Chapter Thirteen
An Inventory Nobody Wants to Take
I flew into Reno with my wife and daughter and started work immediately at the VA Medical Center in Reno. My two ladies went house hunting. They were as completely enchanted by Lake Tahoe as I had been. They found a chalet on the California side of the lake, and I was soon driving 45 miles each way to and from work daily.
During my previous experience as a clinical psychologist, I generally worked with extreme cases, and the Alcohol and Drug Treatment Program (ADTP) at the Reno VA Hospital offered some of the most extreme. By this, people usually mean bottom-of-the-barrel, chronic, or hopeless addicts.
Not long after I got there, the Hospital Director appointed me Chief of the Alcohol and Drug Treatment Program. I promptly renamed it the Addictive Disorders Treatment Program, which preserved the same initials, ADTP.
I was appointed to replace other staff, who had worked hard to secure funding and establish a new program before leaving. Their accomplishments in Reno had not been easy, and I appreciated their hard work. But the focus on substance abuse was as limiting as the specialization in pathological gambling had been. It did not really sanction us to treat all the life-threatening problems our patients brought with them, and it did not seem to allow for other addictions, such as pathological gambling. I didn’t want to let go of my old gambling specialty completely. Since Reno was a gambling town, some interesting cases might turn up. Indeed, they soon did.
When I went to Reno in the summer of 1985, pathological gambling had already been recognized by the American Psychiatric Association and the World Health Organization as a mental illness for five years, but there still were almost no treatment programs for addictive behavior that even asked new patients whether or not they gambled. One of my first tasks was to get our staff to begin asking that question of all patients.
So our staff underwent a major shift in focus. Fortunately, we didn’t have to repaint the signs directing people to the ADTP. Same initials. Same space. Same staff. Expanded view.
Also, we did not remove the slogan painted in huge letters on the corridor walls: “Sobriety is the No. 1 priority, along with honesty and responsibility.” The founders of the Reno program had established moral accountability as the cornerstone of recovery from addiction. From the first day of treatment, the patient was told that recovery was in his or her hands, and would require a complete personality change. I was in total agreement with this thinking. All I wanted to do was get us away from the notion that only a chemical can cause an addiction.
Gamblers like to call abstinence clean time, or being clean. But a gambler gambling is not in a sober state of mind any more than an active drunk or someone high on drugs. Sober, clean, straight … to me they were just other words for a normal, non-altered state of mind. Look up sober in the dictionary and you will see that the sober state of mind has relatively little to do with alcohol or intoxication. Gamblers, like all addicts, need to learn what sober really means, so we kept the slogan and the philosophy.
Many people are comfortable with their normal state of consciousness, and find that mind-altering activities make them nervous and uncomfortable. Millions of others, of course, react differently. They find their non-altered, normal state of mind extremely unpleasant. Without the help of mood or mind-altering activities, they are angry, depressed, anxious, and generally unhappy with life. Addiction seems to grow best in the fertile soil of human discontent, and the psychological immaturity that causes it.
All addictions have serious physical and mental consequences. Some things about pathological gamblers had always seemed obvious to me, without much detailed research. All I had to do was count up our patients’ other problems. A third of them had cardiovascular disease of one kind or another. Ninety percent of them were smokers. Forty-five percent were alcohol abusers. About half were overweight and ate compulsively. Some abused street drugs and some abused prescription drugs. Many seemed dependent on finding numerous different sexual partners; that is, they were sex addicts.
The numbers for these other problems among gamblers were far above national averages for adults. Something much deeper than gambling was going on, and I could not help asking what.
The very name Alcohol and Drug Treatment Program gave the staff permission to ignore the smoking, gambling, and other patterns of abuse that went on under the surface of what we said we were treating. Time after time, these hidden problems undermined our best efforts by causing relapse in the primary addictions we were trying to treat.
What convinced me of the need for a larger focus on addictions in general was the persistent finding that relapse during recovery from addiction could, in case after case, be traced to the development of new addictions. There is nothing like a new alcohol dependency or a new pattern of drug abuse to undermine the firmest resolve to abstain from gambling.
I became convinced that quality recovery from pathological gambling is impossible if other addictions go untreated. And this made me a real pain in the neck for patients and staff, who preferred to focus only on one addiction at a time. I was also concerned because several people on the staff seemed to be heavy gamblers, and some were smokers. Early in my time at the Reno ADTP, I discovered the extent of this problem.
“Say, Henry,” I said to one of our counselors, “the Director wants to know if you’ll authorize electronic deposit of your pay directly into a bank account, instead of taking a paper paycheck. Your money would be in your account a day earlier, and it would save the government almost $2 in costs.”
“No way,” said Henry (and several others to whom I put that question). “If I cash my check at the casino they give me two free pulls on a slot machine, two free drink tokens, and a buffet ticket.”
Henry (not his real name, of course) was a recovering alcoholic, and I think he probably traded the drink tokens for more buffet tickets, which would build his already considerable girth. I suspect he had a heavy gambling habit, if not an outright addiction. Over my five years in Reno, I saw quite a few staff members, including physicians, nurses, and counselors, who were involved in significant gambling activity.
It was a natural step in the development of addiction treatment in the 20th Century to start with specialized programs that dealt with only one addiction. But by the 1980s, it was becoming clear that addiction went much deeper, and cast a much wider net. Even state governments seemed to have conspired by creating certificates and licenses for alcohol or drug treatment specialists. Eventually, to my dismay, we began to create gambling treatment specialists instead of addictive behavior specialists. At the time, even the American Psychological Association did not have a special interest section devoted to addictions.
