayal from the group. The feelings of bitterness and resentment towards the whole intervention experience wipe out the initial good intentions. This, in turn, makes for poor motivation to accept and adhere to treatment. Trust towards the family system is broken which would likely take a long time to mend.
A 3rd strategy is known as CRAFT – which advocates for positive communication, positive reinforcement and allowing for natural consequences to happen. This approach takes a longer time to implement and focus on identifying actions by the affected person which are helpful towards recovery, expressing empathy towards the person’s suffering and offering to work with the person to find a solution.An example of positive reinforcement could be to engage the person in activities within the family system that the person still values. The 3rd aspect is counter-intuitive; to allow the person to bear the natural consequences of their actions, instead of covering up for them or trying to make everything “all right”.In so doing, the realities of the consequences of the addiction is experienced fully by the affected person which can create the turning point to seek treatment.
Is the Family’s Job Done When They Ship Off the Affected Person?
Addiction is a life-long recovery process and parallel to the individual’s recovery is the family system’s rebalancing process.
In broad terms, the individual’s stages of recovery are as follows:
Withdrawal – Detoxing
Honeymoon – Addiction Stops
The Wall – Protracted Abstinence
Adjustment – Working through Underlying Issues
Resolution – Acceptance of lifelong Abstinence
What is the Parallel Journey for the Family System?
Pre-treatment and Withdrawal
At the initial stage, the affected person will test the limits of the system by engineering and re-engineering their way to get to their addiction.A person in active addiction is usually not rational, nor are they conscious of the effect of their actions on others.There may be many false promises made in order to get to the addiction or manipulation of family system dynamics to garner support for their continued addiction.
Here are a few pointers that family members can keep in mind at this stage:
Get an Accurate Understanding of Addiction.
Create Unison in the Family Approach.
Relinquish Control of Outcome of Addiction.
Self-Care and Emotional Coping for Shame, Anger and Blame.
Learn How to set and Communicate Boundaries.
Find Family Support Groups to Brainstorm Strategies – Link to Visions Programme.
During this stage, the affected person would have stopped the active addiction. The person reverts to their pre-addiction persona that the family was used to and readily embraced.There is a delusion that all is victorious, and the person is cured.Some people would even deny that there was ever an addiction in the first place.Family members and individual alike start to make wonderful plans for a new future, unaware of the undercurrent of the recovering person’s vulnerabilities to triggers, anxieties, and relapses.
Here are a few pointers that family members can keep in mind at this stage:
Adjust Family Life to Reduce Triggers.
Rebuild Trust and Learn To Discern Through Observations.
Learn About Adjustment Process and Strategies with Other Families – Link to Visions Programme.
By the time the recovering person reaches this stage, his/her body is trying very hard to stabilise and find its new baseline. The struggle without their past go-to coping mechanism manifests in depression, irritability, and inability to find pleasure in the usual activities. Family members may take things personally when their overtures to reintegrate the person into their lives are rejected. Some family members may start to prefer the “happy” person who was previously addicted or start being highly suspicious that the person has relapsed.
Here are a few pointers that family members can keep in mind at this stage:
Maintain Unison in The Family Approach.
Learn Emotional Coping to Rejection, Anxieties and Tolerance for Uncertainty.
Share and Validate Family Experiences with Other Families – Link to Visions Programme.
When the recovery process reaches this stage, both the individual and the family have crossed some major milestones (It is typical that some 6 months would have passed from the start of journey.).The most daunting challenges are now bubbling up in the horizon.Family relationships, lifestyles and values may be examined at a fundamental level and permanent changes may need to be made for recovery to be sustainable over the long haul.Past hurt and traumatic experiences would need to be resolved for both individual and family to move forward to a new way of interaction.
Here are a few pointers that family members can keep in mind at this stage:
Commit to Family Approach Without Complacency.
Address the Emotional Well-Being of Other Neglected Members.
Learn Emotional Coping on Forgiveness, Grieving, Acceptance and Letting Go.
Learn Goal Setting and Strategies to Create a New Family Life Experience with Other Families – Link to Visions Programme.
The last stage is not a phase per-se but a continual process for the lifetime of the individual and for the family system that has learnt and grown alongside him/her.The individual is practicing commitment to his/her sober life free from addiction every single day.The family system has likely been permanently transformed by the recovery process and is now reintegrating the member into its new dynamics.
Here are a few pointers that family members can keep in mind at this stage:
Embrace the New Family System, Lifestyle, Values and Norms.
Celebrate Successes and All Learning Experiences as A Family Unit.
