What does it mean to be "alcoholic"? The DSM, psychiatry's diagnostic bible, does not have a category termed alcoholism per se, only diagnostic criteria for alcohol abuse and alcohol dependence. For many people with problematic drinking, physical dependence on alcohol is not an issue; they don't necessarily drink daily or suffer withdrawal symptoms beyond a hangover. Many problem drinkers therefore would deny that they are alcoholic because they think of the alcoholic as a daily drinker who requires a shot or two to get out of bed in the morning. Are they right?

Like many things in life which are not always black or white, alcohol use should be considered in the  context of a continuum; alcohol can be used, abused, and depended upon, both physically and psychologically, but how one draws the distinction is hotly debated. Another consideration is that problem drinking  is often progressive. What this means is that tolerance occurs over time, which means you need more and more alcohol to achieve the desired effect. Along with this increased tolerance comes impaired physical health and a host of other consequences. But this happens to all heavy drinkers over time and some would disagree that heavy drinking should always be considered "alcoholism". 

As the former director of a substance abuse program and in my private practice, I have worked with hundreds of people in trouble with alcohol. Some call themselves alcoholics, some do not. Sometimes the people who are comfortable with that label can have less problematic drinking than those who deny it.  I know of someone who had a liver and two kidneys transplanted  due to drinking who denies being an alcoholic! I also know of people who are not generally problem drinkers but who have gotten a DUI or, in one case, hit and killed someone with a car,  due to a single incident where they had too much to drink. 

If you are reading this, you may be wondering if you are indeed "an alcoholic". Considering that not everyone agrees on precisely what defines "alcoholism" except in its more extreme and obvious cases, I would suggest that you might be asking  the wrong question. Here are perhaps some better questions to ask yourself:

1.  Would my life improve if I stopped drinking:

 Would I get along better with significant others? Would I be better at my job ? Would I be a better parent? Would I feel better physically? Would I be more productive, sharp, on top of my game? And, perhaps most importantly, would I like myself better?

2. Do I notice that over time, I need significantly more alcohol to get the same kind of effect?

Did I used to get high on two glasses of wine and now I need 5 or 6? Or 8 or 10? And, if so, do I understand that alcohol in these quantities is damaging to every organ system in my body?

3. If I set myself a limit, can I consistently abide by it?

This to me is key. I often advise my clients who are debating with themselves if they truly have a problem with alcohol to try this little experiment: For one month, set yourself a limit on how many drinks you'll consume per day (or night).  The limit should be set by you but should be within what would give a person of your gender, height and weight a pleasant buzz, perhaps 2 for women, 3 for men. Can you do it?

4. Does my personality or behavior become problematic when I drink?

Do others tell me I get nasty or belligerent? Do I get weepy and sad? Do I get into conflicts with others I otherwise would not? Do I have blackouts (periods while drinking where chunks of time can't be recalled)? Does my judgement become impaired? 

So, in conclusion, whether or not you identify as alcoholic or not, if you answered yes to the first two questions, no to the third, and yes to the fourth, if I were you, I'd seriously consider giving up alcohol.

Intimate relationships fascinate me. I am amazed at how no amount of grief can shatter some relationships, and how the seemingly slightest thing, in other cases,  can torpedo the whole affair.

Why do some people stay in abysmal unions that no amount of outrageous behavior seems to kill? And how  it is that some people accept behavior from a lover they would NEVER tolerate from anyone else? 

For some people, why does desperate longing for the unavailable other feel like love? Why, for some,  does a "nice guy" have  much less appeal than the sonofabitch who is the source of constant pain?

Why do otherwise socially appropriate  and kind people think it is acceptable to go for the jugular with their lover but are appalled when their lover goes for theirs? And why do some  of us expect a level of attunement from a lover we would not expect from anyone else? Or consider it our right to be the center of another person's universe and feel mistreated  when,  inevitably, we are not?

Why are relationships so difficult for so many of us?  Why do we dearly want to have them anyway.

How do we lose ourselves slowly, over time, to the pressures of the other person's point of view, their needs and expectations, the relentlessness of accommodation and compromise?  How do we reassert ourselves without inflaming the other? 