When someone has more than one addiction, and the behaviors seem to exist independently one from another, I call that multiple addiction. For example, some gamblers never drink and gamble at the same time. They either drink or gamble, and when they do, either it is not in moderation and it always causes problems. When someone substitutes one addiction for another, I call that cross (or substitute) addiction. For example, many gamblers I knew substituted an addiction to work, alcohol, or even exercise when they stopped gambling. And when someone has two addictions that seem to go hand in hand, I call that co-addiction. An example of the latter I remember in my own life. During 22 years of cigarette smoking (I stopped many years ago and substituted eating), I could not drink a cup of coffee without lighting a cigarette. When I quit smoking it was almost impossible to drink coffee without feeling a nicotine urge. In my years of not smoking, the attraction of caffeine has almost disappeared.
As a result of my clinical experience, I began to wonder if all addictions were merely symptomatic of a single, underlying mental illness. This was actually an old idea in psychiatry and psychology, an idea that failed because it had led treatment specialists to ignore the drinking or gambling in an effort to develop the patient’s understanding of his or her own psychodynamics. The theory was that if a person could just develop sufficient insight into their own developmental history, they would naturally stop the addictive behavior on their own. Unfortunately, this just didn’t work since it is impossible to do good psychotherapy when the patient is practicing a serious addiction.
However, I was ready to re-examine the notion of a unified theory of addiction, the idea that we were looking at many different manifestations of a single disorder, or vulnerability. Must we, I often wondered, deal with each addiction one by one, or are we really looking at a single, general disorder? The list of recognized addictions gets longer every year. Must we establish separate treatment programs for each separate addiction, and then certify counselors in each area? Is the gambler correct when she claims that if she had to quit smoking, or drinking, she would relapse immediately to gambling? Or is that just another way in which an addiction protects itself? Do self-help groups like Gamblers Anonymous have a right or obligation to encourage members to look at other addictions? Would recovering gamblers have the courage to do that?
One day I was paged to come to Admissions immediately. When I arrived, the area was in chaos: tables overturned, chairs scattered about, red-faced interns and nurses scurrying about, and security men holding a man in street clothing on the floor.
“One of your drunks, Taber!” cried a nurse.
“I knew when they started to admit these damn druggies and drunks we were in for trouble,” muttered a housekeeper.
“Can’t keep a place clean with all these sick people around,” I agreed. “A hospital would be a great place to work if we just got rid of the patients.”
“Can you get this guy a shot to calm him down?” begged one of the security men.
“I’m a psychologist. I don’t write scripts for shots. If the admitting doc didn’t order a tranquilizer, there must be a reason.”
“Right,” said a resident. “This guy was asking for Valium, and the record shows he’s a benzodiazapin (Valium or Librium) abuser. He got pissed and wanted to fight me when I said no. And I don’t see any reason to admit him now.”
“Steve,” I said to the man on the floor, “we need to talk. Can you behave yourself if we let you up?”
“Let him up?” cried security. “Just call the cops and get this turkey locked up in jail. He sure doesn’t belong in a hospital. You think you can sweet talk this creep into acting nice?”
“We’ve tried locking drunks and druggies up in jails for hundreds of years and it hasn’t worked,” I said. “Have you tried sweet talk yourself?”
To Steve I said, “How about it, Steve? It’s talk to me calmly or go to jail.”
To the staff I said, “Steve and I go back a bit. He’s one of our outpatients, and he’s been active in our Alumni Group. If he promises to be calm and behave, I’ll take responsibility.”
Steve seemed a little confused at seeing me, and then seemed to remember we’d met. A familiar face helped my cause that day.
“Doc,” he said, “I’m just trying to stay sober. God knows I don’t want to drink again. Yeah, we’ll talk, but you have to do something one way or the other. I’m going nuts.”
“OK, Steve. As soon as the men let go of you we’ll go outside and talk. We’ll make some plans.”
We sat together in the sun at a picnic table behind the Nursing Care Unit, and that was when I began to put together a test that we would eventually give to every new patient coming to the ADTP. Steve was antsy, but I got him to relax with some deep breathing exercises. Then he began to describe all the bad habits he had developed during his life. We took an inventory of his addictions, and the list was impressive. Finally, we went back inside and got him admitted to ADTP once again. Our physicians on the unit could help Steve detoxify from Valium, a process that can be quite dangerous if not supervised by medical experts.
Steve had been sober since his inpatient treatment in Reno, and had been working in construction. His treatment for alcohol dependence, along with AA, had worked, at least in a limited sense. But Steve was convinced that he could not stay sober without Valium to calm his nerves. And he still loved to spend time playing the slots in casinos, where he smoked constantly and drank large amounts of coffee.
Coffee has been the semi-official beverage of AA since its earliest days. I think the founders of Alcoholics Anonymous made a simple mistake that many of us have been making ever since; they assumed that getting a drunk sober as soon as possible was a necessary step. But they also sometimes practiced what they had known all along; small, measured amounts of alcohol itself could be used to help someone sober up without experiencing some of the worst effects of detoxification.
Some alcohol treatment programs with no medical staff still used alcohol to help manage anxiety during detoxification. In fact, some senior AA members carry whisky on service calls to active alcoholics, in case it’s needed to calm someone enough to get them into treatment.
But large amounts of caffeine, in my opinion, simply adds to the stress already being placed on the alcoholic by alcohol abuse.
