Licensed Pushers

The opiates that killed Jaclyn Kinkade were not trafficked by the Mexican or Colombian drug cartels. They were prescribed by duly licensed professionals, distributed by duly licensed pharmacies and produced by reputable pharmaceutical manufacturers.

In some cases, I believe, the expense was covered by health insurance. We’re a compassionate people, after all.

One sees the value in the libertarian position that narcotics should be legalized, but, truth be told, they already are.

The Wall Street Journal reports this morning on the epidemic abuse of prescription drugs, most especially painkillers:

The U.S. spends around $15 billion a year fighting illegal drugs, often on foreign soil. But America's deadliest drug epidemic begins and ends at home. More than 15,000 Americans now die annually after overdosing on prescription painkillers called opioids, according to the Centers for Disease Control and Prevention—more than from heroin, cocaine and all other illegal drugs combined.

Rising opioid abuse means that drug overdoses are now the single largest cause of accidental death in America. They surpassed traffic accidents in 2009, the most recent CDC data available.

Paradoxically, the legality of prescription painkillers makes their abuse harder to tackle. There is no Pablo Escobar to capture or kill. Authorities must contend with an influential lobby of industry representatives and doctors who argue against more restrictions, saying they would harm legitimate patients. And lawmakers have been reluctant to have the federal government track Americans' prescriptions, leaving states to piece together a patchy, fragmented response.

The problem does not just involve painkillers. Who can forget Barbara Gordon’s memoir of her Valium addiction: I’m Dancing As Fast As I Can.

And then there was Elizabeth Wurtzel’s story of her Ritalin addiction: More, Now, Again: A Memoir of Addiction.

When it comes to painkillers the authorities are on the case. They have been prosecuting many of Kinkade’s licensed pushers.

One doubts that very many physicians have been held to account for overprescribing Valium.

For her part Wurtzel did not, as I recollect, have any especially negative feelings toward the physician who kept writing her prescriptions, often without seeing her in person.

Most internists refuse to prescribe painkillers except in extreme cases. Another class of physicians, specializing in pain management is clearly more expert and, the Journal article suggests, less scrupulous. 

Gordon got her Valium from a psychiatrist. Wurtzel got her Ritalin from a psychiatrist.

One appreciates the difficulties that a physician faces. When a Jaclyn Kinkade insists that she is suffering from severe back pain, even when tests show that nothing wrong with her back, what is a physician to do?

Addicts are very persuasive. They are exceptionally good liars. Unless a physician has superhuman perceptual powers, he will have a great deal of difficult telling the difference between a drug addict and someone who is really in pain.

Then again, drug addicts are often in pain. They can be in pain from withdrawal; they might even be suffering psychological pain.

Jaclyn Kinkade was also prescribed psychotropic medication.

People who are depressed often report that they are in agony. Theirs is mental anguish. It is more difficult to treat and to understand than physical pain.

Also, when physicians hand out opioid medications, patients might conclude that taking them is safe. A physician writing a prescription validates the act of taking drugs. It removes the stigma, removes the sin and makes it a part of normal everyday life.

And then there is the culture. Our culture holds it as an article of faith that there is a pill for whatever that ails you. We live in a culture that has a pill for every pain, whether physical or mental.

As a nation we are suffering from what they used to call the sin of sloth.

Sometimes we call it leisure; sometimes we call it laziness.  We believe that we have a god-given right to benefit the most from from the least effort.

If a patient suffering from depression is given a choice between managing his condition by engaging in regular aerobic exercise or else by taking a pill, which one will he choose?

If he takes a pill and it works for a while, he will come to believe that his problems are biochemical and there is nothing he can do beyond taking pills.

If the pills cease to work there are always other pills…

Has Shame Lost Its Sting?

It's one thing to ask why we are so interested in scandal. Following Laura Kipnis I did it two weeks ago. Link here.

It's quite a different thing to ask what happens to the culture when scandal becomes a staple of everyone's mental diet, and what we should do when it does.

Laura Kipnis addresses those questions today, as part of her abbreviated presentation of her book: How to Become a Scandal: Adventures in Bad Behavior. Link to her new essay here.

Given the new media, and especially given the prevalence of social media, the chances for public exposure and humiliation have been multiplying.

Aspects of personal life that would never have been revealed have become subjects of everyday conversation. Images that were reserved for intimate moments are on public view on the internet.

We have, as a result, become desensitized to scandal. When a major public figure like Pres. Bill Clinton is caught with his pants down, we express appropriate horror and then quickly forgive him his indiscretion. Within two years of the Lewinsky scandal Bill Clinton was back on top of the world.

Kipnis argues that we are fast losing our sense of shame, and since shame is the emotion that regulates the distinction between what is fit for public consumption and what must always remain private, the boundary between public and private is disappearing.


I consider her point well taken, though there are also some counterexamples that are worthy of attention. Bill Clinton might have overcome his personal scandal, but, by all reports, Monica Lewinsky has not.

Kipnis does not seem to be concerned about it, but when you break down the barrier between public and private, when you allow private matters to seep over into public interactions, you are going to undermine decorum and propriety, making it more difficult, if not impossible, to function with a harmonious community.