How is it possible to maintain sexual passion for someone who is as familiar to us as our own faces?  How do we continue to love someone who knows all our faults when a new lover would enable  us to reinvent ourselves? How have so many of us conflated erotic or romantic  intoxication with everlasting love, thereby setting the stage for almost inevitable disappointment?

These questions obviously have no simple or definitive answers. They are conundrums wrapped in mystery. We are such complicated creatures, it seems. We have incompatible and often contradictory needs, like simultaneously wanting deep intimacy and autonomy, similarity and difference, familiarity and mystery, dependency and independence, to be known deeply and still be idealized, to be loved unconditionally while loving  conditionally.

We are often blind to our true motivations. We think we know ourselves but self-knowledge is an elusive thing because the self is ever evolving. We value choosing a life partner at a relatively young age when who we are at 25 is often radically different than who we are at 40 or 50.  It takes many years to mature and maturity is essential to sustainable healthy relationships. We all must learn that our childhood wounds cannot be healed by regressing with a lover, hoping that he or she will correct the slights of the past. We have to learn how to expect less, not more, from those we love and who love us,  to 

be satisfied with what another is capable of giving. We have to learn that our most important relationship is with ourselves, with our own integrity, as that is the basis of all other relationships. 

We certainly have our work cut out for us.

Most people who have narcissistic traits, which is most of us, do not qualify for a diagnosis of NPD. What is the difference between a person who has "narcissistic issues" and one who is pathologically narcissistic?

When referred to in everyday language, people who have narcissistic traits are often said to have "big egos".  This means that they get obvious gratification from being admired and demonstrating that they are special. They may brag about accomplishments and become prickly and defensive when questioned about them. But essentially, they have a reasonably realistic sense of their own importance in the universe, which a narcissist most assuredly lacks.

To some extent, we all share a desire for admiration and approval, and we want to be loved as individuals. That is part of having a sense of self, which is essential to mental health and social well-being . However, reasonably mature individuals can absorb and eventually neutralize the inevitable insults life sends our way. We can be rejected in love and still feel worthwhile, we can do poorly on a test and still believe we're intelligent. We are able to maintain a positive sense of self even though we know we are not perfect nor universally loved. This is called "healthy narcissism".

There are many people who do not qualify for the diagnosis of NPD but who have narcissistic attributes. They may fundamentally fail to understand that they are not the center of other people's universes. For instance, I often hear people express the belief that when they walk into a room, everyone is scrutinizing them, evaluating their worth with every word they utter. I had a friend once who would call me after a social event stressed over her imagined impact on the group. She overvalued, in terms of impact, her every comment, facial expression, and gesture. What she failed to realize is that no one was paying that level of attention to her and therefore her interpretation of reality was quite distorted. This is a narcissistic issue.  More seriously, some people with narcissistic problems expect their own needs and desires to be considered first and foremost, regardless of needs and desires of others. 

Like virtually all psychiatric diagnoses, pathological narcissism or NPD exists on a continuum.  In other words, someone can have a mild case  all the way up to a severe one.  If you think of those "big egos", the guys that brag and strut but don't have other symptoms,  as being on the very end of a NORMAL continuum, you can start to see where the NPD continuum begins.  I believe that what separates the boasters from the NPDs is, in a nutshell, an impairment in the ability to empathize. These people are emotionally shallow. They may profess to have concern for others, but scratch the surface by probing a little and you will find that they really couldn't care less about anyone but themselves.

So what ARE the symptoms of NPD? I have always been dissatisfied with the DSM criteria for NPD so I will share the proposed amended criteria by renowned expert and self proclaimed pathological narcissist Sam Vaknin, in abbreviated form:

1. Feels grandiose and self-important.

2. Is obsessed with fantasies of unlimited success, fame, omnipotence, beauty, etc.

3. Convinced he or she is unique and special and that others must regard him as such.

4. Requires excessive admiration and attention.

5.  Has a strong sense of entitlement.

 

6. Is interpersonally exploitative, i.e., uses others to achieve his/her ends, regardless of the consequences to others.

7. Is devoid of empathy. Is unable to experience genuine concern for the rights and needs of others. Only his own needs matter.

8. Constantly envious of others and tries to hurt or destroy the objects of  envy.

9. Behaves arrogantly and haughtily. Because he is so special, he does not believe rules apply to him and may rage when contradicted or confronted.