Offer to Be a Supportive Family System to Other Families – Link to Visions Programme.
Caregivers with a family member affected by addiction problems are often exhausted, drained dry of their empathy and compassionate capacities.
They recount countless cycles of suspended hope followed by just as many broken promises as they watch the affected person return time and again to their compulsive addiction despite a seemingly obvious trail of destruction behind them.
Caregivers learn to cope with the endless demands on their energies by blending the words uttered by the affected persons as a cocktail of lies, manipulation and attention-seeking antics to get what they want.In time, the cries for help from the affected person turn into cries for help by the boy who cried wolf and eventually fading into indistinguishable white noise.
Professor Lisa Firestone of the Glendon Association observes that there is a natural tendency for caregivers to minimise any suicide expressions in general.Responses such as, “Well, his past attempts weren’t serious.” or “He is just manipulating to get something.” are commonly observed.There is also a general tendency to not want the expressions to be true.In the case of addicts, words such as “I want to die” or “I am going to end my life” no longer convey the same meaning or gravity of their sense of desperation.
Why should we want to pay attention to an addict’s cry for help?
In Singapore, we lose 1.1 lives every day to suicide.It is still the leading cause of death for youths aged 10 to 29.While direct correlation evidence is still being researched on, studies in America have shown that more than 90% of people who kill themselves suffer from depression have a substance abuse disorder or both. Suicidality and addiction share a high concordance relationship.
When we overlay the statistics with a physiological lens, we note that both groups of persons have been observed in studies to have a dysfunctional hypothalamic-pituitary-adrenal (HPA) axis which essentially controls our body’s response to stress.
In a person with a normal functioning HPA axis, on the reception of a stressor, the hypothalamus in our brain instructs the secretion of the corticotropin-releasing factor (CRF) and vasopressin to stimulate our pituitary glands to produce the adrenocorticotropic hormone (ACTH).The ACTH, in turn, stimulates glucocorticoid synthesis and release (commonly referred to as cortisol) from the adrenal glands.This chain reaction provides a person the increased energy to handle the stress event and to do so without suffering from the pain and fatigue.When the stress event is gone, the body produces a negative feedback loop which then brings the body system back to homeostasis.
In a person exposed to a persistent or extreme level of stress, or in a person who frequently activates the HPA axis through substance use, the body starts to blunt the sensitivity of the HPA axis and blunt cell receptivity to cortisol in its efforts to return to and maintain homeostasis.This alteration to the sensitivity of the HPA axis affects our ability to tolerate physical and mental stresses and creates a need for a much bigger stimulus to activate the HPA axis (which may mean higher dosage of substance use); and when the HPA axis does react, produces a much bigger and exaggerated response (which may translate to more aggressive behaviours).
What Does This Mean In Practical Terms?
Many suicidal persons described having a voice in their head which is constantly there; telling them how much they need to seek fulfilment and comfort by reaching for the desired stimulus, whether it be a substance or a behaviour, of which one is killing themselves.Their mind starts to command them to constantly plan, to seek out and to take actions to soothe the unbearable lack that they are feeling.Eventually, the voice in the head goes from coaxing and persuading to being more intensive and aggressive towards the self to take immediate drastic actions.
The relief of death, a final refuge, becomes alluring and pleasurable and the fear of dying eventually transforms into the fear of not dying and becoming the loser, disappointment, and burden that they already believe themselves to be to their caregivers.This dual push towards drastic action and the need for an ever-increasing amount of substance in addicts leads to an increase in the risk level of suicidality.
What Can We Look Out For?
How then does the caregiver separate the wheat from the chaff amid the chaos that addiction has already wrought onto the family system to detect the risks of suicidality?
Below are some, though not exclusive, common markers to look out for. It is particularly useful to note changes in the content of the affected person’s expressions and any escalation or sudden extinction of intensity.
Intense Emotional Outbursts
Extreme Isolation or Withdrawal
The feeling of Being a Misfit in Every Way
Researching or Procuring Means of Suicide.
Self-Harm, Including Risky Substance Use or Behaviours.
Planning of Affairs.
Presence of Trigger Events
Loss of Primary Relationship.
Physical or Mental Health Conditions That Debilitate.
Abuse or Trauma Events.
What Can Caregivers Do On Observing The Signs?
Ask the Suicide Questions:
In the past few weeks, have you ever wished that you were dead?
In the past few weeks, have you felt that you or your family would be better off if you were dead?
In the past week, have you made plans about killing yourself?
Have you tried to kill yourself?
If the answers are yes to any or to all the questions, caregivers are encouraged to take the following first steps:
Be empathetic towards the suicidal wish.
