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Wise Counsel Interview Transcript: An Interview with Marc Kern, Ph.D. on Rational Alternatives to Alcoholics Anonymous

David Van Nuys, Ph.D.

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David Van Nuys, Ph.D.: Welcome to Wise Counsel, a podcast interview series sponsored by mentalhelp.net covering topics in mental health, wellness and psychotherapy. My name is Dr. David Van Nuys. I am a clinical psychologist and your host.

[music]

On today's show we will be talking about addiction with my guest Dr. Marc Kern. Founder of Addiction Alternatives, Dr. Marc F. Kern has over 30 years of experience as a clinical psychologist and addiction specialist in his private practice in Los Angeles helping people overcome self defeating problem habits with alcohol, street drugs, prescription drugs and other excessive behaviors involving gambling, pornography, shopping, overeating, sexual addiction and Internet addiction. He has shown clients how to use a wide variety of life management skills and tools to manage their negative behaviors and live happier lives. Now here is the interview.

Dr. Marc Kern, welcome to Wise Counsel.

Dr. Marc Kern: Thank you, very much David. Thank you for having me.

David: You specialize in the treatment of addictions. How did you manage to get into this particular area?

Marc: Well, that is really quite a long story and you probably do not have enough time. But the bottom line is that I had my own addiction. I graduated from Ohio State in architecture, had joined a fraternity and learned how to drink and use drugs sufficiently enough to develop an addiction by the time I had graduated, in several substances. So that is what ultimately led me to this profession; specializing here.

David: You know, I remember when I was an undergraduate, which was like a long time ago. I was an undergraduate at an Ivy League school and I remember that there were guys in the dorms who probably were well on their way to becoming alcoholics at that point.

Even though I don't think that at that point in time that I, you know, I don't think we identified or thought in those terms. But as I think back about it, you know there were people who had things that probably very clearly later turned out to be big problems.

Marc: Absolutely. I mean there was a naiveté back when, not speaking of either of our ages here, about the role of substances and elixirs. I will use that term throughout our discussion because I see addictions as all various forms of elixirs. And again, there was a naiveté and there was no intention to harm people but many people graduate from college with a total degree in addiction of some sort, so yes.

David: It is probably more of a problem, today with all the various substances that are available that were not available back when I was there. I mean it really was all about alcohol at that time. And I remember there was one guy who was very charismatic and who might have had a larger impact on me than he actually did.

But he was a charismatic guy and I remember he got into a period of getting cough medicines, you know, for the codeine. At the time I think were over the counter. And...

Marc: Correct. Right, right. They were, as many drugs were over the counter at one time.

David: Yes. So he was kind of raving about how great that was and fortunately I didn't follow him in that.[laughter]We might not be here talking about this, today. So most people immediately assume that a twelve step program is the way to go in treating addictions. I gather that you don't agree.

So that is why I wanted to talk to you, to get your perspective on that.

Marc: Well, I by far am not an entire twelve step individual. I just found when I was diagnosed with an addiction, actually several simultaneously, and was sent to a psychologist one of their recommendations was to go to a twelve step meeting. And you know I tried it. I went two or three times. I just didn't feel that it clicked with me. I didn't understand it.

Being trained as an architect in undergraduate school, things made sense. They were logical, one thing, you know, was built upon another. The twelve step program did not fit that mindset; that prototype. And so I started on a journey to find out if there were other ways to recover other than the twelve step program.

And almost to my surprise there were hundreds of different ways. And actually twelve steps was just one small part of the addiction treatment community.

David: Well, do you recall what aspect of it was that just didn't quite click for you? Was there some part of it that was 'off putting'?

Marc: The most, there were many parts that were 'off putting'. I was very high functioning. Even at the beginning of all my treatment I was working full time in an architect's office. But the biggest part was the religious emphasis, the higher power, powerlessness, just didn't 'synch' with how I looked at life at that time, nor today. And I just couldn't integrate it and if I couldn't integrate it I couldn't utilize it.