While a mere braggart is irritating, a pathological narcissist wreaks tremendous havoc in the lives of others, causing substantial misery to those in his path. The more severe the NPD, the less he cares about his impact on others. In other words, the narcissist is at the center of the universe and others are mere players in his game, with no more intrinsic value than chess pieces. A psychopath (or sociopath) is at the extreme end of the narcissistic continuum. A psychopath has NO empathy and feels NO guilt. 

One of the reasons extreme narcissists have so much power to harm is that "normal" people simply cannot believe that someone can be devoid of  empathy or conscience. For many people, it just doesn't compute...."How can you do this to me and not feel badly?".... People fail to protect themselves when they think that everyone has a moral or ethical line they will not cross.  

Another and perhaps more important reason people are taken in by narcissists is that they are often very charming and present a false self in order to ensnare others. A narcissist will be whoever you want him to be, at least at first. By the time his persona starts to crack, a person is already deeply attached to the original (false) self he presented and still believes "he's in there somewhere".  He is not.

Pathological narcissists can cause catastrophe in business (think Jeffrey Skilling of Enron and  Bernie Madoff as examples) and in politics and global affairs (think Assad, Sadam Hussein, Hitler, Stalin, Robert Mugabe, Idi Amin...this list, unfortunately can go on for quite awhile).  But being in a personal relationship with a narcissist can turn your world upside down and make you doubt your sanity.  Why? Because a major defense of the pathological narcissist is to blame others, always, for any perceived flaw in his image or behavior. In other words, the narcissist NEVER takes responsibility for his actions. And even if you have an  "air tight" case, PROVING that he did something wrong, he will talk in such circles, with such flagrant disregard for the truth,  you will start to doubt your own perceptions.

Narcissists are unable to truly love others.  They need others to feed their incessant craving for admiration, adoration, and self-importance, and will idealize those who steadily supply them with it.  But woe to person (object) who withdraws those supplies,  for she will meet with vicious condemnation.  Lacking the ability to love, which requires that a person see the other as a distinct individual who is at the center of her own universe, not his, there is no genuine attachment to those who disappoint him. When a narcissist is rejected by a lover, he may go to great lengths to win her back, but love has nothing to do with it. What the narcissist wants back is not the lover per se, but the restoration of his grandiose sense of self which the rejection has injured.

Narcissistic Personality Disorder is often very hard to diagnose, even by seasoned mental health professionals, because it can take a fairly long time for the narcissist to show major cracks in his persona. The blatant disregard that narcissists have for other peoples' rights and boundaries does not often show up in the "wooing phase", that is when a narcissist is charming the other into accepting his distorted image of himself. Indeed, it is quite common for the narcissist to idealize the other at this stage, making the object feel he truly sees her as exceptional. What is really going on is that he is projecting his inflated self-image onto the other, which is what he really loves. Should the person dare not to conform to his idealized projection, idealization is quickly replaced with devaluation; "You are the love of my life " can suddenly become "You are lower than a crushed bug on the bottom of my shoe". 

You hear the term "self-esteem" all the time, right? We all know we should have it, wish we had more of it, or don't know how to get it, but do we really understand what it means?

There are several misconceptions about what self-esteem actually is. Some people think it means loving yourself unconditionally.  Others believe that if you have it, you are either selfish or conceited. Neither of these is correct.

I define "self-esteem" as justifiable positive self-regard. What I mean by "justifiable" is that it is based on congruence. Congruence means, in this context, that one's behavior stems and flows from one's principles. For instance, if I think stealing is wrong and I shoplift or it is wrong to cheat on my spouse and I do it anyway, that should rightly detract from my positive feelings about myself. Conversely, if I make a mistake and own up to it rather than lie, that accrues positively to my sense of self. When one behaves congruently, he or she is neither selfish nor conceited, usually the opposite.

Another important point about self-esteem is that it does not require perfection. Perfection in human life is like a unicorn; it doesn't exist. Failure and missteps are invaluable tools for growth, and positive self-regard need not suffer from setbacks. However. perfectionism will always cause feelings of inadequacy.

Sometimes in life, despite our intentions, we do something we regret. Principled living does not adhere to the law of perfection either; we are human, we make mistakes. So self-forgiveness is another aspect of healthy self-esteem. But here's the catch; To forgive yourself your trespasses you must make every effort not to repeat them.  When I was growing up, some of my friends would go to the mall and shoplift. They would then confess their sins at church on Sunday and then go out and shoplift again, which baffled me. I don't think a confession or an apology has any meaning whatsoever if it is not backed up by a positive change in behavior.

