Take It Easy

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From Failure to Enthusiasm

Guest Post

By Andy

"Success is walking from failure to failure with no loss of enthusiasm." —Winston Churchill

One of the reasons I love this quote, is because for many of us, being able to keep our enthusiasm up in the midst of trying times can be very difficult to achieve. But once you figure out how to never lose it, no matter how hard life can get, it will mark the difference between giving up and succeeding. I love this quote and remind myself every time that sobriety success is shaped by my attitude. In this post I’m going to take you through my personal sobriety journey.

The Addict/Alcoholic

When I was 4 years old my parents made the life changing decision of moving from Colombia to California. It was 1986 and the situation in my country was scary and very violent. Upon arrival in California my parents took on many jobs to be able to provide for me and my siblings; they worked really hard to make sure we would have a life full of opportunities.

The great thing about latinos is that culturally not only are we very hard working people, but we are also very happy people who love to party. And of course, no Colombian party is ever complete without that anise-flavored drink called Aguardiente. Not that all Colombian’s are drunks, it’s just simply something they enjoy once in awhile, when there’s a good excuse to celebrate.
The first time I got drunk was at a family friend’s house party when I was nine years old. I was always a pretty mischievous kid, therefore at the party my cousin and I played a game to see who could steal more shots of aguardiente without getting caught.

After a few shots I was feeling very different inside. I felt comfortable, more secure, I danced salsa with my sister and all my cousins, I felt great. From that night on I drank every time I had the chance.
At 15 a friend introduced me to marijuana. Although today teen drug use is declining, back when I was a teenager the statistic was increasing and at 19 I attended a party and some guys introduced me to meth and so began the downward spiral. At 23 I found myself incarcerated in Idaho on drug related charges for two years.

You might be wondering why I left so many parts of the story untold. Well, I’m not writing this to reminisce on war stories, being eight years sober now I believe myself to be a bit wiser and truth be told, a little tired of recounting my crazy times. Jail in Idaho was the starting point of my recovery, and that is the part of THIS story I really want share.

AA and NA

When you are in prison, any activity that can take you out of your cell is welcomed with open arms. So when I was told that I could attend the Alcoholics Anonymous meetings I did not hesitate. At the time I was not interested in recovery, in fact, I thought I didn't have a drinking problem or substance abuse problem. I just needed to do something else than read in bed. So I attended meetings without participating. It took three months of going to these meetings to realize that I might have a slight drinking and drug problem.

One day, a fellow inmate told the story of how he hit rock bottom. He was a high level accountant abusing drugs in order to deal with the insane amount of work and stress at his job, until one day, having suicidal thoughts, he got drunk and drove his car into a local store. He lost his job, his wife filed for divorce, his family had lost hope (this wasn’t his first run in with the law). He shared that apart from coming to terms with his drug and alcohol problems he had also realized that he also had an anger management problem, he concluded that “rage spawns from anger, anger spawns from hurt, hurt spawns from getting your feelings hurt.”

Like I said before, I thought I didn't have a problem. I was convinced that I was fine, that I wasn’t hurting anyone. But thanks to that inmate sharing his story and his realization my eyes were opened: I had hurt the only person I had to live with for the rest of my life and the damage I had done to myself needed to be repaired. I had a drinking problem, a drug problem, a personality problem...a life problem.

The Workaholic

Prison was everything but easy, but attending the AA and NA meetings and the friendships I built helped me get through it. Once I was released I had a new sense of responsibility, I knew I needed to find a job, and be able to provide for myself. But it wasn't easy. Having a criminal record made it a challenge to find a good job, so I struggled for months. And when I finally found one, I was unmotivated and feeling trapped in a routine. Despite attending my AA and NA meetings on a regular basis, I relapsed. I lost my job and life seemed unbearable, hence my voluntary check in to a rehab center in Idaho.

After 3 months in rehab I moved back to California where I landed a job selling knock-off cologne. Being closer to my family helped me immensely, therefore my motivation was higher than ever. I would wake up at 5:00 am to pick-up my co-workers and go to gas stations, shopping center parking lots, flea markets, etc. to sell perfume out of the trunk of my car. After a few months I had become very good at selling. I had learned how to approach strangers, how to pitch my product, make people feel comfortable and how to overcome rejection. The job was purely commission based, thus if I didn’t sell, I didn’t make money. There is a great feeling about making cash on a sale that I cannot really describe. It is a feeling of accomplishment, it is a feeling that I wanted to replicate time and time again. I was determined to keep working harder and harder.