How can people deal with the culture's loss of a sense of the importance of shame. Many people have tried to pretend that exposure is no big deal. The prevalence of confessional memoirs and high school sexting tells us that many people are trying to reduce the shame attendant on overexposure by inducing more people to expose more of their private life.

Shame isolates and ostracizes and rejects people. If everyone is doing the same thing, if everyone is equally exposed, then there will be less of a feeling of being a pariah.

Kipnis also recommends that we deal with this situation by becoming addicted to scandal. I suppose that this is a variant on the addiction to pornography, pornoholism.

I imagine that she is being provocative by using the word addiction, but my own observations of addicts would not lead me to recommend that anyone become addicted to anything.

We can revel in bad behavior, especially the bad behavior of others, and feel that we have just found a new and innocent diversion. And yet, the more we enjoy bad behavior, the more entertaining we find it, the more people will be induced and enticed to behave badly. The more people behave badly the more dysfunctional society will become.

You cannot run a business or a family if you are constantly distracted from the task at hand by the latest scandal. Such addictive preoccupations are anything but economical. They are, dare I say, decadent. And decadent cultures, as much fun as they must be, end being poorer for as much.

If shame has lost its sting, the reason must be that we have become numbed to it. For all the thrills we gain from each day's new scandal, it is not necessarily a good thing to dull the emotional barometer that tells you when you have been offended or demeaned, or when you have simply done wrong or failed.

If you are sensitized to insult you can address one the first time it happens. If you are desensitized, you will be absorbing a serious amount of abuse before you start feeling emotional pain. By then you will no longer be able to respond temperately, but will feel compelled to seek justice for a pattern of abuse.

And this same shame, when it is functioning correctly, will also  tell you when you have made a mistake, when you have gone astray, when you have failed yourself or others. No shame, no feelings of having failed. No feelings of having failed, an excessive confidence, even an arrogance, about your own abilities.

You may think that there is something good about overcoming shame, because shame is the most painful emotion, and we do want to protect people from pain. Yet, toying with human nature is usually a bad idea.

When people have lost their sense of shame they behave more rudely, they will insult you with impunity, will abuse you and invade your privacy, and will feel that they have a right to be offensive, vulgar, and generally disrespectful.

People will no longer get along; they will act out psychodramas. Their lives will be consumed in the passions that are provoked by bad behavior.

In a culture that extols bad behavior work does not get done, people do not have satisfying relationships-- either friendly or erotic-- and they do not know how to cooperate, collaborate, or live harmoniously in community.

If shame regulates behavior; if it promotes good behavior and shows how to deal with bad behavior to ensure that it be less likely to be repeated, what happens when we lose our sense of shame? How are we to know good from bad behavior, right from wrong, what we should do and what we shouldn't even think of doing?

If shame does not work, then a culture will fall back on guilt as a regulator. If it no longer makes sense to ostracize people-- that being the primary sanction in a shame culture-- then we will have to punish them when they misbehave.

Many people find the guilt/punishment model more liberating than the shaming model. As a culture we only punish the most grievous transgressions. A guilt culture will punish you for committing grand larceny; a shame culture will shame you for being rude and disrespectful, and sometimes, even for looking or acting strange.

Even though a guilt culture tolerates more bad behavior, it also produces a dysfunctional social environment.

But what happens in a guilt culture when people misbehave, insult and offend and abuse their neighbors? These are not crimes; they do not do not gain you a place in the local penitentiary.

The culture deals with them by filing lawsuits. Bad behavior is regulated through the system of tort law. When a simple apology will not do, when a pledge not to offend again does not cut it, people decide that they can only gain justice by suing, thus, punishing the offending party-- not by taking his time or his hand or his life-- but by taking his money or his property.

How Does Alcoholics Anonymous Work?

Brandon Koerner's excellent article in Wired is entitled: "The Secret of AA: After 75 Years We Don't Know How It Works." Link here. But as he wisely notes, for many people the important thing is not knowing how it works, but knowing that it works. And that it works better than anything else currently on the market.

David Brooks picked up on Koerner's article and offered some good commentary in his column today. Link here. I will also mention that I have discussed this topic in a previous post. Link here.

As a treatment method, 12 step programs are an anomaly. They are effective in treating what we consider to be a medical problem, but they were invented by people who had no training in medicine or psychology. They do not insist on laboratory-like conformity to a specific procedure, but allow different groups to introduce their own modifications. They do not cost anything, and they are completely unregulated by government.

Members of AA groups have sponsors, but you do not need to have any credential to become a sponsor. Those who lead AA meetings do not have to be licensed professionals.

Many trained and licensed therapists are queasy about this exercise in human freedom. Understandingly, they do not like to compete with an alternative that costs nothing, and that, by all indications, works better than what they are offering. They have often warned of the cult-like atmosphere surrounding AA and have decried the absence of licensed professionals.

As Koerner writes: "Addiction-medicine specialists often raise the concern that AA meetings aren't led by professionals. But there is evidence that this may actually help foster a sense of intimacy between members, since the fundamental AA relationship is between fellow alcoholics rather than between alcoholics and the therapist. Those close social bonds allow members to slowly learn how to connect to others without the lubricating effects of alcohol."