David: Now you say that there are hundreds of alternatives. But it seems that the twelve step approach is about all that we hear about and wonder is there in fact any good research data on the twelve step approach? Somewhere I have gotten the idea that maybe AA doesn't release any data.

Marc: Well, they do release data; not a lot. It is very difficult to do solid research on a program such as AA. It is very organic. It is a community. But there is research and the research isn't all that hot. The research suggests something between, depending on which piece you read, and this actually comes out of AA, somewhere between five and fifteen per cent of the people who walk in the door are still attending at the one year mark.

And as we go down to the two year mark, it is even less. Now obviously with those kinds of numbers, those people are not about to promote it. The research is available and there has been other pieces of research. But it doesn't suggest that, you know, the bulk of the people that walk in really are that successful in the long run.

David: Well, that is interesting. I think, somehow it has such an aura of success. I think lots of the psychologists and so on that I know, they get somebody who is suffering from addiction, they feel like they are duty bound to refer that person to AA or some other kind of twelve step program.

Marc: Yeah, and I feel that is a very unfortunate position for most psychologists to be with. And again, this is not to say that twelve step approach isn't right for some clients those in particular who don't have a social community that they can turn to that is not based on alcohol or drugs and some other variables. But this is really a function of the sort of the politics of addiction in this country.

For example, this issue of the twelve steps being the only way is really an American phenomenon. I mean if we would walk up just, excuse my language there, up into Canada we would find literally the reverse. Twelve steps are hard to find. Traditionally in Canada it is all harm reduction based. We can talk about what harm reduction is.

Similarly in Europe, England, France, Scandinavian countries, Australia, I mean it is pretty difficult to find a twelve step program. Their societies have not taken on the twelve step program as gospel.

And of course since the twelve step program seems to lean heavily into the disease model, the medical community in this country and the twelve step community have sort of befriended one another and reinforced the idea that there is a one size fits all. Or this is the way to go if you have an addiction.

David: Well, that is interesting. You refer to the politics of addiction, is that what you are talking about, this alliance between the medical community and twelve step organizations?

Marc: Absolutely and the politics goes very deep to the philosophical underpinnings of this country. I was just reading last night the percentage of people in the US that believe that there is a god, and I don't want to get too far into the religious side of this all, but that this country was built on religion and religious freedom and the value of it. Where a lot of other countries were not and therefore they haven't taken to their bosom this idea that a higher power is going to save them from this "disease".

David: I guess you would say that the Puritan ethic somehow cuts deep into our psyche and is still with us. So maybe, is expressed in this idea of 'once you are an alcoholic, you are an alcoholic forever.'

Marc: Correct, but that statement leads into the whole idea of it is all about being a disease. It is still very kind of curious if you really stand back as a rational individual and say, 'Well if it is a disease, why are we sending him to a religious or spiritually based sort of recovery program?' I don't send people with cancer or for a broken arm to a religious based support group. It doesn't even make sense even on the most superficial levels.

David: I was interested in your remark that the twelve step movement is not as strong in other countries. I wasn't aware of that and you say that elsewhere the emphasis is on harm reduction. That is a new concept to me. What do mean by harm reduction?

Marc: Well, I am going to step back on that term a little bit. Harm reduction is what I believe is the paradigm of the future and harm reduction in the most general sense is something that we all are very familiar with.

If someone goes into a treatment center for cancer, depression or whatever, they are not really trying to eliminate cancer or depression. They are trying to reduce the harm or the frequency of the problem associated.

We are a country built on harm reduction. Seat belts are for example, a form of harm reduction. We are not going to not get in a car. It is very dangerous to drive an automobile. But we are going to reduce the harm or the danger associated with driving by wearing a seat belt. If we look around this entire country, the world is built on a harm reduction paradigm but there is something very unique that they seem to suggest that in the addictions we cannot approach it from a harm reduction approach. We have to approach it from black and white.

Now, if someone was depressed we would say, 'You can never get depressed again.' That is the black and white sort of notion of the American sort of disease model. Where, Harm reduction in Canada or throughout the world is just the idea that our goal, the therapist's let's say goal, is to reduce the harm associated with the substance, or the elixir these people are involved with and not necessarily get caught up in the black and white notion that the goal must be abstinence.