Months went by and next thing I knew I was training more than 10 people to sell perfumes and other beauty products on the street. I had my own office, had ads running in the paper, had a secretary taking calls, etc. In that year I had lost ten pounds, I had zero friends, and I barely saw my family.

After a long conversation with a friend he presented me with a book by Jeffery Combs called Psychologically Unemployable (Jeffery is also a recovering addict). One of the most important things said is that you should never confuse obsession with passion. After reading it and studying it for a few weeks, I understood that I had simply traded drugs and alcohol for work. It was an addiction and it wasn't any better. I was getting physically sick and emotionally unstable from the pressure I was putting on myself.

The Entrepreneur

I sold my perfume business and moved into my parents house. It was really important in my road to recovery to have their support. After a month I got a job at Target, so I could help my parents pay the bills and have some sort of income. I had no passion for that job whatsoever, and I was completely unmotivated in that point of my life. I couldn't find balance between success and a healthy, happy life. Being afraid of relapsing I started attending weekly AA/NA meetings. I acquired a really good sponsor that I am very grateful for. He gave me the task of taking a class at the local community college.

At the time I was not very happy to do the task. I felt old and I thought there was no point in taking a measly course. I just wanted to go to work, do my job and pay my bills, that was it. Nevertheless, I forced myself to take a class. The class I took was called Introduction to Website Development (HTML). I liked computers and websites, so I thought, why not give it a shot?

You should have seen my bedroom after three months in the class. I had stacks of books and papers about HTML and website design. I found myself at the computer for hours, coding, creating, learning. Finally, one day I thought to myself that it would be great if I could make a business out of my new acquired skill.

Nine years later I co-own a successful digital marketing agency. I have a great team that I feel are like my family, in fact, my brother is part of it. We are based in Medellin, Colombia, which means my life has taken a 180 degree turn. 30 years ago my parents left Colombia to give my siblings and I a better life, now I am back with that better life.

I still go to meeting and try to keep in touch with some of the good friends I made on my way to recovery. We always give each other support during rough times. Being sober has become a part of my life now. My attitude defines me and I do not let anything take control of my emotions, it only gets easier with time. I have learned to attend dinner parties and skip the wine; to dance with my colombian friends and kindly decline those beers and still enjoy myself. In regards to my business, I didn't let myself get lost while pursuing success. I have learned that balance is what makes you successful. Being able to work hard for months enjoying what you do, but also taking a weekend off to recharge has proven to be a critical part of my work-life balance. I feel very fortunate because I went out and found something I was passionate about, put my skills and knowledge to work and built a business. Sobriety, just like building a business, does not happen overnight, one has to commit to it and work hard.

It’s Not All About You

When you are in the process of recovering, every single thing you do to maintain your sobriety seems to be about you. Every one of the 12 steps you complete, every single task or piece of homework your sponsor gives you, every book or article you read is all about you and your recovery. But after a while you realize, there's a bigger picture. And going back to that Winston Churchill quote, "Success is walking from failure to failure with no loss of enthusiasm," learning that failing is just a part of the process. Behind the most successful people are years of failure, even if it's on their way to sobriety or on their way to being a successful entrepreneur. The issue is not failing, since we all will go through it, it's to never lose enthusiasm. Good luck and thank you for reading my story.

Graphics: https://pocketperspectives.com

Why Will Power Fails

How to strengthen your self-control.

(First published August 12, 2013)

Reason in man obscured, or not obeyed,
Immediately inordinate desires,
And upstart passions, catch the government
From reason; and to servitude reduce
Man, till then free.
—John Milton, Paradise Lost

What is will power? Is it the same as delayed gratification? Why is will power “far from bulletproof,” as researchers put it in a recent article for Neuron? Why is willpower “less successful during ‘hot’ emotional states”? And why do people “ration their access to ‘vices’ like cigarettes and junk foods by purchasing them in smaller quantities,” despite the fact that it’s cheaper to buy in bulk?

 Everyone, from children to grandparents, can be lured by the pull of immediate gratification, at the expense of large—but delayed—rewards. By means of a process known as temporal discounting, the subjective value of a reward declines as the delay to its receipt increases. Rational Man, Economic Man, shouldn’t behave in a manner clearly contrary to his or her own best interest. However, as Crockett et. al. point out in a recent paper in Neuron “struggles with self-control pervade daily life and characterize an array of dysfunctional behaviors, including addiction, overeating, overspending, and procrastination.”