With the exception of those alcoholics who are ordered by courts to attend 12 step programs, most who attend meetings are there voluntarily. People are anonymous; they are free to come and go; they can follow the 12 steps or ignore them.

For these, and many other reasons, it is very difficult to determine how well and how consistently the programs work. And yet, as Koerner suggests, most therapists who work with addicts are persuaded that they do work and that they provide a vital service.

Strangely enough, 12 step programs feel like the untherapy. Had Bill Wilson and Bob Smith set out to offer a perfect rebuke to psychotherapy, they could not have done a better job. As Brooks adds, they also repudiate the value system that forms the basis of our therapy culture.

Where modern psychotherapist believed they were inventing a grand theoretical construct, Wilson and Smith had a single criterion for AA: whether or not it worked. As long as it did, people did not much feel the need to ask how it worked.

As Koerner notes, other forms of contemporary therapy, especially those that are based in cognitive psychology or that are solution focused, have also produced positive results with alcoholics and other addicts. And yet, he adds, AA still works better.

No one is still pretending that old style psychotherapy, the kind that involves searching into the root causes of your problems, uncovering your miserable childhood and your repressed traumas, provides an effective treatment for addictive disorders.

Yet, this old form of psychotherapy still survives as a potent cultural phenomenon. Even there, David Brooks notes, AA rejects therapy culture values: "... in a culture that thinks of itself as individualistic, A.A. relies on fellowship. The general idea is that people aren't really captains of their own ship. Successful members become deeply intertwined with one another-- learning, sharing, suffering and mentoring one another. Individual repair is a social effort."

Psychotherapies that try to make you an independent, autonomous, self-sufficient individual fail to acknowledge you as a social being. If they derive from Freud, they do not even allow you to form a connection with the therapist. AA, however, is all about fellowship, about connecting with other people.

In Koerner's words: "To begin with, there is evidence that a big part of AA's effectiveness may have nothing to do with the actual steps. It may derive from something more fundamental: the power of the group. Psychologists have long known that one of the best way to change human behavior is to gather people with similar problems into groups, rather than treat them individually.

AA deviates from old style therapy for not being a mind-over-matter, ego-over-instincts method. If anything it begins by telling the alcoholic that his ego will never be strong enough to control his addiction. Thus, only a higher power, a force greater than his individual will, must be invoked and involved in the treatment.

As Brooks says: "In a culture that generally celebrates empowerment and self-esteem, A.A. begins with disempowerment. The goal is to get people to gain control over their lives, but it all begins with an act of surrender and an admission of weakness."

Rather than seeking to empower the mind or the ego, AA works to involve people in a program, a set of steps, a set of new behaviors, that will hopefully show the way toward a new way to socialize.

Nowadays scientists and physicians are hard at working trying to figure out how AA works. And they have made considerable progress toward understanding the way the different steps influence brain chemistry. Yet, their research has not produced a better or more effective treatment.

In Koerner's words: "What we do know,however, is that despite all we've learned over the past few decades about psychology, neurology, and human behavior, contemporary medicine has yet to devise anything that works markedly better."

Should We Blame the Technology?

Is alcohol responsible for alcoholism? Scientists know what alcohol does to your brain. Will this knowledge deter alcoholics? Does it relieve them of responsibility for their behavior?

No serious person suggests that alcohol is responsible for alcoholism. Blaming alcohol is the way into alcoholism, not the way out.

Responsibility is not a scientific issue. But when science encroaches into ethics, it can very easily mislead.

Often enough, research into addiction makes people feel utterly powerless to fight against it, or even to control it. If that is true, wouldn't it be logical just to give in to it?

The same line of reasoning applies to recent articles about internet addiction. We read about people who are hooked up to email, Facebook Twitter, texting and the like as though they were on an intravenous opiate drip.

They can't live with it; and they can't live without it.

In yesterday's New York Times Matt Richtel described a family, the Campbell family, that, by all appearances, is hooked on electronic gadgets and social media. Link here. Richtel's long and detailed account of how these gadgets have taken over the life of this family should certainly sound a cautionary note.

According to scientists, these Steve Jobs-produced gadgets elicit something that they call "a dopamine squirt" that is positively addictive.

One can only stand back and marvel at the imagination of the scientific mind!

I am not going to belabor the by-now old idea that Steve Jobs is an incarnate devil luring us all to emotional and intellectual ruin.

I prefer looking at another concept that Richtel engages: multitasking. I have already expressed by thoughts about why multitasking is a bad idea, here and here.

Today I want to emphasize how cultural values lure people into addictive behavior. When the culture decides, for example, that multitasking is a desirable, it induces people to believe that if they can multitask-- bouncing between Facebook and Twitter and email in split seconds-- they are enhancing their productivity and creativity.

The culture transmits ethical values. When it tells you that it is a good to do several things at once, you are more likely to try to reorganize your life to correspond to this new principle. If it seems to be making you distracted and disconnected, well then, the only conclusion must be that you do not multitask enough.

One other reason causes you to persist in this most modern form of multitasking: it produces repeated "dopamine squirts," and thus becomes addictive.