The objective is not to agree with the act of suicide but to understand what has happened to lead the affected person to the conclusion that suicide is the only solution.
Find a genuine connection with the affected person.
However difficult that person might have been in your life, express what this person means to you personally and how the loss of this person would affect you.
Make a safety plan.
Ask the affected person to agree to not take or delay any action to harm themselves until they get to or you get them to professional help.
Professor Lisa Firestone observes that suicidal persons are generally ambivalent: a part of them wants to die but a part of them wants to live as well.There is often a process of the dividing up of the self within the person, between an aspect which is life affirming and engaging with the outer world; and the anti-self, which is self-critical, self-hating and ultimately suicidal.The key to recovery is to connect with and help strengthen that part of them that wants to keep on living.
6 Dazzi, T., Gribble, R., Wessely, S., & Fear, N. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychological Medicine, 44(16), 3361-3363. doi:10.1017/S0033291714001299
Predictive algorithms, the creation of alternate realities in which we are unlimited by the constraints of the real world we live in – such methods are extensively practiced by the gaming industry to draw players in. Gaming is undeniably a popular and widely-adopted mode of de-stressing, but how much is too much?
In May 2019, the World Health Organisation officially recognised “gaming addiction” as a mental health condition. It is diagnosed when a person displays a gaming behaviour pattern that causes significant disruption to their daily life for a period of 12 months. Meanwhile, a study showed that Singaporeans aged 18 and above spend a weekly average of 7 hours and 26 minutes playing video games, and that approximately 10 percent of Singaporeans game for more than 20 hours per week. This ranks us as the highest in Asia, and third highest in the world, falling only behind Germany and the United States.
What leads these addicted individuals to their compulsive gaming behaviour? Besides the prevalence and ease of access to games on various gaming platforms, video games often act as a form of escapism for many players. As a shining proponent of the alluring, edge-cutting virtuality, games allow for players to throw themselves into a virtual landscape that is contrasted from their – comparatively – mundane everyday lives, and can serve as a distractor from real-life problems that they are unconfident or reluctant to face. Moreover, it can be easy to fall into the trap set by game creators. Game designers construct games in a way that applies principles of behavioural economics as well as psychological mechanisms to explore stages and levelling up processes that trigger the brain’s reward system. In-game statuses matter a lot to gamers – the higher the rank you possess, the more pride and self-esteem you hold, knowing that you can show it off to your friends or gaming counterparts. As a result, individuals are often inclined to continue striving to climb the virtual hierarchy.
Naturally, excessive gaming has its consequences. When an individual develops a gaming disorder, his lifestyles can be disrupted in more ways than one. What is also important to take note of, is that the harmful effects of gaming addiction is not only limited to the individual alone, but could also affect the people in his or her social circle. Some of these adverse effects can include:
Obsessive Behaviour Individuals who are addicted to video games are always anxious to get back to games and will often display irritable, bad-temper aggressive behaviour whenever they are separated from their games unwillingly.
Increased Social Isolation With extended periods of intense gaming, these individuals become more withdrawn and disconnected from family, friends and colleagues, causing them to drift away from their loved ones.
Other Mental Health Conditions Gaming addiction can eventually lead to other issues that include depression or anxiety disorders. Sometimes, depression may follow due to the prolonged social isolation.
Other Physical Health Conditions A gaming addiction can also have a number of physical effects. When one devotes an excessive amount of time to the gaming activity, this can lead to physical conditions such as the carpal tunnel syndrome, migraine, back-aches or eye-strain. Extreme addiction may cause gamers to skip meals and rest, or neglect their personal hygiene as they lose control of themselves and can’t resist the desire to play more and more.
Gaming addiction is a serious matter, and can be degenerative if not addressed in the early stages with the initial symptoms and signs. Habits, including unhealthy gaming habits, can be formed anytime between 1 to 3 months, and it will be significantly easier to curb such self-destructive behaviour the earlier we try to tackle it.
While we are concerned with the various health risks and conditions commonly associated with gaming addiction, we cannot deny that video games are also undoubtedly entertaining and can be a good way to de-stress. However, as the risk of gaming addiction increases with increasing time spent gaming, what we want to advocate is moderation, rather than complete avoidance. With that said, if you are someone who is battling gaming compulsion, try to keep the amount of time spent gaming under control by setting time limits for play and stick to them. If possible, try reducing your playtime gradually by setting a timer on your phone, or use softwares such as ‘Cold Turkey Blocker’ to help you do this by blocking access to websites or applications so that you can get offline when you need to.