Previous research has focused primarily on “the effortful inhibition of impulses” known as will power. Crockett and coworkers wanted to investigate another means by which people resist temptations. This alternative self-control strategy is called precommitment, “in which people anticipate self-control failures and prospectively restrict their access to temptations.” Good examples of this approach include avoiding the purchase of unhealthy foods so that they don’t constitute a short-term temptation at home, and putting money in financial accounts featuring steep penalties for early withdrawal. These strategies are commonplace, and that’s because people generally understand that will power is far from foolproof against short-term temptation. People adopt strategies, like precommitment, precisely because they are anticipating the possibility of a failure of self-control. We talk a good game about will power and self-control in addiction treatment, but the truth is, nobody really trusts it—and for good reason.  The person who still trusts will power has not been sufficiently tempted.

The researchers were looking for the neural mechanisms that underlie precommitment, so that they could compare them with brain scans of people exercising simple self-control in the face of short-term temptation.

After behavioral and fMRI testing, the investigators used preselected erotic imagery rated by subjects as either less desirable ( smaller-sooner reward, or SS), or more highly desirable ( larger-later reward, or LL). The protocol is complicated, and the analysis of brain scans is inherently controversial. But previous studies have shown heightened activity in three brain areas when subjects are engaged in “effortful inhibition of impulses.” These are the dorsolateral prefrontal cortex (DLPFC), the inferior frontal gyrus (IFG), and the posterior parietal cortex (PPC). But when presented with opportunities to precommit by making a binding choice that eliminated short-term temptation, activity increased in a brain region known as the lateral frontopolar cortex (LFPC).  Study participants who scored high on impulsivity tests were inclined to precommit to the binding choice.

In that sense, impulsivity can be defined as the abrupt breakdown of will power. Activity in the LFPC has been associated with value-based decision-making and counterfactual thinking. LFPC activity barely rose above zero when subjects actively resisted a short-term temptation using will power.  Subjects who chose the option to precommit, who were sensitive to the opportunity to make binding choices about the picture they most wanted to see, showed significant activity in the LFPC. “Participants were less likely to receive large delayed reward when they had to actively resist smaller-sooner reward, compared to when they could precommit to choosing the larger reward before being exposed to temptation.”

Here is how it looks to Molly Crockett and her fellow authors of the Neuron article:

Precommitment is adaptive when willpower failures are expected…. One computationally plausible neural mechanism is a hierarchical model of self-control in which an anatomically distinct network monitors the integrity of will-power processes and implements precommitment decisions by controlling activity in those same regions. The lateral frontopolar cortex (LFPC) is a strong candidate for serving this role.

None of the three brain regions implicated in the act of will power were active when opportunities to precommit were presented.  Precommitment, the authors conclude, “may involve recognizing, based on past experience, that future self-control failures are likely if temptations are present. Previous studies of the LFPC suggest that this region specifically plays a role in comparing alternative courses of action with potentially different expected values.” Precommitment, then, may arise as an alternative strategy; a byproduct of learning and memory related to experiences “about one’s own self-control abilities.”

There are plenty of caveats for this study: A small number of participants, the use of pictorial temptations, and the short time span for precommitment decisions, compared to real-world scenarios where delays to greater rewards can take weeks or months. But clearly something in us often knows that, in the immortal words of Carrie Fisher, “instant gratification takes too long.” For this unlucky subset, precommitment may be a vitally important cognitive strategy. “Humans may be woefully vulnerable to self-control failures,” the authors conclude, “but thankfully, we are sometimes sufficiently far-sighted to circumvent our inevitable shortcomings.” We learn—some of us—not to put ourselves in the path of temptation so readily.


Photo Credit: http://cassandralathamjones.wordpress.com/

Drugs and Disease: A Look Forward

First published 2/18/2014.

Former National Institute on Drug Abuse (NIDA) director Alan Leshner has been vilified by many for referring to addiction as a chronic, relapsing “brain disease.” What often goes unmentioned is Leshner’s far more interesting characterization of addiction as the “quintessential biobehavioral disorder.”

Multifactorial illnesses present special challenges to our way of thinking about disease. Addiction and other biopsychosocial disorders often show symptoms at odds with disease, as people generally understand it. For patients and medical professionals alike, questions about the disease aspect of addiction tie into larger fears about the medicalization of human behavior.

These confusions are mostly understandable. Everybody knows what cancer is—a disease of the cells. Schizophrenia? Some kind of brain illness. But addiction? Addiction strikes many people as too much a part of the world, impacted too strongly by environment, culture, behavior, psychology, to qualify. But many diseases have these additional components. In the end, the meaning of addiction matters less than the physiological facts of addiction.