But as Richtel points out, multitasking makes distraction into a way of life, causes people to lose focus, and produces fragmented thought patterns.

Unfortunately, multitasking also feels good. And the culture has for quite some time taught us that: If it feels good, do it.

How can something that feels good be bad for you? Well it can, and addictive behaviors must have been invented to ensure that when we grow up we put away notions like: If it feels good, do it.

Of course, you do not need high technology and social media to get addicted to fragmented thinking and incoherent sentences. You could have learned as much by doing psychoanalysis and learning how to free associate. Call it a low-tech addiction.

For those of who trained in psychoanalysis in Paris way back when, the idea that free association is addictive is not news. The French analysts did not exactly use that word, but that was their sense of it.

Free association is an acquired skill. Given that it is socially dysfunctional behavior precious few people have an instinctive ability to say whatever comes to mind, regardless of its relevance or the effect it might produce on a listener.

When a patient wants to show his analyst that he is learning how to free associate, he starts speaking in thought fragments, jumping around from one topic to another, throwing in an occasional bizarrely disconnected. Ah yes, talking about my girlfriend made me think of a walrus!

It is all supposed to lead to Ah! Ha! moments, moments where it all becomes clear, where it all makes sense, and where it all proves that Freud was right. Amazingly, this was theorized before scientists had discovered "dopamine squirts."

If you want to know why some people spend so many years in psychoanalysis-- in the old days I knew a number of people who had had more than 20 years of analysis-- and why they need to see their analysts every day, why they even like doing it every day, and why some of them go into withdrawal when they terminate treatment, then perhaps the reason is that free association is like an addictive drug.

The Tiger Woods Saga: Feminism Weighs In

No one has ever accused me of being a feminist. Perhaps I have been gender-disqualified, or perhaps the phrase "male feminist" feels too much like an oxymoron for anyone to embrace it willingly.

Even if I were offered honorary membership is what looks to me like a cult, I would respectfully refuse. Feminism is an ideology; its cause is the propagation of its own ideas.

As best as I can tell as a self-defined outsider, feminist ideology is founded on a fundamental category error. Feminism is blind to the distinction between equal and identical.

No serious individual would disagree with the notion that women should have equal rights and equal opportunities. To go from there to believing that men and women are really the same thing, and that they will become the same thing once we have overcome the patriarchal repression that has set up artificial gender roles... is an error.

Unfortunately, it is a fundamental error.

Far too often I have seen mixed-gender relationships undermined because one of the partners decides that both should have exactly the same roles. No one seems to have noticed or seems to care about the fact that the division of labor makes for a more efficient and harmonious household.

Assuming, that is, that feminism really wants to produce more harmonious relationships. I suspect that it does not.

Relationship harmony requires each party to accommodate gender difference. Pretending that men and women are all the same gives each party a way out of accommodation and a way into drama. If you don't believe me, try it.

But it is not all one-sided.

Prof. Henry Higgins in "My Fair Lady" wondered out loud why women cannot be more like men. Today's feminists are less tolerant than Higgins. They insist that men be more like women, that they get in touch with their feminine sides, and that they become metrosexuals. If it happens that women are not especially attracted to these omega male types, then that is surely a sign that the culture has not evolved beyond gender differences and gender prejudice.

Truth be told, anyone who believes the the two genders are identical or the same is suffering from what the clinicians call narcissism.

If you believe that when you look in your lover's eyes you should feel like you are looking in a mirror, if you believe that whatever you do he or she should do, then you are indulging a narcissistic misunderstanding of human relationships.

Excuse this rather long preamble to my comments on a recent feminist text on the Tiger Woods saga. Link here. Written by Hanna Rosin it purports to present us with the latest in feministically-correct thinking about Tiger Woods. As the French would say: il ne nous manquait que cela. Rough translation: just what we needed.

According to Rosin, calling men sex addicts is a victory for feminism, regardless of whether it is a valid diagnosis and regardless of whether it is true.

Since women have been labeled promiscuous and nymphomaniacs, Rosin considers it a good thing that men who fool around too much have their own psychiatric diagnosis. How else can we show that these men are really sick? How else can we shame them?

We will not even get into the great debate about how much is too much? And we will pass over the obvious point that what is too much for a woman might not be too much for a man.

Making our way through Rosin's muddled thought is no small task. Perhaps nymphomania was a psychiatric classification in the 19th century; it is surely not part of the DSM IV. And since when is a psychiatric classification used to shame people? Should people be shamed for suffering from an illness?

And keep in mind, that in everyday parlance, terms like promiscuous, slut, tramp and the like, when used to describe the sexual behavior of women ... are most often uttered by women. It is women who stigmatize promiscuity, not men.

Amazingly, Rosin declares that she is thrilled that "predatory" men can now be called promiscuous. In her fantasies, perhaps. In reality, surely not.

She believes that the term promiscuous had henceforth been used to describe hysterical women... which is not true.

Besides, she is committing an unconscionable slander when she conflates promiscuity with being a predator. In our culture sexual predators are rapists and pedophiles. A man who calls up a prostitute or two for an evening's romp is not preying on anyone. He is paying for their services. A man who takes up the offer of a young woman who throws herself at him and offers her sexual favors is not preying on her. He is being kind enough not to reject her.