Yet abstinence may be a harm reduction approach but it is not the only sign of making progress. If you are drinking a six pack a day and you go down to two or three beers a day, are you not making progress? Well, that would be considered a harm reduction approach.

David: OK, and in fact you believe that an alcoholic can become a controlled moderate drinker. Is that right?

Marc: That is a very tricky question and the truth is I believe that everyone who has an alcohol problem is not an alcoholic. First of all, I do not even know what an alcoholic is. There is probably 1, 001 definitions and if you look in the DSM4, which is our book which we use to diagnose people, there isn't the term alcoholic in the entire volume. It is a lay term. It is just a general term that people use to call people with problems with alcohol.

I am a believer that many people who have problems with alcohol would be considered alcohol dependent. Let's say even all of my fraternity brothers. Are they all destined to become full blown alcohol dependent alcoholics where they can never drink again? Well, the research suggests that most people mature out of it. Most people have a single involvement of excessive let's say alcohol use and they mature out of it due to a variety of forces. And most people return to a non-problematic ways of drinking in spite of their indoctrination into the disease model.

There was even a piece of research earlier around 2000 where they followed classically defined alcoholics for five years and found that the vast majority of them returned to non-problematic drinking without being endorsed by their treatment involvement. So it is a very controversial topic. So I am going to be a little picky on the semantics of it all.

David: OK. Well, hearing you talk about that reminds me that I guess I grew out of that. I mean I can remember when I was a young person in the years of college and I guess early graduate school as well, there were times when I got so drunk I can remember staggering around and falling down on the lawn and not being able to get the key into the keyhole in the door. And at this point in my life I probably we have liquor in the house that doesn't get touched in a year. [laughter]

Marc: So what does that mean to suggest that you have never had a drink since college days?

David: No. No, not at all. I will drink on occasion, but the impulse to drink for me is very rare. It is a social thing usually, and the occasions where I will drink are just very rare. What really got me out of it was a pretty quick--well, it wasn't totally quick-- but I did learn that my body just didn't handle it well and that I hated the feelings of hangover and just that feeling of just being wrecked.

Marc: Right. Right.

David: I also learned that continued drinking, that after reaching a certain point of feeling high and that wonderful feeling of euphoria that drinking more wasn't going to prolong it or make it feel any higher. I would kind of reach a peak, and at that point it was time to stop because it's not going to get any better.

Marc: Well, I appreciate your openness. I sincerely do, but you are an example of someone who would at one time give your college a description of being an alcoholic who has learned to become a non-problematic consumer. It is some interesting points you have made about what you have learned.

Lots of people that I see that truly do have problems with alcohol later in their life don't learn many of those things. Many of them don't suffer severe hangover effects that you described, and it is more difficult for them to sort of make that cause benefit analysis and say alcohol is not working for me.

David: Yes. I don't think I can claim any particular moral superiority. Rather, I think my biochemistry taught me really quickly that, hey, this isn't going to work for you. This is poisonous for you. I gather that there are other people who their biochemistry just doesn't tell them that.

Marc: Well, to start answering that question, you know, within practice pretty much anybody can get really good at drinking, and they can increase their tolerance and stuff like that. But, yes, people's biochemistry does play a big role in the feedback loop, and many people don't get the hangovers. Unfortunately, that leads to further problem drinking.

Some people seem to be born with an ability to drink a lot or develop tolerance to alcohol and not notice that they are being undermined behaviorally, their coordination and things like that. In a sense, it is almost like the old adage about having a wooden leg or I'll be able to drink you under the table.

We are seeing college's strengths, but in actuality over time those strengths actually turn into the indicators often of a point of someone who may have problems down the road.

David: I was on your website, and I noticed that you talk about the stages of change as being important in overcoming addictive behavior. Maybe, you can take us through those stages.