One of the attractions of medical models of addiction is that there is such an extensive set of data supporting that alignment. Specifically, as set down in a famous paper by National Institute of Drug Abuse director Nora Volkow and co-author Joanna Fowler: “Understanding the changes in the brain which occur in the transition from normal to addictive behavior has major implications in public health…. We postulate that intermittent dopaminergic activation of reward circuits secondary to drug self-administration leads to dysfunction of the orbitofrontal cortex via the striato-thalamo-orbitofrontal circuit.” This cascade of events is often referred to as the “hijacking” of the brain by addictive drugs, but nothing is really being hijacked. Rather, the abusive use of drugs changes the brain, and that should come as no surprise, since almost everything we do in the world has the potential of changing the brain in some way. “Why are we so surprised that when you take a poison a thousand times, it makes some changes in your head?” said the former director of a chemical dependency treatment program at the University of Minnesota. “It makes sense that [addictive drugs] change things.”

Critics like Fernando Vidal object to a perceived shift from “having a brain” to “being a brain.” He is saying that he cannot see the point of “privileging” the brain as a locus for the study of human behavior. In “Addiction and the Brain-Disease Fallacy,” which appeared in Frontiers in Psychiatry, Sally Satel and Scott Lillienfeld write that “the brain disease model obscures the dimension of choice in addiction, the capacity to respond to incentives, and also the essential fact people use drugs for reasons (as consistent with a self-medication hypothesis).”

An excellent example of the excesses of the anti-brain discussions is an article by Rachel Hammer of Mayo Clinic and colleagues, in the American Journal of Bioethics-Neuroscience. “Many believed that a disease diagnosis diminishes moral judgment while reinforcing the imperative that the sick persons take responsibility for their condition and seek treatment.” But only a few paragraphs later, the authors admit: “Scholars have theorized that addiction-as-disease finds favor among recovering addicts because it provides a narrative that allows the person simultaneously to own and yet disown deviant acts while addicted.” Furthermore: “Addiction reframed as a pathology of the weak-brained (or weak-gened) bears just as must potential for wielding stigma and creating marginalized populations." But again, the risk of this potentially damaging new form of stigma “was not a view held by the majority of our addicted participants…”

And so on. The anti-disease model authors seem not to care that addicted individuals are often immensely helped by, and hugely grateful for, disease conceptions of their disorder, even though Hammer is willing to admit that the disease conception has “benefits for addicts’ internal climates.” In fact, it often helps addicts establish a healthier internal mental climate, in which they can more reasonably contemplate treatment. Historian David Courtwright, writing in BioSocieties, says that the most obvious reason for this conundrum is that “the brain disease model has so far failed to yield much practical therapeutic value.” The disease paradigm has not greatly increased the amount of “actionable etiology” available to medical and public health practitioners. “Clinicians have acquired some drugs, such as Wellbutrin and Chantix for smokers, Campral for alcoholics or buprenorphine for heroin addicts, but no magic bullets.” Physicians and health workers are “stuck in therapeutic limbo,” Courtwright believes.

“If the brain disease model ever yields a pharmacotherapy that curbs craving, or a vaccine that blocks drug euphoria, as some researchers hope,” Courtwright says, “we should expect the rapid medicalization of the field. Under those dramatically cost-effective circumstances, politicians and police would be more willing to surrender authority to physicians.” The drug-abuse field is characterized by, “at best, incomplete and contested medicalization.” That certainly seems to be true. If we are still contesting whether the brain has anything essential to do with addiction, then yes, almost everything about the field remains “incomplete and contested.”

Sociologists Nikolas Rose and Joelle M. Abi-Rached, in their book Neuro, take the field of sociology to task for its “often unarticulated conception of human beings as sense making creatures, shaped by webs of signification that are culturally and historically variable and embedded in social institutions that owe nothing substantial to biology.”

And for those worried about problems with addicts in the legal system, specifically, over issues of free will, genetic determinism, criminal culpability, and the “diseasing” of everything, Rose and Abi-Rached bring good news: “Probabilistic arguments, to the effect that persons of type A, or with condition B, are in general more likely to commit act X, or fail to commit act Y, hold little or no sway in the process of determining guilt.” And this seems unlikely to change in the likely future, despite the growing numbers of books and magazine articles saying that it will.

Opponents of the disease model of addiction and other mental disorders are shocked, absolutely shocked, at the proliferation of “neuro” this and “neuro” that, particularly in the fields of advertising and self-improvement, where neurotrainers and neuroenhancing potions are the talk of the moment. Sociologists claim to see some new and sinister configuration of personhood, where a journalist might just see a pile of cheesy advertising and a bunch of fast-talking science hucksters maneuvering for another shot at the main chance. When has selling snake oil ever been out of fashion?