Steve had been buying Valium on the street because he had run out of physicians to prescribe it for him. When his street connection failed, he turned up desperate and panicky in our waiting room. The resident on duty had returned what he saw as simple belligerence with scorn and derision of his own. In four years of medical school, students seldom got more than a lecture or two on addiction, and that deals mostly with the biochemistry of alcohol.
Steve was previously treated for alcoholism in other VA hospitals. Like many other alcoholics, Steve was first given Valium by the VA itself to help with his detoxification. About 10 years before, Steve got a large amount of Valium to take home after he left treatment, on the theory that he would not relapse to drinking because the Valium would control his anxiety. At that time, the addictive quality of Valium was not recognized. In ignorance, we were actually helping create a substitute addiction.
As I talked with Steve at the picnic table, I realized that he could have been diagnosed, depending on the specialization of the treatment program where he turned up, as a compulsive gambler, an alcoholic, a drug abuser, or as having an antisocial personality disorder. Some therapists would see his problem as depression, others would see it as family conflict, and yet others as simple schizophrenia. Where lay the truth? I knew we would never find it as long as Steve was living the way he did, trading one addiction for another while making no lasting personality changes.
With Steve safely back in treatment, I got busy on my new inventory. On this test, zero is the top score. Only angels and saints get a zero. Humans, I included, never do.
The inventory is reproduced here in somewhat simplified form, but the content is exactly that given to our patients. We called it the Consumer Lifestyle Index, because, as part of our research, we planned to administer it to non-hospitalized people who did not have severe addictions. That’s called a normal control group, a group of normal people used as a comparison group for patients in treatment for addiction.
We asked for name, age, date, and sex. A battery of other psychological tests was also given to all the patients, and that helped me to see the test results in a broader context. On one sample of about 50 patients, we gave the test twice to each, several months apart. From this we found that patients were extremely consistent in their own self-reports. The first test score correlated very highly with the second. Of course, some people minimized their addictive behavior while some tended to exaggerate it, but their minimizing or exaggeration was consistent over time, and we could factor that out in our research.
There were 41 items on the test. With each being rated twice, there were 82 answers. The test took only a few minutes to complete and just a few more minutes to score.
The following instructions were printed on the first page of the Consumer Lifestyle Index:
This index asks about certain habits that you may or may not have. It is important that you be completely honest; all the answers you give will be held in the strictest confidence.
Please consider each item carefully before answering, and then answer by placing the number beside each item that best describes you in relationship to the item. For example, the following item asks about your use of exercise.”
1. EXERCISE
Use in the last 6-12 months ____
Highest lifetime level of use____
2. SCALE
0 - Zero or very light use
1 - Light use
2 - Moderate use
3 - Moderate to heavy use
4 - Heavy use
5 - Very heavy use
In the example, you would first select the number between 0 and 5 that best describes how much or how often you have exercised during the last 6-12 months. If you did not exercise at all you would, of course, put a 0 beside ‘Use in the last 6-12 months.’ If you used exercise a very great deal, you would enter here a 4 or even a 5.
Next, you would select the number between 0 and 5 which best describes how much you used exercise at that point in your life when you were using it the most. You would place that number after ‘Highest lifetime level of use____”
Please do not omit any item. Be sure to rate each item twice, once for use in the last 6-12 months and once for the time of highest use in your lifetime.
1. Cocaine:
6-12 month use___ Lifetime use___
2. Heroin:
6-12 month use___ Lifetime use___
4. Amphetamine or similar “pep” pills:
6-12 month use___ Lifetime use___
4. Morphine or related opium-like drugs:
6-12 month use___ Lifetime use___
5. Gambling for money:
6-12 month use___ Lifetime use___
6. Marijuana:
6-12 month use___ Lifetime use___
7. Pipe, cigar, cigarette, snuff, or chewing tobacco:
6-12 month use___ Lifetime use___
8. Alcohol; beer, wine, liquor, whiskey, etc.:
6-12 month use___ Lifetime use___
9. Barbiturates and similar sedative drugs:
6-12 month use___ Lifetime use___
10. Hallucinogenic drugs (LSD, PCP, mescaline, etc.):
6-12 month use___ Lifetime use___
11. Caffeine (tea, coffee, cola beverages, etc.):
6-12 month use___ Lifetime use___
12. Stealing, shoplifting, petty theft, etc.:
6-12 month use___ Lifetime use___
13. Sugar-based foods (candy, baked goods, ice cream, etc.):
6-12 month use___ Lifetime use___
14. Fatty, oily or greasy foods:
6-12 month use____ Lifetime use___
15. Salt from the shaker and/or salty foods:
6-12 month use____ Lifetime use___
16. Highly seasoned or spicy foods:
6-12 month use____ Lifetime use___
17. Spending just for the sake of spending:
6-12 month use____ Lifetime use___
18. Work for the sake of being busy:
6-12 month use____ Lifetime use___
19. Anger, fights and arguments:
6-12 month use____ Lifetime use___
20. Trying to manipulate and/or control other people:
6-12 month use____ Lifetime use___
21. Trying to get attention for attention’s sake:
6-12 month use____ Lifetime use___
22. Reading for reading’s sake:
6-12 month use____ Lifetime use___
23. Trying to get others for care for me and do things for me:
6-12 month use____ Lifetime use___
24. Exercise, jogging, playing sports or working out:
6-12 month use____ Lifetime use___
25. Seeking and having sex with another person:
6-12 month use____ Lifetime use___
26. Seeking and using pornography (sexually oriented pictures, books, etc.):
6-12 month use____ Lifetime use___
27. Watching television:
6-12 month use____ Lifetime use___