Marc: Oh, certainly. Stages of change were not developed by me. They were developed by Prochaska and DiClemente. These are some psychologists, as you probably know.

They developed a little model about how people change, and they originally developed it for cigarette smoking. I have applied it as they have applied it to alcohol and drugs as well.

The first stage is what they call pre-contemplation which is commonly in AA the denial stage. I don't have a problem. You might think I have a problem. I don't have a problem. That is what they call pre-contemplation stage.

Then, people move up to ideally what is called a contemplative stage where they say, "Well, yes, I do have a problem with alcohol, for example, but I am not ready to make the change. I am going to contemplate making a change". People often stay in this contemplative stage for a long time, sometimes years and, to be honest, sometimes until their death.

They never make movement to what DiClemente and Prochaska would call the next stage which is preparation. Preparation is where they are getting ready to change. They say, "I have a problem. I am going to do something about it". They start to prepare to do something.

The next stage would be called action. Action is actually where they are doing something about it. They are actually reducing their drinking pattern. They are seeing a therapist. They are getting into treatment. That is one of the shorter phases.

And then, there is maintenance which is the long term stable state and/or relapse where they fall back into a prior state of involvement with their elixir, their alcohol of choice.

Now, the stages of change, I laid out that sort of sequence first to help people understand that there are different strategies to be taken with someone who is in a pre-contemplation phase versus a contemplation phase. In a pre-contemplation phase you should not recommend someone stop forever. They are just going to dismiss you, but in the action phase that tool might be very, very practical.

Therapy is good when someone has made the commitment. They are beyond the contemplation phase, and they are ready to do something. There is a tremendous naïveté for most therapists, most family members in the idea that just because the client has shown up, let's say; at the treatment center they are ready to do something about it.

More often than now, my experience has been that just because they are at the treatment center or just because they are in the therapist's office does not mean they are ready to do something.

You need to use different tactics to motivate people to move one step at a time, one stage at a time and not sort of bring in the heavy guns too early in the process. If someone is still unsure if they have a problem, well, let's discuss that unsureness.

Let's discuss motivating them to consider it rather than to change it. Consider the consequences. Consider their relationship with it rather than to start going to 90 meetings of AA in 90 days. I can go in more details, but I am trying to give the essence of it.

David: Yeah, that's good. And one of the last stages that you mentioned was relapse, and relapse means returning back to the addictive behavior. Isn't it the case that people who succeed--I know in the case of quitting smoking--most people who ultimately succeed in quitting actually had several periods of relapse where they kind of fell off the wagon, so to speak. But, they kept at it and eventually were able to quit permanently.

Marc: Absolutely. I mean, the disease notion is that if you relapse, or the AA notion is that if you relapse you are a failure. If you went to AA you'd have to raise your hand and say you are a newcomer. Unfortunately, that brings about a lot of shame and embarrassment.

A lot of people avoid going back to using the 12-step program here because of that shame of relapse where the reality is most people relapse. Most people if they conceptualize relapse in a positive way as a moment of learning what are your strengths, what went wrong. They can actually bounce back from the relapse sooner and get back on the horse, so to speak, and ultimately succeed.

Relapse is a very important sort of a dimension, I believe, in recovery. Relapse should be expected not necessarily prescribed, and it should be handled in a way that does not bring about shame or blame because... If you had depression and you were seeing a therapist and six months into treatment you had a bout of depression, you would not be shamed because you had depression.

And yet, that is what happens in the disease model in the AA. They shame people in a way that often makes them feel bad that they have fallen back, when it is really a normal part of the recovery process.

David: OK. And then, I thought I saw a final step in the change model which you haven't discussed yet, which was called transcendence.

Marc: Oh well, that is actually my addition to the original Prochaska-DiClemente model. I am of the belief that beyond the model that they developed which seems to stop at maintenance that there is actually a stage where an individual actually transcends the entire struggle.

For me, I used to be a smoker, a cigarette smoker. Yes, I went through all of the stages just as they said, but there was also at this point, I believe, I transcended the sort of struggle, and I no longer really consider it. Oh, yes, once in a while I think about it, but I am beyond just maintaining maintenance.