For harm reductionists, addiction is sometimes viewed as a learning disorder. This semantic construction seems to hold out the possibility of learning to drink or use drugs moderately after using them addictively. The fact that some non-alcoholics drink too much and ought to cut back, just as some recreational drug users need to ease up, is certainly a public health issue—but one that is distinct in almost every way from the issue of biochemical addiction. By concentrating on the fuzziest part of the spectrum, where problem drinking merges into alcoholism, we’ve introduced fuzzy thinking with regard to at least some of the existing addiction research base. And that doesn’t help anybody find common ground.

Graphics Credit: http://www.docslide.com/disease-model/

Hazelden Offers Companion to the “Big Book”

New guide attempts a modest AA update.

The founders of AA published their book, Alcoholics Anonymous (The Big Book) back in 1939. The world has changed a great deal since then, so it’s not surprising that there have been periodic calls for an update. Barring an official revision, which is unlikely, Hazelden, the Minnesota treatment organization, has published an updated companion volume to the Big Book. (Narcotics Anonymous published their version of the basic text in 1962). “The core principles and practices offered in these basic texts hold strong today,” says Hazelden, “but addiction science and societal norms have changed dramatically since these books were first published decades ago.”

Hazelden’s book, Recovery Now, billed as an easy-to-follow guide to the teachings of Alcoholics Anonymous and Narcotics Anonymous, dispenses with the divisive question of medications for withdrawal straightaway. In a foreword by Dr. Marvin D. Seppala, chief medical officer at Hazelden, the doctor makes it clear: “I agree with the majority of treatment professionals who support using these meds to help with cravings when it is appropriate to do so. Addiction is a disease that calls for the best that science has to offer.” The unnamed authors of the “little green book” agree, stating that “for some mental health disorders, medications such as antidepressants are needed. These aren’t addictive chemicals and so professionals, as well as AA and NA, accept that we can take them and still be considered clean and sober (abstinent).” There are now, as well, specific Twelve Step groups for those with both addiction disorders and mental health disorders: Dual Diagnosis Anonymous and Dual Recovery Anonymous among them.

As Seppala points out in the foreword, when some alcoholics and other drug addicts hear about the research showing that addiction is similar to many other mental and physical disorders we call diseases, it reorients their thinking amid the shame, stigma, and negative emotional states associated with active addiction. For some, it opens the door to treatment.

Okay. Hazelden, Betty Ford, and many other major treatment providers are no longer fighting a rear-guard action against a host of medications, from buprenorphine to Zoloft. But two-thirds of the Big Book consists of stories of how people recognized and dealt with their sundry addictions. That’s really about it, which tracks well with AA’s core operating principle: one drunk helping another. AA believes that much of its success stems from the fact that the program is run by the members, without direct rule setting and intervention from organizations, including their own. (All statements hold for NA as well).

What else? Recovery Now takes on another sticking point for many: the fact that “the AA Big Book and other writings include traditional male-focused and religious language, like discussing God as a ‘he.’” And there is the matter of “the realities and stereotypes of the 1930s, which is why it contains a chapter titled ‘To the Wives.’” Hazelden continues the recent tradition of broadening acceptable interpretations of “higher power.” One example given is from Samantha, a young cocaine and alcohol addict: “My higher power is the energy of this group. I call her Zelda.”

The book presents some of the psychological aspects of the AA program as a sort of reverse cognitive behavioral therapy. CBT attempts to teach people how to unkink their thinking and turn harmful thoughts into helpful ones. AA attempts to convince people to first change their behavior—“fake it until you make it”—and helpful thoughts will follow.

Perhaps the genuine sea change lies in this passage, which can be contrasted with the faith and certainty with which the Big Book proclaims that AA will work for all but the most stubbornly self-centered. Even with the myriad of choices of AA groups now available, Hazelden acknowledges that “a group based on the Twelve Steps doesn’t work for all of us. Some of us have found help in recovery groups that offer alternatives to the Twelve Steps, such as SMART Recovery, Women for Sobriety, and Secular Organizations for Sobriety.”  This is a change of heart, given that groups like SMART Recovery don’t necessarily buy the idea of total abstinence, and often structure recovery as an exercise in controlled drinking. Hazelden also suggests that many of “us” have found the necessary ongoing support for recovery at churches, mental health centers, and nonreligious peer support groups.

As for anonymity, Recovery Now states: “While Twelve Step members do not reveal anything about another member of the group, any one of us may choose to go public with our own story.” Another promising development is the proliferation of Twelve Step meetings catering to specific populations—AA meetings for African Americans, Latinos, Native Americans, women, seniors, gays, and drug-specific (Cocaine Anonymous).