These distinctions make a considerable difference. If you miss them you are wearing ideological blinders, and cannot see reality for your obscurantist mythology.

After all that, Rosin concedes that according to the standards that define sex addiction, Tiger Woods does not seem to qualify.

Does it matter? Not to Hanna Rosin. Woods is a man; he cheated on his wife; he deserves to be punished. Being called a sex addict shames him. The monk-like existence that he is enduring in Mississippi might help him to get in touch with his feminine side.

So, sex addiction is a good thing because, from a feminist perspective, it offers yet another way to humiliate men.

But Tiger Woods might not have been a sex addict. From a feminist perspective it does not matter, because we do not want to miss the opportunity to punish him.

Even though Tiger Woods might not be a sex addict, it is good, from a feminist perspective, that he be treated for it anyway.

As I said, this is an extraordinary muddle, enacting an adolescent revenge fantasy against men.

From Rosin's perspective the important point, expressed as a subtitle, is that: "sex addiction is victory for feminism."

Of course, you might read this subtitle to say that when a man becomes a sex addict it is a victory for feminism... which does not make a lot of sense.

More likely, Rosin means that the diagnostic category of sex addiction, which is not in the DSM IV, is a good thing because it allows women to humiliate men. One man's pain, one man's humiliation, one family's hard times... all the suffering is redeemed because it is a victory for feminism.

Is it a victory over sexual difference? Is it a victory for ideology over human nature? Or is it a victory for a culturally-induced gender dysphoria?

Feminism gains at the expense of men, but also, by extension, at the expense of the women and children who love them or are related to them. As I said, this is about ideology, about propagating ideas, regardless of the effects on real people.

Nowhere does Rosin show any willingness to accept the intuitively obvious point that male and female sexual behavior are not the same thing. And we haven't even gotten to the question of the sex drive of alpha males. Where is Darwin when we need him?

And since Rosin wants Tiger Woods to be punished, to do penance in a monk-like facility, she seems to know nothing of reality of the sex rehab program. When she says that sex rehab does not even allow a hint of sex she is demonstrating a woeful ignorance.

As I mentioned in my previous post on the topic (link here), sex addiction rehab involves talking about sexual experiences. Since this runs the risk of exciting and arousing the participants, the groups has a safe word that any member can pronounce to stop the description.

And if Rosin or anyone else imagines that sex rehab meetings do not lead to hook-ups, she is either naive or blinded by her ideology.

Last, Rosin shows no awareness of the fact that sex rehab at Dr. Carnes' clinic involves coming clean to one's spouse. As has been widely reported Tiger will be obliged to tell his wife all of his sexual indiscretions, in detail.

Is there a woman alive who would want to hear about all of it, in graphic detail? I do not know any. Would Rosin want to hear about it herself? I doubt it.

When you are trying to save a marriage you should never, never, never, never engage in a willful effort to humiliate and abuse your spouse. Why would any woman want to be tormented by visions of her husband's sexual acts with other women?

If you want to humiliate a man, and if you want to proclaim a victory for your ideology, then you are likely to ignore the effects these horrors will have on real human beings.

As I was saying, an ideology is about propagating its ideas, not about improving the lives of real people.

Is Tiger Woods a Sex Addict?

It may not be the most burning issue of the day-- or better, it is surely not the most burning issue of the day-- but we have all learned from a reasonably reliable source-- that is, the National Enquirer-- that Tiger Woods is being treated for sex addiction in Mississippi. Link here.

We have also learned that he's theret because his wife urged him to do it-- or better, because she threatened to take his children to Sweden where he would never be able to see them again.

Not much of this makes a lot of sense. Have you ever seen or heard of a pre-nup that stipulated that one parent could take the children so far away that they other could not have normal visitation? Or else, have you ever heard of a judge who would allow such an arrangement?

Are we so consumed with anger at Tiger Woods that we are willing to believe just about anything about him? And are we so compelled to side with his wife that we are willing to grant her everything? For my previous posts about Tiger, see here.

Back to today's question: Is Tiger Woods a sex addict? And what is this thing called sex addiction anyway? Is it a treatable condition that can be controlled with a 12 step program or is it, in Tiger's case, a public relations move designed to salvage Tiger's reputation and endorsements?

Is rehab going to cure Tiger's addiction or restore his public image?

Nowadays America believes in rehab. Rehab has become the new therapy.

America also believes in 12 step programs. 12 steps have become the new psychoanalysis.

America is so thrilled at the effectiveness of 12 step programs that physicians are working to label each and every moral failing as an addiction.

Rehab has helped solve the greatest problem with 12 step programs. Clinicians have always know that these were effective against alcoholism. But the same clinicians could not embrace these programs because... they were free.

Now, with rehab, they have learned how to monetize 12 step programs. Apparently, Tiger Woods is paying $60,000 for his stay in the Pine Grove Behavioral Health and Addiction Clinic.

Would Bill Wilson and Bob Smith be proud?

Anyway, is Tiger Woods a sex addict?