For example, your description of yourself with alcohol. You've really transcended the struggle. You are really not just maintaining abstinence or for the most part from alcohol. You have transcended that push-pull, that triggering sort of effect that transcended the addictive struggle.

I think it is actually a useful notion to have that there for the person with an addiction that they can actually look forward to a day when they have transcended the entire dilemma, and the struggle is, for the most part, gone.

David: Well, what's your sense of success? I mean, you work with people around addictive issues. I think that addiction in general has this perception of being very difficult to treat, very challenging, maybe, not all that rewarding in area for a psychologist to devote his career to. What's been your experience?

Marc: Well, again, another very difficult question. I have not done any formal follow-up, but, you know, we have to understand what is success. In depression, again, I am bringing that in as a comparative sort of issue; do we say a person ever gets depressed again?

Well, as a specialist in harm reduction I don't necessarily mean that life long absence with never having a slip is the only marker of success. I see people who no longer have alcohol, for example, interfere with their life as successful.

So, success is actually a lot higher for me than, maybe, even perhaps a formal treatment program would say because I am not all caught up in the absolute notion that abstinence is the only criteria of success.

I really evaluate success in terms of quality of life. Do these individuals sustain healthy relationships in careers and the things that really are important? In a sense, only secondarily in concern would be these elixirs, the alcohol.

As a psychologist, this is very satisfying to work with people and help them achieve a stable state which may or may not include an occasional drink. And actually beyond the first couple of months I work with someone, most of the work is about overall life.

Functioning relationships and careers, and sort of health and spirituality are all part of the evolution out of an addictive relationship with a substance or an elixir.

David: OK. Another interesting thing that I saw on our website, I see that you have had some very kind of high profile interview situations. I feel very proud to be able to join the ranks of Larry King, for example. You were on the Larry King Show being interviewed.

Marc: Yeah.

David: And I read through the transcript of that interview. One of the nice things about being interviewed by me, I've been told by other interviewees, is that they have the luxury of kind of explaining themselves at some length.

I felt badly for you as I read through the Larry King interview where he had about six or seven people on, you know, round robin and it's moving really quickly, and you didn't really have much of a chance to explain yourself.

In a way, I thought maybe you had been blindsided because they introduced the case of Audrey Kishline as a potential blow to the concept of being able to, of moderation. She had written a book called "Moderate Drinking", and she was one of the founders of Moderation Management.

And she wound up killing two people after drinking. She killed two people in a car accident, and Larry King put the question to you, "Would you agree that that was a severe blow to the concept?" Let me ask you that question again.

Marc: It was a severe blow to the concept, but, again, it was more of a severe blow in terms of the politics. The reality is that Moderation Management today is alive and well and thriving. There are groups, and there are Internet groups all over the country. And there are thousands of people in it.

The reality is that most people, I mean, well over half the people with alcohol take on a recovery on their own and learn to either abstain or stop completely on their own without assistance from a therapist or a treatment program or AA or even a self-help group.

The politics was hurt because it did cast a bad shadow, but, again this is in my estimation, politics is the reporting. Even Larry King forgot to mention that Audrey had, well before the accident, left Moderation Management.

She was ultimately diagnosed as bi-polar and had difficulty. She couldn't hold on to keep within the Moderation Management goals and had left MM and had started attending AA.

During her involvement with AA and again going back to the shame and blame of relapse, when she relapsed she was too ashamed to go back to AA and apparently just kept on drinking. This is during the time where the accident happened. She was an active member within AA, attending regularly with a sponsor, doing the steps and was not an active member within MM at the time.

Again, on the political front and I've heard that many times people have approached professionals at different treatment programs, and they say, "Well, I want to learn how to drink moderately". And they just say, "Look at the founder of MM. She drove and killed people. And so, it means that no one can do it". Well, in that respect the movement was harmed, but the reality is people are going to try to moderate on their own with or without Audrey's situation.