In the end, one of the best arguments for attendance at the AA program (free of charge) is that many addicts have “worn out our welcome” with families and friends, “and they have a hard time putting all that behind them and supporting us completely. But at most Twelve Step recovery meetings we can find the support we need.”

Craving Relief

Why is it so hard for addicts to say “enough?”

One of the useful things that may yet come out of the much-derided DSM-5 manual of mental disorders is the addition of craving as a criterion for addiction. “Cravings,” writes Dr. Omar Manejwala, a psychiatrist and the former medical director of Hazelden, “are at the heart of all addictive and compulsive behaviors.” Unlike the previous two volumes in this monthful of addiction books, Manejwala’s book, Craving: Why We Can’t Seem To Get Enough,  focuses on a specific aspect common to all addiction syndromes, and looks at what people might do to lessen its grip.

Why do cravings matter? Because they are the engine of addiction, and can lead people to “throw away all the things that really matter to them in exchange for a short-term fix that is often over before it even starts.” When Dr. Manejwala asked a group of patients to explain what they were thinking when they relapsed, their answer was often the same: “I was so STUPID.” But the author had tested these people. “I knew their IQs.” And the best explanation these intelligent addicts could offer “was the one explanation that could not possibly be true.”

In my book, The Chemical Carousel, I quoted former National Institute on Alcohol Abuse and Alcoholism (NIAAA) director T.K. Li on the subject of craving: “We already have a perfect drug to make alcohol aversive—and that’s Antabuse. But people don’t take it. Why don’t they take it? Because they still crave. And so they stop taking it. You have to attack the other side, and hit the craving.” However, if you ask addicts about craving when they are high, or have ready access, they will often downplay its importance. It is drug access unexpectedly denied that sets up some of the fiercest cravings of all. Conversely, many addicts find that they crave less in a situation where they cannot possibly score drugs or alcohol—at a health retreat, or on vacation at a remote locale.

Why are cravings so hard to explain? One reason is that “people use the word to mean so many different things.” You don’t crave everything you want, as Manejwala points out. Cravings are not the same as wants, desires, urges, passions, or interests. They are “stickier.” The brain science behind craving starts with the downregulation of dopamine and other neurotransmitters. As the brain is artificially flooded with neurotransmitters triggered by drug use, the brain goes into conservation mode and cuts back on, say, the number of dopamine receptors in a given part of the brain. In the absence of the drug, the brain is suddenly “lopsided,” and time has to pass while neural plasticity copes with the new (old) state of affairs. In the interim, the unbalanced state of affairs is a prime ingredient in the experience of craving.

Cravings are “disturbingly intense” (Manejwala) and “incomprehensibly demoralizing” (AA). Alcohol researcher George Koob called craving a state of “spiraling distress.” Cravings are not necessarily about reward, but about anticipating relief. “The overwhelming biological process in addictive craving is really a complex set of desperate, survival-based drives to feel ‘normal,’” says Manejwala.

The late Alan Marlatt, a psychologist who studied cravings for years, proposed that apparently irrelevant decisions could trigger or prevent relapse, almost without the addict knowing it. Turning left at an intersection, toward the supermarket, or turning right, toward the liquor store, can feel arbitrary and dissociated from desire. We also know that environmental cues can trigger craving, such as the site of a crack house where an addict used to do his business. Manejwala points to research showing that “some relapses related to cues and context are mediated by a small subgroup of neurons in the medial prefrontal cortex,” and suggests that it may be possible in the future to target this area with drug therapy.

Manejwala is unabashedly pro-12 Step, and favors traditional group work as the standard therapy. For example, he points to a Cochrane analysis of 50 trials showing that group participation roughly doubles a smoker’s chance of quitting. One of the reasons AA works for some people is that AA attendance reduces “pro-drinking social ties.” Simply put, if you are sitting with your AA pals in a meeting, you’re not out with your drinking buddies at the tavern. The author admits, however that alternatives such as SMART recovery work for some people, and that “sadly, much energy has been wasted as members of these various organizations bicker with each other about which works best, and this leaves the newcomer perplexed…. Over 20 million American are in recovery from addiction to alcohol and drugs. I can tell you this much: they didn’t all do it the same way.”

And along the way, you can be sure that all of them became familiar with cravings. Manejwala offers several strategies for managing cravings, and I paraphrase a few of them here:

—Join something. Participate. Get out of your own head and become actively involved in some group, any group, doing something you are interested in.

—Hang around people who are good at recovery. Long-timers, with a solid base of sobriety. You will not only learn HOW to do it, but that it CAN be done.

—Write stuff down. This makes you pay attention to what you’re doing. Keep a cigarette log. Count calories. Know what you’re spending per month on alcohol. Educate yourself about your addiction.