28. Talking for talking’s sake:
6-12 month use____ Lifetime use___
29. Searching for, buying, and collecting certain items:
6-12 month use____ Lifetime use___
30. Lying (for no good reason):
6-12 month use____ Lifetime use___
31. Aspirin or other non-prescription pain medications:
6-12 month use____ Lifetime use___
32. Controlled (prescription only) pain medications:
6-12 month use____ Lifetime use___
33. Laxatives:
6-12 month use____ Lifetime use___
34. Nasal decongestant sprays and inhalants:
6-12 month use____ Lifetime use___
35. Antihistamine pills or other decongestant pills:
6-12 month use____ Lifetime use___
36. Antacids, stomach remedies:
6-12 month use____ Lifetime use___
37 Fast and/or reckless driving (not including driving under the influence):
6-12 month use____ Lifetime use___
38. Valium, Librium and related ‘minor tranquilizers:’
6-12 month use____ Lifetime use___
39. Physical violence:
6-12 month use____ Lifetime use___
40. Cough and/or cold medications:
6-12 month use____ Lifetime use___
41. Religious activity:
6-12 month use____ Lifetime use___
***
Alcoholics Anonymous had started this process, by asking for a moral inventory in their Step Four. Gamblers Anonymous had inserted a second request, for a financial inventory. And now I had seen a need to take an inventory of all addictive behaviors. I do not place my own thinking above that of the groups mentioned; this was just a part of our treatment philosophy.
I think it can be argued that the term moral includes areas such as financial honesty and self-destructive addictions. Moral is an extremely general word. Our morals, whatever they are, pervade all aspects of living. Sometimes our moral principles are consciously selected, but we also accumulate values and attitudes pretty much by accident as we grow up. In terms of a moral inventory, however, financial misdeeds are only part of the larger picture, as are disorders of appetite.
My concern with multiple addictions as a focus of treatment led me back to the difficult questions about the meaning of morality, about how one picks a moral standard, and how one changes personal standards that have not worked well in the past. And concern with morality lead back to questions of spirituality. Do treatment professionals have a right to define and teach a moral standard, let alone a spiritual one?
There are some professionals who say we should leave moral and spiritual questions alone. Once the gambler or alcoholic has begun a program of recovery, these critics claim, he or she will find the correct moral pathway. This sounds familiar; it sounds like the thinking of mental health people who said that with insight and self-understanding the addictions would fall away.
However, from everything I had learned, the beginning of sobriety or of clean time was only the start of recovery. It was only the opportunity to get on with the personal growth and development that addiction had arrested and prevented.
And it seems to me one of the most powerful tools we can find for personal growth is AA’s original version of Step Four: Made a searching and fearless moral inventory of ourselves.
For years I had required all patients entering treatment to write out an autobiography, as preparation for more work at a higher level, on moral principles.
The task of doing a moral inventory is frequently honored more by lip than deed. Some members of Gamblers Anonymous work the steps by reading them at every meeting, and perhaps by thinking about them from time to time. But I am impressed by the old tradition that insists you take pen in hand and, over a period of weeks or months, actually write out an inventory of character and personality. When this inventory is finished, it is given to a trusted confidant, a sponsor, spiritual leader, or other person whose love and judgment one has learned to accept. Then the inventory is discussed, questioned, and sometimes either rewritten or expanded. This is very hard work, and is best done in the privacy of the one-to-one relationship.
Finally, when the writer and sponsor feel satisfied, the inventory is burned, as a lesson in humility. Then the habit of daily inventory is begun, under the sponsor’s supervision. This is a classic moral inventory of character defects, a kind of spiritual rebirth that frequently seems to be ignored or done too hastily.
Flinging humility to the winds, a number of ex-gamblers have actually published their life stories for commercial profit. In my opinion this is a very poor idea, and I cannot say strongly enough how foolish I think it is.
The inventory of appetites, like the financial inventory, may need to be developed and acted upon over a very long period of time. Is it really reasonable to take stock of moral and spiritual needs while ignoring physical desires, those appetites to which we are likely become subservient if they are neglected? Is it possible to grow along spiritual lines if we are not in touch with the material addictions that drive our lives in an endless series of cycles? I think not. These other appetites, like the urge to gamble, wash us back and forth on violent waves from desire to satisfaction.
Putting life in order must mean calming the entire sea of appetite. Can anyone put down any particular wave if the condition of the entire ocean is ignored? This is a question I love to raise in any group of clients with a little clean time behind them. It is often a very unpopular subject. It always stirs up a discussion. But I think that self-help groups, just like professional treatment programs, will never achieve their potential until they address the problem of multiple addictions.
“Doc, I just want to quit gambling. I don’t want to be a saint or a goodie-two-shoes.”
“I know you’re in no danger of becoming a saint, and what the hell is a goodie-two-shoes, anyway?” I ask. “Sainthood isn’t the goal of anybody who becomes a saint. What is your goal, really?”
“But they told me that if I just quit gambling life would get better, that things could go on pretty much like always.”
“Hear me, friend,” I respond. “If you do it right, life will never be the same again. If you really understand and work the program offered to you, what you used to think was important will seem trivial and stupid.”
“Give me a little time before you start harping about my other habits. I’ll get around to them eventually.”