I can't imagine one single person within AA who hasn't tried moderation. I mean, no one comes to the conclusion that you can't drink or shouldn't drink unless they have proven to themselves that moderation isn't viable. What Moderation Management offers is a legitimate forum for people to discuss openly, constructively be given guidelines and limitations and strategies where they can figure out whether moderation is viable or abstinence is the next step.

In fact, I am of the belief that Moderation Management, now that we're talking about this as a support group, is going to be one of the major stepping stones to people to abstinence. Now, there are many alternative abstinence groups other than AA. There are Smart Recovery, SOS, Women for Sobriety, a Life Ring and some others.

MM is a place people can come and talk openly about their relationship with alcohol, how much, how often and be given legitimate, professional guidance and come to the conclusion themselves whether they need to take that next step into lifelong abstinence or not.

David: That's all very helpful and very clarifying, and also it makes it clear. I didn't want to paint you into a corner of seeming to be against abstinence. So, you made it clear that you do recommend abstinence for those people for whom that's the only path that is going to work for them.

Marc: Right. I do tend to lean away from referring them to the traditional 12-step approach and refer them to... I work with them from a cogent behavioral standpoint which is the foundation of what Smart Recovery is. Smart Recovery stands for smart self-management and recovery training, and that's a national 501C self-help support group that also supports abstinence as the long term goal.

Again, I seem to have positioned myself in my career in my little niche as someone who people come to that are looking for an alternative to AA or an alternative to life long abstinence. It is often a very difficult step, and I help them come to a determination whether moderation is viable or not.

David: Talking about how you position yourself professionally, on your website I got the impression that you were positioning yourself more as a coach than as a psychotherapist. Was I reading that correctly?

Marc: Oh, absolutely. You are very astute. On my website and we are talking about either www.habitdoc.com website or my aaalternative.com website, I believe that there is a tremendous future in providing distance learning or providing second opinions to people around the country about their alcohol problem.

I am not yet convinced that the Internet can actually replace psychotherapy, so the reasoning behind my positioning myself as a coach on those websites is that I really don't believe that psychotherapy can be professionally provided with the current technology.

And that a coaching stance is really what I can provide or a second opinion about what are the resources, how severe the problem is. That is a much more authentic and comfortable stance for me on the telephone or via email with someone with an alcohol or drug problem than a therapist.

David: OK. Well, thanks very much for that clarification. That pretty much brings us to the closing point here unless there is anything else that you would like to add before we end up.

Marc: Just that if someone is looking for clarification around alcohol or looking for an alternative for abstinence there are many, many resources out there, many, many support groups. They should consider visiting one of my sites or even www.addictioninfo.org site which will just give them literature about this topic.

We don't live in an era of a shortage of information. You wouldn't go to a doctor who was trained in 1935 if that is still the mind set in this country around alcohol that the paradigm of 1935 still holds. That's the year of the big book being developed. Thank you for letting me say that, too.

David: Yeah. OK. I will definitely make sure that we put links to your various websites in our show notes. So, Dr. Mark Kern thanks so much for being my guest today on Wise Counsel.

Marc: Thank you so much, David.

[music]

David: I hope you learned some good information in this interview with Dr. Mark Kern and that you were not too distracted by the summer cold I am currently suffering from. I am sure you noticed the difference in my voice, and I think at times I may have been a little slower on the uptake than usual.

If you are interested in learning more about Moderation Management and harm reduction in relation to alcoholism and other addictions, be sure to check the links in our show notes on mentalhelp.net.

You have been listening to Wise Counsel, a podcast interview series sponsored by mentalhelp.net. If you found today's show interesting, we encourage you to visit mentalhelp.net where you can add a comment or question to this show's web page, view other shows in this series or simply page through the site which is full of interesting mental health and wellness content. Access this show's page and show archive information via the podcast box on the mentalhelp.net home page.

If you like Wise Counsel, you might also like Shrink Rap Radio, my other interview podcast series which is available online at www.shrinkrapradio.com, and rap is spelled r-a-p.

Until next time, this is Dr. David Van Nuys, and you have been listening to Wise Counsel.