—Tell someone. Tell somebody you trust, because if there is anything harder than dealing with cravings from drinking, smoking, or drugging, it’s doing it in secret.

—Be teachable. Watch out for confirmation bias. “When you think you have the answers, it’s hard to hear alternatives.”

—Empathy matters. The author notes that the Big Book insists that by gaining sobriety, “you will learn the full meaning of ‘Love thy neighbor as thyself.’” Altruism may have evolutionary, physiological, and psychological implications we haven’t worked out yet.

Looking For the Science Behind the Twelve Steps

Transcendence, or nonsense?

What is it with the Twelve Steps? How, in the age of neuromedicine, do we account for the enduring concept of spiritual awakening available through “working the steps?” In Hijacking the Brain, Dr. Louis Teresi, former chief of neuroradiology at Long Beach Memorial Medical Center, along with Dr. Harry Haroutunian of the Betty Ford Center, sets themselves a formidable goal: “The sole intention of Hijacking the Brain is to connect the dots between an ‘organic brain disease’ and a ‘spiritual solution’ with sound physical, scientific evidence.” (For those who have grown weary of the overuse of “hijacked” brains in science writing, Teresi notes that an earlier term for the same idea was “commandeered.”)

Twelve Step programs remain popular, work for some addicts, and have their very vocal advocates in the recovery community. Outsiders are sometimes surprised to learn, writes Keith Humphreys, research scientist with the Veterans Health Administration and a professor at Stanford, that many of the people most profoundly and successfully affected by the 12-Step Program had “little or no interest in spirituality.”

The primary manifestation of this is the Twelve-Step Facilitation model (TSF), or Minnesota model, in honor of the Hazelden treatment facility in that state. Put simply, how do we go about explaining, in scientific terms, how a program like AA can have direct effects on a disease of the brain?

According to one strongly held view, we can’t. If there is something spiritual about recovery, it’s not anything that a medical doctor, who should have oversight of drug recovery and treatment programs, ought to be directly concerned with. Since the Twelve Step principles are explicitly spiritual in nature, how they apply to an organic brain disease is not at all clear. If you have cancer, your oncologists first line of thought is not usually, “why don’t you join a self-help group?” Writing for The Fix, health journalist Maia Szalavitz notes that “for no other medical disorder is meeting and praying considered reimbursable treatment: if a doctor recommended these religious or spiritual practices for the primary treatment of cancer or depression, you would be able to sue successfully for malpractice.” 

At an immediate level, the “power of the group,” which AA and other Twelve-Step Programs seems to tap into isn’t so hard to understand. Here are some of the obvious advantages of group work, as Teresi sees it:

--A reduction in the sense of isolation addicts feel.
--Useful information for addicts who are new to the processes of recovery.
--A way for people to see how others have dealt with similar problems.
--Additional structure and discipline for people whose living situations are often chaotic.

Teresi follows a common methodology, splitting the question into three dimensions: physical (an “allergy of the body driven by exaggerated limbic activity), mental (cognitive obsessions and compulsive drug use), and spiritual (an existential dilemma; a malady of the “soul”.) But the “spiritual awakening” that relieves this feeling and allows the addict to enter sobriety remains maddeningly ineffable: “The personality change sufficient to bring about recovery from alcoholism (addiction) has manifested itself among us in many different forms,” the Big Book cryptically affirms.

What makes it click for many addicts is what Teresi terms “empathic socialization,” defined as follows: “Positive socializing experiences received in support and therapeutic groups, such as praise, affection and empathic understanding, activate the brain’s reward centers as much as other natural rewards and similar to addictive substances. More importantly, belonging to an empathetic group reduces stress, a predominant cause and catalyst of addiction.”

Most people have only a hazy idea about what the Twelve Steps entail—something about admitting powerlessness over drugs, making amends for past wrongs, invoking a vague power higher than oneself. And the payoff? The reward for all the strenuous self-searching and personal honesty?

As Teresi sums it up: “inner peace, freedom, happiness, intuition, and alleviation of fear.” A heady package, indeed. All in return for achieving an emotional state called gratitude. Where are we to find the science in these claims?

Even though he doesn't solve the mystery, Dr. Teresi does offer  thoughts on some of the mechanisms in question, one of which is commonly referred to as an “attitude of gratitude” among Twelve-Step practitioners. “Gratitude for blessings received,” as it says the Big Book, is biochemically effective, Teresi argues. “In this regard,” Teresi writes, “grateful people show less negative coping strategies; that is, they are less likely to try to avoid the problem, deny there is a problem, blame themselves, or use mood-altering substances. Those with gratitude express more satisfaction with their lives and social relationships.”