Like other forms of addictions, don’t try to go cold turkey at one go. Stopping altogether may cause you to feel as though there is a huge void in your life, hence increasing the likelihood of a relapse instead.
According to the World Health Organisation, tobacco kills more than 8 million people worldwide each year, and is one of the biggest public health threats the world has ever faced. But contrary to popular belief that smokers are “uneducated regarding it’s harmful effects”, or are simply “not bothered to make an effort to quit”, studies have shown that 70% to 80% of smokers do hope to quit smoking. The only thing holding them back is that they can’t.
Nicotine is widely known to be a highly addictive substance. It is the chemical in tobacco that makes it hard to quit and nicotine withdrawal symptoms that smokers experience can be extremely unpleasant physically and mentally. Apart from the intense craving for nicotine, withdrawal symptoms may also include sweating, increased irritability, difficulty in concentrating, as well as difficulty in sleeping. However, nicotine dependence is causing the compulsion to smoke, it is other chemical substances that cause physical damage to the body. Chemicals such as tar can paralyse the hair-like structures in the lungs (also known as the cilia), contributing to diseases such as chronic bronchitis. Moreover, smokers are also vulnerable to the development of lung cancer. Cigarette smoke contains a cancer-causing substance, benzopyrene, which can attack and damage the p53 gene. When the tumour-suppressor gene is damaged, cancer cells have a higher chance of proliferating due to uncontrolled cell division, hence increasing the risk of tumour growth.
Ideally, quitting smoking and nicotine completely would be the best, but it’s proven to be tough for addicted cigarette smokers to stop all at once. As such, a harm reduction strategy would be switching to a less harmful nicotine alternative for smokers, and ideally would result in them ultimately quitting nicotine use altogether. This is all about lowering the health risks to individuals and wider society associated with tobacco smoking. Some of the more commonly known alternatives include electronic cigarettes and heated tobacco products (also known as heat-not-burn or HnB). Although these may not be accessible in Singapore, other countries have legalised these smoke-free nicotine products that generally deliver far lower levels of toxic compounds.
E-cigarettes are battery-operated electronic devices that mimic the act of regular smoking by heating a liquid to generate an aerosol, which is inhaled by users through the mouthpiece and exhaled as a visible vapour. Often, the usage of e-cigarettes is also known as “vaping”. Not to be confused with e-cigarettes, HnBs work in a different manner. In some way, HnBs are a hybrid of traditional cigarettes and e-cigarettes. In HnBs, the tobacco is heated to 350℃, compared to traditional cigarettes that combust and burn at a temperature of up to 900℃. On the other hand, e-cigarettes heat nicotine-containing liquid to approximately 250℃, causing it to be vapourised and then inhaled.
Although not risk-free, what makes e-cigarettes and HnBs a better option compared to conventional, combustible cigarettes? Cigarette smoke is pretty much the main cause of harm, with thousands of toxins released in high concentrations upon the combustion of tobacco. Unlike traditional cigarettes, its alternatives are smoke-free – this means that smoke-induced health effects are significantly reduced. When smokers make the switch to using e-cigarettes or HnBs, these devices also have the added advantage of replicating the ever so familiar hand-to-mouth ritual of smoking. However, it is crucial to note that both e-cigarettes and HnBs still contain nicotine, so while smoke-induced health effects are reduced, the effects of nicotine consumption is still prevalent, for as long as these products are used.
It must be acknowledged that many health professionals, tobacco-use control professionals and policy-makers who recommend the harm reduction alternatives have very good intentions. They advocate reduction in conventional cigarette smoking as a pragmatic way of reducing the devastating health effects associated with nicotine dependency. However, good intentions must always be supported by strong evidence.
This year, the Asia Pacific Behavioural and Addiction Medicine Conference (APBAM 2020) will be a socially distanced online conference. Focusing on “Tobacco Harm Reduction – Myths and Reality” for it’s first forum, the speakers will examine the use of new ways to overcome nicotine dependence, as well as the various policies that different countries have taken in their approaches and their effects on reducing the harms caused by cigarette smoking. Speakers will include Prof Alex Wodak (AUS), Dr. Jeremy Lim (SG), Dr. Takao Ohki (JP), Dr. Rusdi bin Abd Rashid (MY), Dr. Ben Cheung (HK), Dr. Munidasa Winslow (SG), Andrew da Roza (SG) & Dr Sivakumar Thurairajasingam. Do join us on 26th September 2020, we hope to see you there!
To non-smokers and those who have an occasional cigarette at a party or outside a bar, it is baffling why smokers just can’t simply quit. What’s the big deal?