“How much time do you need? A year? Maybe you need 10 years, like Homer over there who’s been coming to Gamblers Anonymous half drunk ever since he quit the dice tables. Don’t do it for me. Set yourself a time schedule and get a sponsor to work with you. Join other groups if you have to.”
“Jeez, Doc, what does a person have to do to quit for good and do this spiritual thing?”
“Whatever it takes,” is my only answer. “Addiction is a radical illness and it takes a radical, self-imposed cure. If you want to avoid a relapse and learn a new way of living you will do whatever it takes. You will go to any lengths, and pay any price.”
Back in 1961, I started working with an organization called TOPS, which stands for Take Off Pounds Sensibly. I was a skinny smoker, fresh out of graduate school. Another psychologist and I met weekly with members of two TOPS groups in Cleveland, Ohio. All the members were female.
Almost all the women were middle aged, and took care of a home and children. After working with these ladies for 10 weeks I realized why real change would probably be impossible for any of them. One task I gave them was to list their three most interesting personal activities or hobbies. One lady said she loved to play the organ, but it disturbed the kids and her husband. She could not practice regularly, and could not be spared from the home to attend meetings with other musicians. Another lady said she was an artist and had sold pictures, but now her studio was her husband’s home office. Besides, with kids to feed, the paints were too expensive.
Most said there was no time for regular exercise. They said they had to cook the foods their families liked, and they felt out of place eating diet meals that were different from the food they prepared for the family.
On and on it went, with reason after reason why these unfortunate women could not change anything about their lives. They were prisoners of their own values and beliefs. Could they change their bodies if they did not change their lives? I thought not. Certainly, they experienced enormous pressure to lose weight; sometimes the family was actually cruel in its treatment of the overweight mother. They were desperate to lose weight, but were locked into a lifestyle of their own creation. And they experienced enormous pressure to stay in the wife-mother-homemaker role while not making any waves in the family. The longer they did that, the fewer the options for change they could see, and the more desperate they became.
For these women, the most foolish demand in the world was, “Leave everything just the way it is, but lose the weight.”
What are some of the prices people have paid to avoid a relapse into addiction, and embark on a program of spiritual growth? Getting divorced. Changing jobs. Changing names. Leaving home. Ignoring the pressure from others to stay the same. Returning to school. Joining a religious cult. Whatever it takes! Those who avoid a relapse and have a quality recovery are willing to pay any price, and go to any lengths. It’s that simple. Compromise with an addiction always fails.
If you make the big, tough, life-changing decisions, then the smaller decisions such as eating less or getting more exercise become far more probable. The decision to stop gambling is actually a small one, compared to dealing with the much more basic problems that create the fertile soil of unhappiness in which an addiction can grow. Gambling is the visible problem, the tip of the iceberg. Good therapy should help in seeing the more fundamental problems.
Addiction is a radical illness. You can’t argue with it, and you can’t compromise with it. The AA program advises, “Half measures will avail you naught.” I agree. If you want to recover from an addiction, be willing to pay any price and go to any lengths.
“I came here for my alcohol (or gambling, or drug) problem, and you’re asking me to give up everything.” The patient then proceeds to assure me that if he or she tries to give up their other vices they will (a) have to go back to drinking (or gambling, or drugs); (b) have to commit suicide and get the misery over; (c) be bored to death; or (d) become so damn good they couldn’t stand themselves.
I then tell them about choice (e), the possibility that staying sober is increased, not decreased, with every new evidence of increasing self-control in other areas. Alcoholics and gamblers are very good at protecting their other addictions with rational-sounding arguments, but we must believe that protecting any addiction is never rational, and never helpful.
Members of Gamblers Anonymous are self-identified as gamblers. But, like millions of Americans, they share a host of other addictions that, until identified as problems, continue to undermine spiritual, social, and personal growth. It is not my business to take anyone’s personal inventory. I have, however, given folks a good shopping list, and in doing so have run the risks of getting people perfectly furious. If someone does get mad, it may be because he or she is taking an inventory of the person they know best. It’s not easy.
Possibly, you will find anger listed on your inventory when you take a general inventory of character defects. If you are a gambler, please remember the awful resentment you felt when someone first suggested that you ought to stop gambling. The things we most resent giving up are usually the things we most need to give up. Let resentment work for you as your measuring rod. Let it judge the need for change. If someone makes a suggestion you resent, it may be an idea you need to fall in love with.
The co-founder of Alcoholics Anonymous, Bill Wilson, tells us that alcoholism is a threefold disease; spiritual, mental, and physical. Somehow, gamblers seem to have the idea that compulsive gambling is not a physical problem. They look down on the alcoholic for the way he is killing his physical body, and most gamblers are sure they can control their drinking or other appetites.
In suggesting an inventory of appetites, I hope to extend the focus to the quality of physical existence upon which all higher forms of existence in this world are based. Through the hospitals in which I worked passed some of the most abused bodies imaginable, the bodies of terminal-stage compulsive gamblers. The ravages of self-neglect and over-indulgence were everywhere to be seen in their medical records. With amazing regularity, we saw obesity, dental decay, poor nutrition, alcohol abuse, tobacco-related respiratory problems, and habitual drug abuse. We also saw the ravages of stress in older gamblers, which included serious stomach, heart, circulatory, and skin problems. And the chances of cross-addiction or poly-addiction either before, during, or after a period of compulsive gambling are higher for gamblers than for the general population.