Personally, I would vote No. An addict will show signs of dysfunction in his everyday life. Addiction compromises focus and concentration, making it difficult for the addict to relate with others, and to complete his work successfully.

An addiction is a compulsion that consumes your life and makes it nearly impossible to function. For some people sex might become such an addiction. But does this describe Tiger Woods?

Golf is an especially unforgiving taskmaster. If your focus and concentration are off, if you mind has been pickled by alcohol or addled by narcotics or flooded with images of naked lovelies, you game is going to suffer.

In golf it does not take very much to break down your concentration. When it does, the effects are immediately evident.

A golfer-addict plays like John Daly, not like Tiger Woods.

I would also vote No because Tiger's sexual antics can be explained by other factors. To diagnose Tiger Woods as a sex addict you have to distinguish a sex addict from someone who has a strong sex drive, fueled by competition, victory, money, and a gaggle of readily available women.

Also, when you make sexual indiscretion into an addiction and try to treat it with 12 step programs you will create several problems. When someone is addicted to alcohol, narcotics, or gambling he can begin treatment by renouncing the behaviors. You can live without alcohol, narcotics, and gambling. It is far more difficult to live without sex, which is, a normal adult activity.

Next, when an alcoholic goes to an AA meeting he hears stories of the abjection visited by alcoholism. These visions provide a cautionary reminder of what happens if he abandons the program.

What happens when a sex addict goes to meetings for his addiction?

As everyone knows, if you go to a sex addiction meeting and listen to people recount their sexual experiences, you might get aroused and you might find someone who is similarly aroused.

Sex talk can easily become pornographic. Assembling a group of recovering sex addicts in a room to talk about sex can easily become combustible.

Those who run these programs have tried to deal with this problem by creating a "stop word," known to all participants, whose utterance by anyone signifies that the account is getting too racy and that it needs to be stopped.

Wherever did they get this idea? I would guess that they did not glean it from a medical or psychological textbook. If it resembles anything, it represents a staple of extreme forms of masochistic rituals, where the victim of sadistic abuse will have a word he can utter to stop the process.

But that is not the worst. As the New York Post headlined, Woods' sex addiction treatment will involve something called "Disclosure Day." On that day he will be required to tell his wife about each and every time he betrayed her. In detail...

I have it on very good authority that such a practice would never be permitted in AA. It is not one of the traditional 12 steps. Even if you stretch things and class "Disclosure Day" under the step of making amends to those you have hurt, that step also says that you should not do so when you will be hurting the other person.

Can any sensible person really imagine that Elin Woods wants to hear all about her husband's sexual escapades. Isn't this a clear case of adding insult to injury?

And why would any sensible person imagine that this would be therapeutic for a marriage?

The fact that the program is being administered by a physician who has written a book on sex addiction does not justify putting these two people through such a harrowing ordeal.

If Tiger and Elin want to put their marriage back together, one good step would be to look forward, not backwards. Making Tiger assume a posture of extreme abjection will not contribute to their marriage. Nor will forcing Elin to feel utter and complete disgust about her husband's behavior.

It is bad enough that this practice has received legitimacy and respectability because it is being called medicine and is being practiced by a physician. Larger problems arise when people who have committed sexual indiscretions, regardless of whether they rise to the level of a life-consuming compulsion, start thinking that they now know how to solve their problems.

They can proclaim themselves sex addicts, declare that they have no control over their behavior, and propose that they work their way out of it by telling all of the sordid details to their wives.

Do you really think that that will help?

About 12 Step Programs, Especially Steps 8 and 9

Everyone knows about 12 step programs. Still, these programs do not get very much respect within the psychiatric or psychological establishment.

This makes some sense. The 12 steps do not set forth a medical or paramedical treatment. They involve spiritual renewal and changes in the way people conduct their lives.

Medicine does not pay too close attention because 12 step programs are not medicine and are not based on science.

Psychology, which is part science and part philosophy, has not shown very much interest either. One reason, I have suggested, might be that the 12 step program was not the brainchild of a great European philosopher.

We favor great minds. We believe that all valuable ideas come from great minds. Therefore, we are not predisposed to write learned commentaries on a 12 step program cobbled together by a couple of drunks in Akron, Ohio.

We are wrong to allow our fascination with the great thinkers cause us to ignore the lessons of 12 step programs, but that is as it is.

The final reason why medicine and psychology have tended to downplay 12 step programs is that they are difficult to monetize. AA meetings are free. They provide an effective treatment for alcoholism. No one who charges for services wants to compete against something that is free and that works.

These were my thoughts when I finished reading Elizabeth Bernstein's article about apology in today's Wall Street Journal: "Who's Sorry Now? Nearly Everyone." Link here.

Bernstein argues that the seeming pervasiveness of apology in today's culture signals the power of the therapy culture. I would argue the contrary point, that the pervasiveness of apology signals the decline of the therapy culture's influence.

According to Bernstein, apologies are busting out all over. People are using Facebook and other networking sites to get back in touch with people they knew in the past. Once they make contact they use the new communication channel to express their regret for having harmed or wronged the person years ago.

As a sophisticated writer Bernstein maintains an ironic detachment from this phenomenon. But, she is more puzzled than dismissive.