It seems a basic truth that people want to be liked and admired by others. Nothing wrong with that. But what seems most important to me is that I like and admire myself. Usually there is a lot of overlap. However, many people routinely betray themselves in order to be accepted by others. For instance, they may laugh at racist or homophobic jokes when they themselves are neither racist nor homophobic. They may bend to peer pressure in all sorts of ways for fear of being disliked or rejected. But the price they are likely to pay is that they like and respect themselves just a little bit less. 

If you will accept as I do that the most important relationship you have is with yourself, you will be much more reluctant to chip away at your own positive regard in order to be liked.  Why is the relationship with self the most important one you have?  The reason  is that it is the relationship from which all others stem. If I don't think much of myself, how can I believe others think highly of me? If I am unable to treat myself compassionately, why would I expect compassion from others? If I don't protect myself from mistreatment, why am I surprised when I am mistreated? If I can't take responsibility for my own behavior, then what makes me think I have the right to expect that from others?

 Unfortunately, I have known so many people who are eminently worthy of self-esteem who consistently feel inadequate or "not good enough". Why is that?  The reasons are numerous and beyond the scope of this article, but  a simple way of understanding it is that they are lousy friends to themselves.  I listen regularly to people judging themselves far more harshly than they would any other person and ask them to notice how much more compassion they would show to a friend under similar circumstances.

There is also a problem I've heard called , humorously but aptly,"the piece of shit at the center of the universe syndrome".  In other words, you think poorly of yourself  AND  that  everyone is paying attention to your every move. It is both humbling and liberating to understand THAT NO ONE IS SCRUTINIZING YOU.  I had a friend who after a party would call me up to chew over all the social mistakes she thought she made and all the ways everyone in the room must feel about her. It was all in her mind, of course, but I found it remarkable that she was convinced that people were paying her such close attention. They weren't. 

To conclude, you are with you from birth to death, 24 hours a day. You had better be your best friend or you are in for a world of pain.

When I was going through a divorce some years ago, I found myself ruminating about the many ways I felt mistreated by my not yet ex-husband.  The more I thought about him and his behavior, the more angry, betrayed, and injured I felt. One day, I went out to walk my dogs. It was a gorgeous day, we were entering a beautiful park and all I could think about was what a bastard my husband was being. Then it hit me: WAIT!  These thoughts are like taking poison and expecting someone else to die! I'M the one whose suffering and ruining what could be a perfectly lovely walk. Why am I doing this?

Why do people obsess about painful things they cannot control? Why is doing something so excruciating and unproductive so utterly compelling? The image that came to mind was of a moth inexorably drawn to a flame which will burn it alive. The answer, it seemed to me, was that on some level, I was trying to solve a problem. In other words, I misguidedly believed that thinking obsessively about an injustice would somehow ameliorate the hurt and give me control over it. This thought had never been conscious before and now that it was, I saw how utterly irrational I was being.

So I decided to deliberately and actively THINK ABOUT SOMETHING ELSE. I forced myself to notice the spring flowers, how happy and cute my dogs were, running around with each other, what I would make for dinner.....anything that wasn't about my divorce. At first, I felt the pull of the distressing thoughts, but I persisted in directing my attention to other pleasant or neutral things. And guess what happened? At the end of the walk, I noticed that I'd had a really good time! If I had persisted in my ruminations, I would now have felt miserable. I felt a huge sense of relief knowing that what caused me so much unnecessary pain could be avoided if I CHOSE not to engage with it. What I could not control (his behavior) need not torture me if I shifted my thoughts away from the subject. 

This is an example of a cognitive-behavioral intervention. What that means is that a person becomes conscious of the irrationality of their thinking and then does something different. Sounds simple? Well, it is and it isn't. The hard part is the persistence it takes to successfully distract your thinking away from the troubling material. But persevere, and you will be amazed at how much needless misery you can avoid.

There is an old saying; "Suicide is a permanent solution to a temporary problem".  But when you feel like life is unbearable, you lose awareness that your feelings will change. One of the most horrible things about being depressed, and many suicidal people are, is that there is a pervasive sense of hopelessness and despair that nothing you can imagine will relieve.  Every thought you have takes you to a dark place, all roads lead to hell.