For a long time we gave each incoming gambler a self-administered stress response checklist, which contained many physical signs of life stress. Most gamblers had high scores, and most responded favorably to our daily relaxation training classes. Older patients, mostly men over 45, almost always had one or more stress-related physical illnesses that required treatment in our specialized medical clinics.
Gamblers nearly always want us to say that gambling is an illness, a sickness, or a disease. Let’s go even further. Pathological gambling is a fatal, progressive illness that, left to develop, kills its victims 10 to 15 years before the time predicted by life expectancy tables. No one has collected death rate statistics on compulsive gamblers, but this is my projection based on the clinical evidence I saw.
Along with recovery from gambling must go strong efforts to relieve the life stress caused by multiple and cross-addictions, a life stress that seems to make abstinence from gambling a very chancy, white-knuckle kind of sobriety.
If recovery is ever to become a spiritual experience, if it is to be fully rewarding, the individual must work on all the monkeys sitting on his or her back. My Consumer Lifestyle Index turned out to be a very good shopping list. One may grunt in disgust at first when it steps on a sensitive toe, but maybe it can plant a seed. Members of Gamblers Anonymous are, after all, self-admitted good candidates for growth and change. Everyone in that organization, by virtue of his or her presence, has the courage to face a major life problem and try to do something about it. I am speaking with equal fervor to Gam-Anon members. Marriage partners often have rather similar personalities, and although gambling may not be a problem for a spouse, some kind of dependency is likely to be found. So if you are sensitive and fear being accused of having a variety of different dependencies, you may find something to anger you.
Addictions and dependencies are so varied and so common that I call many of them household addictions. They have been a part of our human culture from the beginning, and we love and cherish them. Below are some common ones.
Drug Abuse: Aspirin and antihistamines are possibly the most commonly overused drugs because we have come to believe that for every problem there is a pill to take, and also because they are cheap, available, and effective. Valium, prescribed for anxiety, doesn’t cure anything; it is at best a temporary crutch, and is highly addictive. Yet millions of prescriptions for Valium and related compounds are still written every year. The list of abused legal drugs is enormous. Abuse of over-the-counter drugs is the rule, not the exception. By comparison, street or illegal drugs are a relatively small part of the total drug abuse scene in America today. Drug manufacturing is so lucrative that medical research now focuses heavily on trials of new drugs, and dedicates far less effort to other treatments such as diet, exercise, and workplace safety.
Smoking: Although the per-capita consumption of tobacco continues to drop, smoking and chewing are still the most important preventable causes of early death. It is one of our most serious public health problems, and yet a fellow psychologist pointed out that there few if any inpatient treatment programs for smokers anywhere in this country. Maybe there should be inpatient treatment programs for tobacco dependence; we treat people in hospitals for less dangerous diseases. Yes, nicotine addiction is a disease.
Alcohol: Alcohol is a deadly toxin, a poison consumed in almost every case to alter the drinker’s mood or mind. Thousands of people die on our highways every year from alcohol related accidents, and as tobacco declines in popularity, alcohol competes with smoking as a leading public health problem.
Sugar: Sugar rots your teeth, makes you fat, and sends the body’s hormone systems into fits. Sugar is said by some authorities to cause depression, agitation, and irritability. It’s difficult to avoid, being in many processed foods, and many homemakers tragically add it to foods out of love for their family.
Impulsive spending: Virtually every married gambler I meet thinks his wife is a compulsive spender. Some wives actually are; more than a few learn to spend it before hubby loses it. Gamblers also seem to be impulsively and unproductively generous, always ready to bail each other out of any scrape. They think this constitutes love. Impulsive spending, however, exists in many thousands of people besides gamblers; it seems to be almost a national lifestyle. For some, spending money is another way to get high, or at least combat depression.
Impulsive stealing: Didn’t we all do it as children? It made us feel great to get away with something. Stealing, like all potentially addictive behavior, is childish and immature. The cost of goods in many stores is much inflated because of rampant shoplifting, and some employees make a second job of selling things they steal at work.
Impulsive talking: Give me a podium and you will see that I have something here to work on myself. Impulsive talkers can make you crazy. Their mouths and hence their lives have gone out of control, and the talking seems to help avoid an empty and depressed feeling.
Pyromania: Every little boy loves to burn the leaves, and some who never really grow up go on to bigger things. This is not a very common problem, but it seems to be a real addiction to some.
Helplessness: Impulsive, immature attention-seeking or sympathy-seeking is easily learned and hard to get over, even for many adults. Our health care system has millions of abusers who show up in every emergency room and psychiatric ward in town. They frustrate the efforts of staff and waste money with their learned helplessness, self-indulgent depression, dependency, and simple begging.
Lying: Impulsive, pointless lying is as common as grass, and is at times turned into an art form by leading political figures. Most active compulsive gamblers, and often the spouses who cover for them, become compulsive liars. I’m not all that sure the habit goes away spontaneously when gambling stops.
Aggression: Anger, hostility, and aggression constitute an addictive lifestyle for millions of people. The men impulsively beat their wives, and either or both are capable of breaking the baby’s ribs in a fit of rage. Incidentally, I have known quite a few wife-battered male gamblers. Violent thinking may precede the act. Many a wife harbors the fantasy of her husband dying in a burning racetrack. When a person is furious, the depression fades for a time as the anger energizes and enlivens life once more. But it solves nothing, because when anger is finally spent the individual is again left tired, empty, and hopeless.