I was surprised, however, that she did not mention the source of this practice, namely in 12 step programs, especially steps 8 and 9.

To refresh your memory, they are: "8. Made a list of all persons we had harmed, and become willing to make amends to them all." And, "9. Made direct amends to such people wherever possible, except when to do so would injure them or others."

Surely, it is easy to dismiss this practice. An adult who apologizes for something he did when he was 10 seems to have embarked on a fool's errand. We would feel strange receiving such an apology, especially if we had long since forgotten the offending incident.

It may be that too many apologies is too much of a good thing, but that does not make it a bad thing.

The important point in these steps is simple: you need not search for the causes of your alcoholism, but recognize that you are fully responsible for what you did to other people while under the influence.

And accepting responsibility means taking an action that shows it. It does not mean that you should understand what made you make the mistake. It will not be solved by self-flagellation or penance.

These two steps are two definitive steps beyond victimhood. The 12 steps do not seek out the infantile root cause of your bad behavior; they enjoin you to take responsibility for the harm you have inflicted on others and to make amends wherever possible.

To me these represent definitive steps beyond the therapy culture.

If your alcoholism caused you to squander the family fortune, mistreat your family, and make serious mistakes on the job... you can only deal with the problem by apologizing and making amends. Doing so restores your moral compass and helps you to rebuild your character.

Let's say that you are on the receiving end of a sincere apology. It might have occurred in childhood-- a parent might have abused a child-- or it might have occurred last month.

Either way, people who receive correct apologies are most often moved by them.

Receiving an apology helps you in two important things. First, it tells you that the person who offended, insulted, or abused you is promising not to do it again. An apology removes a potential threat from your life, and this is a good thing.

Second, it tells you that you need not feel responsible for the offense, insult, or abuse. You did not provoke it and did not deserve it. When someone apologizes to you he relieves you of the guilt you might have been feeling for having been harmed.

People who have been abused often blame themselves. When your abuser apologizes he relieves you of that guilt. And that is the most effective way to deal with the guilt that we sometimes feel when we do not know why we are being abused.

We see abuse as punishment, and if we have been induced to see life through a guilt narrative, we are likely to believe that we must have done something to deserve it. When our abuser apologizes he is effectively mitigating that guilt.

The Complaint Free Life

Jaded New York intellectual that I am, I had happily ignored the hubbub swirling around Rick Warren's book: "The Purpose Driven Life."

And then one day in 2005 a convict named Brian Nichols overpowered a guard in an Atlanta courtroom and murdered three people. After fleeing the courthouse he also murdered a federal customs agent.

Finally, Nichols met up with a pretty blond South Carolina meth addict named Ashley Smith and took her hostage.

You know the rest of the story. Smith did not cower in fear. She did not even fight back. Instead, she read to Nichols from the book that was on her nightstand: "The Purpose Driven Life." Then she offered to pray with him. Eventually, she persuaded him to turn himself in. She was unharmed.

We might want to scoff at Pastor Warren, but clearly his words and his approach worked. In and of itself that should command our respect.

These were my first thoughts when I read Valerie Frankel's article about how she tried to follow the instructions contained in a book called: "A Complaint Free World" written by a Missouri pastor named Will Bowen. Link here.

In her article Frankel offers an amusing view of how her family tried for a week to learn the basics of a complaint free life. Frankel did not merely try to go cold-turkey on complaining, but she enlisted her husband and children in the enterprise.

At the end of a week, Frankel discovered that she could not break her bad habit of complaining, and that it was a good thing she couldn't because that was who she really was.

Trying not to complain made Frankel miserable, so she stopped. She concluded that a complaint free life was not for her. The experiment was a failure, and thus, the pastor's advice is not going to make you happy. It is going to alienate you from your true self, to say nothing of your friends and family.

However compelling Frankel's story, it does not prove the futility of trying to stop complaining. The more salient truth is that you cannot break a bad habit in a week. Under any circumstances, no matter who you are.

If you have spent your life badmouthing everyone and everything, you cannot just flick a switch and become the soul of kindness. Considering the amount of work you probably put into developing your skill at complaining and whining you cannot just shed it like some much dead skin. And considering that everyone you know expects you to complain, you cannot just stop doing it. Your friends will think you have lost your mind.

Given her expertise at complaining, Frankel has many complaints about Bowen's program. Among the worst: she had to repress her impulse to revel in the exchange of catty gossip. Apparently, such exchanges are legal tender among Frankel and her closest friends.

Once she stopped badmouthing people, Frankel felt like an alien being. The feeling was uncomfortable to the point of being painful. Saying nice things was wringing the fun out of her life.

Of course, this makes it sound like Bowen's book was tailor-made for Valerie Frankel.

Her complaints about her week-long experiment, however, are simply a description of the process that anyone would undergo while trying to replace a bad habit with a good one.

If an alcoholic tried to stay off alcohol for a few days, he might well say that he did not feel very good about the experience, that his friends no longer recognized him, and that he needed alcohol to put the fun back in his life.

If stopping addictive behavior felt good, a lot more people would do it. The greatest obstacles to overcoming addiction are that once you stop it: you do not feel normal; you will need to create a new circle of friends; and your life will feel like a lot less fun.