Whatever the reason is for planning a suicide, here is why it is a terrible idea:

First of all, EVERYTHING changes.  Feelings, like the weather, are transient states of being; the clouds roll in and the clouds roll out. We are tremendously fortunate to live in a time where most emotional and mental illness can be successfully treated. It is easy to lose this perspective when emotional pain seems overwhelming. With therapy, time  and sometimes medication, life will start to feel livable again.

Another thing to consider when contemplating suicide is that YOUR LIFE IS NOT YOUR OWN TO TAKE. What I mean by this is that suicide leaves devastation in its wake. Most of us are someone's child, parent, spouse, sibling, friend. The survivors of a loved one's suicide will never be the same.  When people are in the depths of misery, they can convince themselves that their loved one's are "better off" without them. Trust me, this is never the case.

Domestic violence can be defined as any physical, psychological, economic, or emotional abuse used to intimidate, control or harm another person. Women are the most frequent victims of domestic violence but sometimes women are the abusers.  Domestic violence is against the law and both men and women can be arrested for it. Often victims don't  report the abuse for fear of being further harmed, or even killed by the abuser. But domestic violence gets WORSE over time (more frequent and more deadly) and must be stopped. Often the abuser blames the victim for causing the abuse, saying that it was her behavior that "made" him hit her. But no one can make anyone choose violence to deal with anger.  The perpetrator may attempt to make the victim believe that she deserves the violent or controlling behavior. But no one DESERVES abuse. If you or someone you know are suffering domestic violence, I urge you to call the National Domestic Violence Hotline at 1 800 799-7233. You can make a confidential report and learn of the many resources available, such as orders of protection, shelters, safety plans and counseling. An abuser will always promise that "it will never happen again". It always will.

Anxiety is a normal and universal human experience. Everyone feels the stomach butterflies and quickened pulse when they are doing something risky, where the stakes are high and the outcome uncertain (taking a test, trying out for a team, asking someone out, etc.).  But there are people who feel anxiety, sometimes in the extreme, in the absence of any risk, about things they know are irrational to fear. These people suffer from anxiety disorders. There are different kinds of anxiety disorders: Obsessive-Compulsive Disorder (OCD), Panic Disorder, Social Phobia, etc. While their symptoms vary significantly and are too numerous to discuss here, they all have in common a crippling fear which interferes with normal functioning. If this sounds familiar to you, I urge you to consult with a mental health professional.  The good news is, most of these conditions are quite treatable, usually with a combination of therapy and medication.

There are many misconceptions about depression and most people don't realize that it is a serious medical issue. Feelings of hopelessness, despair, anxiety, and inappropriate guilt and shame can and do contribute to substance abuse, overeating, oversleeping, and sometimes suicidal thoughts and actions. Sometimes people are told to "snap out of it" but that is no more possible than "snapping out of" cancer. Whether triggered by an event or by one's own biochemistry, depression involves changes in the brain's neurotransmitter system. If you have ever had your mood altered by a drug, you know that how you feel is not simply a state of mind. When the brain's chemistry is malfunctioning, it can have a profound effect on how you feel and experience life. But there is good news. Depression is highly treatable. Studies show that a combination of antidepressant medication and psychotherapy is the best prescription. 

One very common misconception about depression is that it feels like mere sadness. Sadness is only a part of it. It is very difficult to describe the pain of depression; I always say it's like trying to describe blue to a blind person. If you've never experienced the monster that is depression, there is really no way for you to grasp its horrors. One of the things that makes depression so insidious is that it distorts one's self-perception and causes the belief that the sufferer is morally flawed or weak or bad.  What other medical illness does that?

If you are depressed, please have compassion for yourself.  Get help. If you love someone who is depressed, the most helpful thing is to acknowledge their pain, reassure them they're not to blame, and DO NOT try to "cheer them up"; you will only make them feel worse.

A question I am frequently asked by female clients is "Why do I find it so difficult to leave a man who I know is poison?" These are often intelligent, accomplished, self-sufficient women who simply can't understand why there's a disconnect between what they rationally know and emotionally feel. (This happens to men too of course, but apparently less often.)