Manipulation: Perhaps because they are so good at it, some gamblers are addicted to endless social manipulation. Manipulating your way out of the problems caused by gambling sometimes seems to replace gambling itself as a mood-altering activity. Don’t count on the Twelve Steps to remove manipulation if you don’t view it as a separate and freestanding addiction.
Television: In the average household, the television set is on for up to seven hours every day. In some homes, it is turned off only during sleep, if then. Watching our patients interact with the TV convinced me that it is a true, if minor, addiction. They don’t feel right if a TV set isn’t going, and some will literally watch anything at any time of the day or night.
Reading: Compulsive readers consume an endless series of novels, magazines, tabloids, and even comic books. The compulsive reader’s life is unmanageable when the only way she or he can feel good is to escape into a book. Other people may feel ignored and locked out of the reader’s mind, and indeed, they are.
Pornography: I have seen several cases of gamblers in recovery who were preoccupied with an overwhelming urge to buy, collect, and look at all forms of pornography. I’m talking about thousands of dollars and thousands of hours spent in solitary, guilty pursuit of this obsession. Think what that does for the wife and kids. A pornography obsession is true addictive behavior. For the men with whom I talked, pornography had long since stopped being a source of pleasure; they had become tired of the obsession and full of self-disgust, but they couldn’t let go of it without a special effort. The secrecy had to stop, an admission of powerlessness had to be made, and a program of positive action had to begin.
Religion: We all know at least one born again friend who spends Saturdays terrorizing the suburbs by pounding on doors and preaching salvation. I don’t mind the message; it’s the medium I question. Addiction to religion! Is nothing sacred to the addictive individual?
The list of possible addictions seems endless. I could add nail-biting, thumb-sucking, driving, travel, womanizing, self-exposure, child molesting, voyeurism, going to auctions, doll collecting, chime ringing, lip biting, jaw grinding, lawn tending, self-flagellation, and nit-picking. If you’ve got what it takes personality-wise, and I think we all do at one point or another in life, you can make an addiction of any substance, idea, behavior, or noble cause. I disagree with Robert Glasser, M.D. (a famous psychiatrist who wrote important books that have helped many), who says that we should practice positive addictions such as jogging or work. He failed, I think, to appreciate the real nature of addiction. Nothing followed compulsively or impulsively is worth the pain of the chase.
Depression is closely related to any addictive behavior, and dealing with depression must always be a part of recovery. Dr. Jerome Marmorstein described his basic cure for depression and anxiety in a book titled The Psychometabolic Blues. In 16 years of practicing internal medicine, Dr. Marmorstein saw countless cases of what must be one of the most common sets of symptoms seen in physicians’ offices: frustration, boredom, anxiety, and depression. Millions of Americans seek medical help every year for problems for which there is no strictly medical solution. Here is Dr. Marmorstein’s simple four-step solution to the common mental burnout pattern:
1. Get off the booze. (Even small amounts taken by people who are not alcoholic may be responsible for subtle mood changes, although, of course, we must balance against this the somewhat reduced risk of heart attack and stroke related to limited alcohol intake.)
2. Get off the sugar. (Not just the sugar you add to food, but the sugar added by manufacturers and cooks as well. Read the label, ask questions.)
3. Get off the caffeine. (Check the soft drinks as well as the coffee and tea. A heavy caffeine intake is almost the same as amphetamine abuse.)
4. Take at least one period of good aerobic exercise, such as a long walk, every day. (Rain, snow, wind, cold or heat—every day!)
Attitudes and habits in the public at large have changed for the better in the years since I first put my thoughts on multiple addictions together. But has the gambler changed? In Reno, and everywhere I worked in the federal system, the alcoholics, drug patients, and gamblers coming in for help were very dependent on caffeine and nicotine. Most still disdain moderation in caffeine use, and resist our stop-smoking clinics.
I am sure many of Dr. Marmorstein’s patients believed, as many of us do, that there is a better life through medical chemistry, not through behavior changes. They must have thought he was a nut. They probably walked only far enough to find some other doctor who would provide the chemistry requested. Millions of Americans today are addicted to, or dependent on, physician-prescribed chemical agents that allow them to somehow live with the problems they have not had the courage and counsel to solve. Those who followed Dr. Marmorstein’s good advice were seldom sorry.
I must add that Dr. Marmorstein is not afraid to use medication when he feels there is a chronic biochemical problem or physical cause for depression. But it is obvious to students of the American Way of Addiction that our malaise is generally caused by inactivity and the over-consumption of socially approved toxins. The recommended cure can only be abstinence and systematic exercise.
Where shall we find the motivation to make all these lifestyle changes? Why should we give up all these so-called pleasures of life? Recently I spoke with a man who had a 40-year history of heavy gambling. He had not come to see me of his own accord; he was forced by his wife, a beautiful, strong, intelligent woman. After an hour and a half of talking, he finally came to the realization that there was no way he could continue to gamble and yet live life as he thought it had to be lived. I could literally see him going through the agony of deciding to come into treatment.
Then, after a period of deep silence, this man asked me the bottom line question we all ask when an addiction backs us into a corner. “Doctor, is there any life left for me if I do quit gambling?” Like most terminal stage gamblers, he had been using gambling as an antidepressant, a necessary and life-sustaining tonic in an otherwise totally disorganized life. He found himself staring into a black pit of depression that he felt would kill him. Without help, I felt sure it would. For him, however, it was a turning point, a true vision of his own helplessness. Several weeks of further agonizing followed before he finally entered the gambling treatment program, again brought by his ever-hopeful wife. He had accepted my promise that life without gambling was not only possible, but also potentially rewarding beyond his imagination.