A few days ago, while blogging about Alan Lurie's article about complaining, I suggested that our therapy culture had helped us to perfect the art of complaining.

While Bowen and Lurie, among others, are fighting the good fight to help people overcome this insidious habit, Frankel represents the view of the therapy culture. Her article might have been called: The Empire Strikes Back.

Admittedly, card carrying members of the intelligentsia cannot take minister Bowen's ideas very seriously. And while it may be true that Rick Warren's "The Purpose Driven Life" has sold tens of millions of copies, I can assure you that these copies have not been bought in the tonier precincts where the intellectual elites live and prosper.

And yet, as I like to remind myself, the most effective treatment for the scourge of alcoholism was not dreamed up by a great European psychoanalyst or philosopher. The twelve step program that is most likely to treat addiction was cobbled together by a couple of drunks in Akron, Ohio.

On that humbling word, I will close this post.

Does Rehab Work?

'Tis the season... for celebratory self-indulgence. But once you have had your fill of wassail and grog, and once your mind no longer feels like it has been invaded by dancing sugarplums, your thoughts may well turn to rehab.

Therapy may be going out of style, but rehab is all the rage. But, does it work? Is it worth the $20 billion we spend on it? According to the New York Times, the insurance companies and government agencies that are paying the bill are seriously interested in the issue. Link here.

Asking whether rehab works is easier than asking whether therapy works. At least with addiction we know what treatment success looks like: no more alcohol or drugs.

When we get to the techniques used by rehab centers, things are murkier. As with therapy, there is no clarity, no high concept that tells us what rehab is. As with therapy, it seems that rehab is as good as the individual counselor.

The medical basis for rehab is the need to detox. In many cases this requires strict medical supervision in a controlled environment.

But it does not take a month or two to detox. The rest of the stay in rehab is filled with numerous therapeutic techniques, some more valuable than others.

From group therapy to individual therapy rehab is a therapeutic cornucopia. Among the more effective is a cognitive technique that teaches addicts how to tolerate discomfort and to deal with it by doing something other than reaching for some absinthe or an eight-ball.

So far, so good.

The problem with rehab is that it takes place within a controlled environment. As such, it offers scant preparation for dealing with the temptations that will assault the recovered addict once he or she returns to the real world.

A patient named Angella explained it well to the Times. After completing rehab she remained sober for two months. Then she returned to her addiction. "After a while," she said, "you just start missing your friends."

That is why the most effective treatment programs for substance abuse are based in the twelve step programs that began as part of Alcoholics Anonymous and that have now been extended to other forms of recovery.

Rehab takes you out of your life; it gives you a temporary respite. AA reorganizes your life more constructively and more ethically.

Of course, most rehab programs involve AA-type meetings. I suspect that they all encourage their patients to continue going to meetings once they have graduated from rehab.

As everyone knows, AA works. It works for a patient population that therapy has never claimed to treat effectively. It does not always work, and it does not work for everyone. Yet, it works with sufficient consistency to allow us to say that the program, not the person of the counselor, has produced a therapeutic benefit.

AA differs from therapy because it is one thing, and only one thing. Therapy has dozens of different schools and many more different techniques. If therapy is confusion, AA is high concept. No matter where you go to meetings, no matter who your sponsor is, the program is the same.

If you say that people get better no matter what kind of therapy is being practiced, you are saying that patients are improving despite, not because of, therapy.

With AA sobriety is not the goal, as it would be with therapy. It is the price of admission. It is the basis for participation, not a goal that exists at some existential horizon.

In my view AA is not therapy. It more closely resembles coaching. It shows people how to reconstruct their lives, especially to live more ethically. It insists that they be responsible to themselves and to others, that they exercise discipline, strength of character, and good habits.

Where therapists often traffic in the rhetoric of empowerment and self-help, AA tells addicts that they must accept that they are powerless to control their habit. It adds that they can only get well when they allow a higher power to take care of them.

Therapy tells you that you are alone in the universe and that no one else really cares about you. AA tells you that you are never alone and that someone will, if you allow it, take care of you.

AA meetings are communal gatherings. They are not led by an expert, by a man or woman of science offering learned interpretations of anyone's behavior. This encourages self-discipline and respect for others.

Therapy tells people that they must gain insight into why they have problems before they can fully exorcise their demons. AA tells them to fake it till they make it. It tells them to improve their behavior now, not later.

AA works for those who follow the program. It is not about discovering why you drink. You merely have to follow the instructions laid out in the twelve steps. Recovery is something you earn for yourself by working at it in the conduct of your everyday life.

Obviously, psychotherapy has always had issues with AA. First, because it is free; second, because it does not require credentials.

Also, AA has a dubious pedigree. Psychotherapy arose from the lucubrations of great European thinkers like Freud, Jung, and Adler. AA was cobbled together in Akron, Ohio by a couple of drunks names Bill and Bob.

Psychologists and psychiatrists often learn about AA, but they do not spend their time figuring out why twelve step programs works where insights and epiphanies do not. They learn developmental psychology and advanced psychodynamics but spend precious little time studying why it is necessary to make amends for past failures and why a higher power heals something that they can only wave at.