If you think this, then the conclusion may be: “well they just don’t want to quit”; or “they are uneducated, and don’t know how much damage they’re doing to themselves and those around them”; “they have no conscience” or “they have no self-control”.
The problem with these conclusions is that the scientific evidence doesn’t support them.
70% to 80% of smokers want to quit – and many of them desperately want to quit – and most smokers fail.
A majority have tried to quit multiple times – and about 40% are still drawn to smoking -even after losing fingers and toes to gangrene, or lungs to cancer and COPD, as a result of smoking. Many suffer heart attacks, mouth, throat and colon cancer, or labour under serious diabetes problems; some even lose their close relationships with their families.
They wish that if only they could quit, their lives would be so much better – yet they continue to smoke.
So, there is more to the compulsion to smoking than meets the eye.
Perhaps kindness and compassion for smokers may be a more rational reaction – than dismissal, frustration, irritation, anger or contempt?
There are very good reasons why the chemicals in cigarette smoke are so compelling – and it’s to do with our brains and our bodies. It’s not a mystery.
Although nicotine in the smoke is a comparatively benign substance, and it doesn’t cause the damaging effects of the other harmful substances in the smoke – it is highly addictive. It is the nicotine that causes the addiction – but it is the tar and other substances that cause the damage.
In addition to nicotine, there is another substance, in smoke, that creates a potentially “pleasant” psychoactive effect. It is a monoamine oxidase inhibitor – which results in chemicals in the brain staying longer in the space between neurons and firing those neurons.
And the effect the smoker feels? Well, there can be numerous combinations of “positive” effects.
Those smokers who feel down, moody and unmotivated, may feel a pleasant “lift” or “boost”. Anxious, fearful and nervous smokers, may feel calmer, and more able to think straight. Smokers who are tired, sleepy or lethargic, may be able to focus, concentrate and pull themselves out of their procrastination.
Smoking helps some people become more energetic, have better reactions times and become more effective or efficient. Smoking enables people who are mentally tired with work or constant rumination, to feel like they are taking a break and “relaxing” from their thoughts. They can just let their minds gently wonder. They may even feel that after their “reverie” with a cigarette, they have managed to solve a problem that they have been grappling with.
Some people use smoking as a bonding experience. Ironically, all the community stigma that surrounds smokers makes some feel like a “band of brothers and sisters”, as they stand outside in smoking areas or in smoking rooms. It enables instant connection and the sense of “belonging”.
In short, the effects of smoking depend on how you are feeling in the moment.
Insidiously, mental illness and other addictions result in many becoming vulnerable to smoking – either to cope with: their illness; the difficult side effects of their medication; and the social stigma against mental illness addiction that so oppresses and shames them.
By way of examples, ADHD, schizophrenia, bipolar disorder, anxiety and major depressive disorders, and personality disorders, can all result in life-long suffering – that smoking may appear to “take the edge off”.
There is now persuasive research that some people are more genetically susceptible to being addicted to cigarette smoke. They may get more of a “buzz” from it, they may be more tolerant to its side effects, the effects may wear off faster, and they may feel the withdrawal effects (when not smoking) more keenly. They may have more trouble starting to quit – and staying quit.
There are many other vulnerability factors as well: adverse childhood events (which afflicts 2 out of every 3 Singaporeans); traumas; family and peer modelling; rebelliousness, isolation and loneliness, financial distress, problems in relationships and at work; and many more factors, may all conspire to lead smokers to smoke daily.
Once they smoke enough cigarettes for long enough – the brain changes, it becomes “hijacked” by the smoke.
Smokers experience brain changes as:
Tolerance – the need for more smoking, more often, to get the same effect;
Withdrawals – 45 minutes to two hours after smoking, they may feel the exact opposite of what they felt when they smoked – and therefore need a cigarette to feel “normal”;
Impulsiveness – in the moment (of smoking), they forget about the harms of tobacco and their resolves to quit, and habitually light up;
Smoking triggers – smoking cues are everywhere – and they trigger the urges and cravings – and once these build up, they become overwhelming;
Stress – their stress response slowly but inexorably ratchets upwards, daily – so that even things that used to be experienced as minor, now elicit strong and intolerable emotions. If health, relationships, jobs and self-image are all on the line because of smoking – the stress can be intense.
Luckily – there is a solution. Smokers now have access to psychotherapy, nicotine replacement therapy, quit smoking medication, and any number of other tools to help them on their quit journey. In other countries, new nicotine delivery technologies like e-cigarettes and heat-not-burn are being improved and refined – and they are much safer than smoking.