Unfortunately, he left treatment within 24 hours. Abstinence terrorized him. He was one of the most fear-stricken men I have ever seen.
This man had been gambling for so long and with such intensity that the activity had crowded out everything else. Even his business as a broker of construction materials was gambling. He didn’t know how to do anything else. He felt he was nothing if he couldn’t be a gambler.
The addicted person is convinced life will be worthless if the obsession is given up. He or she asks the final question, “Why live if you have to give up everything?” But the motivation we need has nothing to do with wanting to live forever. Even if death comes tomorrow, my ethic says that we must to the right thing today. In my own life, I found it necessary to give up a 22-year-long, two packs per day smoking habit. It took six years of hard mental struggle before I could finally take the Surgeon General’s advice. But I do not abstain today because I fear hastened death, but because nothing could replace the self-respect gained by eliminating one of the monkeys that pulled on the strings of my life.
Sadly, the addicted person cannot see his or her own future free of the addiction. At first, there are only fear and faith to work with, until at last, from a higher perspective, one can look back down at the road traveled. Anyone who has climbed a good mountain hates to leave the summit, and finds that wherever life then takes you, you leave part of your spirit at the top. Having been to the top of the mountain, one returns to an alien tribe in the valley, whose members were once your own people. Abstinence does make you different.
Self-conquest, having nothing to do with the fear of death, likewise need have nothing to do with competition, or with what those around us are doing. The addicted person must somehow stop the endless compulsion to compare herself to others. This competition may give a few joyless victories when she find herself superior in some detail, but the final result will be a severe loss of self-esteem when she inevitably meets a superior.
The desire to be No. 1 is another of those phony dreams created in Hollywood and marketed by our advertising system. The motive to compete compulsively against imagined enemies is not a helpful one, so let’s put competition on our addictions shopping list and go on to better things. Success in a competitive society, I think, comes from doing very well what you love and what you are good at, not from setting out to master the game of competition itself. If you know how to use the freedoms granted in a free society, you will certainly compete well enough. Well enough is good enough.
Having given up gambling, why work on other addictions? If not for fear of early death or from a spirit of competition, what?
I believe that you can’t really beat one addiction effectively or fully unless you are aware of them all, unless you develop plans to work on them all in turn. The will to abstain from one strong addiction will erode with continued practice of substitute and secondary addictions.
So I think we must take daily inventory of all our habits, appetites, and addictions. We must become entirely ready to have them all removed. Beating one addiction gives strength to tackle the next, and giving up the next adds another layer of protection against a relapse in the first.
I know an alcoholic with 20 years of sobriety who still practices white-knuckle abstinence because of his other un-inventoried addictions. A cigarette in one hand, an eternal coffee cup in the other, he speaks his AA wisdom through teeth clenched into a sugar doughnut. His so-called hobby is gambling. It is as if his mind froze 20 years ago when he walked into AA, when he gave up the only life he knew. In some insane way, he is able to think of his other addictions as tools for alcohol sobriety. He wears out the edges of many chairs trying to explain his lifestyle. And everyone around him can see that the emperor is naked.
Slips and relapses among recovering addicted people are so common that I think they must be part of the overall treatment. The sad thing about a slip is not so much the return to gambling as the loss of abstinence. Through abstinence comes strength to resist temptation. Through abstinence, denial and resentment turn to honesty and gratitude. Only through long abstinence is appetite abated. When a long-time abstainer tells me he has an urge to gamble, I believe it is always because in some form or fashion, knowingly or intentionally, he has taken or fallen into some kind of gamble already. Appetite, after all, as Shakespeare knew and as science has shown, does grow with what it feeds upon. This is true for the large group of people for whom moderation is impossible. The more you eat, the more you want. Emotional eating begets more eating, drinking begets drinking, and gambling begets gambling. That’s what addiction is all about.
Addiction begets addiction.
Abstinence begets abstinence.
I suggest that drinking can lead back to gambling; not always, but often enough to suggest great caution with all addictive activities. Even a little drinking could weaken resolve and lead to a lot of gambling; a major alcohol binge would make gambling relapse even more likely.
When abstinence puts the appetite to sleep, we must become fanatics in order to protect its slumber. If one self-imposed abstinence is good, two are better when you go about it in the right way. Fortunately, if we stay close to the Twelve Steps, we are blessed in knowing the right way to deal with all addiction.
Each time we come face to face with a life-controlling addiction, we go through the same cycle of resentment, denial, resolutions to do better, slips, self-reproach, abstinence, growth, and, finally, gratitude and service to others who still suffer. The only risk we run in working on the removal of additional addictions is that we may have a hard time telling our friends about our growing gratitude, strength, and self-respect. The humility acquired in the process sometimes gets in the way of sharing.
The severely addicted person often cannot see any future beyond the daily service of the addiction. One must work at first on faith alone in the decision to give up any addiction. That’s why surrender and obedience are necessary, and why these must always come before the development of true self-discipline.
An addiction-free life is not only possible, but also beautiful, exciting, and challenging. It may well be the ultimate high, although it is certainly not intoxication. Any lesser goal is unworthy of us. But we must believe this today on faith alone, and this is terribly difficult when we think we have so much to gain from the pleasures of the moment. Addicted people always say, “Show me and I will believe.” The only answer we can give is to have faith, let hope lead you to abstinence, and then understanding and insight beyond your dreams will come.