So what is it about the men these women are drawn to like moths to a flame? And why would a woman stay with a man who repeatedly behaves in ways she would never tolerate from anyone else? 

I see the problem in terms of addiction. First, let's define addiction. An addiction is an obsession which can only be relieved by acting on a compulsion. For instance, a cocaine addict is obsessed with getting the next "hit" which causes the compulsion to obtain it, no matter how irrational she knows drug use to be and regardless of the consequences. This is exactly the  pattern I observe in my female clients who are in horrible relationships they can't leave. For example, a lover does not call when he says he will. She can think of nothing else but when he'll call and she feels miserable until he does (if he does). In other words, nothing can remove her suffering but the very person who is causing it, just like nothing but heroin can cure the misery of an addict in withdrawal.

Let's examine an example of a man to whom women typically become addicted. What are the qualities and characteristics that make him so compelling?  In general, these tend to be men with a high degree of narcissism. Narcissistic people have certain characteristics in common: they are utterly selfish, need tons of admiration, have a poor ability to empathize with others, and are "flexible" with the truth. They also tend to be charming, seductive and exciting. Now what happens when a woman is pursued by such a man? Usually, he tells her everything that she has always wanted to hear, that she is beautiful and wonderful in every conceivable way. Her first mistake is to believe him, but she does not yet know who she's dealing with. What she probably feels is very flattered and excited. Here is a man who finally appreciates her for who she is. Except he doesn't. Being a master manipulator, he knows what she wants to hear. He also knows how to create uncertainty and fear by acting in ways that belie his flattery; in other words, he knows how to give her withdrawal symptoms!

She starts to notice certain things. For one, he is opaque. She starts to catch him in little lies, which she rationalizes away. She starts to feel anxiety and is flooded with relief when he seems to have a good explanation or excuse. He doesn't call or show up when he says he will. Again she is flooded  with anxiety. She will probably start to wonder about her own desirability. Maybe he is losing interest?  But then he calls and explains that he had an emergency. Relief washes over her. The lies and excuses will escalate and he may start to treat her disrespectfully and even cruelly, but by now his "love" is the only thing that matters. She has become addicted

Recent scientific evidence proves that love addiction is not just a psychological but a neurochemical problem. PET cans and MRIs show that the brains of people looking at pictures of their lovers light up in the same places as a person taking cocaine. So love addiction is not just a metaphor. 

HOW TO BREAK FREE

The first step is to become aware of this hopeless cycle of misery. True, the high she gets when he seems interested is wonderful...but it is minuscule when compared to the deep valleys of despair with which she pays for that high. She must also realize that she has, bit by bit, given another person the power over her self-esteem.  In other words, she has allowed someone else to determine how she feels in her RELATIONSHIP WITH HERSELF. Why is this important?

Because the relationship we each have with ourselves is THE MOST important relationship in our lives.  It is the relationship from which all others stem.  If you are unable to treat yourself with compassion and respect, why would you expect to be treated that way by anyone else?  If you behave as if your own needs come last, then others will accommodate you by ignoring your needs. So, for instance, if our hypothetical love addict does not object when her date is 2 hours late, she is clearly telling him that she is fine being treated with utter disregard.  

The second step is to really work to understand that OTHER PEOPLE"S BEHAVIOR IS ABOUT THEM AND NOT YOU.  Many people seem to take personally what is not about them at all. For instance, back to our love addict, she might interpret her boyfriend's failure to call when he said he would as evidence of her lack of desirability rather than what it really is:  irresponsibility, rudeness,  and lack of regard for her feelings.  These are HIS  character defects, not HERS. Yet instead of feeling angry and setting firmer boundaries ("I expect you to call when you say you will"), she tries harder to please this jerk.

If you are struggling with this issue, try this exercise:

Each time you feel badly in reaction to someone else's behavior, ask yourself what the behavior says about the other person instead of you.  Then ask yourself how you would have behaved under the same circumstances.You may start to realize that everyone has choices about how they behave in any given situation and that the choices one makes are not determined by anyone but the person making them.

Then, try making a list of qualities you admire in a person and compare that to a list of qualities your love interest has. Do they line up?

Thirdly, write down what you would advise your best friend to do if she were involved in a similar relationship.

Engaging in this process is a valuable start to getting free of a toxic relationship. A good therapist can help you.