And stress is where Dr. Teresi focuses his argument. More precisely, the working of the steps in Alcoholics Anonymous and kindred organizations involves “letting go” of high-stress states such as fear, guilt, self-loathing, and resentment. In Teresi’s thinking, the “power of the group” resides in its ability to reduce stress responses—and to raise levels of the “tend-and befriend” hormone, oxytocin. Oxytocin interacts with dopamine to increase maternal care, social attachments, and other affiliative behaviors and emotions. Thus, social rewards stir up a fair share of dopamine in reward centers of the brain, too. When alcoholics admit to powerlessness over alcohol, they are moving from a state of high autonomic nervous system tone to a more relaxed, “thank goodness that burden has been dropped” modality. This admission, when made as a conscious cognitive choice, and internalized through repetition and group motivation, lowers blood pressure and stress hormone levels, creating a more relaxed metabolic tone.

That is, in any event, how Teresi sees it. By confronting stress in this fashion, he believes that people with addictions can draw strength from group experience, even in the absence of personal religious belief.

Measures of Twelve-Step success will never be as precise as people would like. Not only does the national organization of AA generally avoid engaging in follow-ups, but the structure, or lack of it, works against precision measurements as well. As Teresi writes, “Anyone can start a Twelve-Step group by contacting the general service counsel of the organization of their interest, finding a meeting place (sometimes a person’s home) and adopting a readily available meeting protocol.” In fully monetized form, the Twelve Steps become Hazelden, or the Betty Ford Center. In supercharged upper income mode, it’s Passages and Promises. There is more going on here than simply a call to the pre-existing church-going addict. “AA,” says Keith Humphreys,  “is thus much more broad in its appeal than is commonly recognized.”

Teresi’s stated goal of connecting the dots isn’t an easy one. AA Twelve Steps and Twelve Traditions states unambiguously that the steps are “a group of principles, spiritual in their nature, which, if practiced as a way of life, can expel the obsession to drink and enable the sufferer to become happily and usefully whole.” In another passage, the Big Book refers to this as a personality change “sufficient to bring about recovery from alcoholism (addiction).” The explanations and definitions are maddeningly circular—unless you happen to be one of the people for whom the obsession to drink has been expelled through this practices.

Teresi believes it is possible to explore this terrain in a “belief neutral” manner, “with findings applicable to those who believe in a single God, multiple gods, or no God at all." Spiritual practices, Teresi believes, promote recovery in three ways. Meditation and some forms of prayer reduce stress levels. Techniques that lower stress have also been shown to stimulate limbic reward centers, “modulating emotion while strengthening attention and memory.” Finally, “spiritual practices, through improving morals and interpersonal behavior, foster closeness and a sense of community with one’s fellows and satisfy our instinctual need for social connection, also reducing stress.”

John Berryman and the Poetry of “Irresistible Descent”

“The penal colony’s prime scribe.”

“Will power is nothing. Morals is nothing. Lord, this is illness.”
—John Berryman, 1971

A year before he committed suicide by jumping off a Minneapolis bridge in 1972, Pulitzer Prize-winning poet John Berryman had been in alcohol rehab three times, and had published a rambling, curious, unfinished book about his treatment experiences. Recovery is a time capsule. If you think we have little to offer addicts by way of treatment these days, consider the picture in the 60s and 70s. In Recovery, treatment consists almost entirely of Freudian group analysis, and while there is regular talk of alcoholism as a disease, AA style, there is no evidence that it was actually dealt with in this way, after detoxification.

Best known for “Dream Songs,” Berryman taught at the University of Minnesota, and was known as a dedicated if irascible professor. Scientist Alan Severence, Berryman’s stand-in persona in the book, comes into rehab hard and recalcitrant, despite his previous failures: “Screw all these humorless bastards sitting around congratulating themselves on being sober, what’s so wonderful about being sober? Great Christ, most of the world is sober, and look at it!” And he is suffering from “the even deeper delusion that my science and art depended on my drinking, or at least were connected with it, could not be attacked directly. Too far down.”

Berryman was a difficult man, and knew it. He quotes F. Scott Fitzgerald: “When drunk, I make them pay and pay and pay and pay.”

Alcoholics, writes Berryman, are “rigid, childish, intolerant, programmatic. They have to live furtive lives. Your only chance is to come out in the open.” Berryman catches the flavor of group interaction after too many hours, too much frustration, and too much craving. One inpatient lashes out: “You’re lying when you say you do not do anything about your anger. You get bombed. It is called medicating the feelings, pal. Every inappropriate drinker does it. Cause and effect. Visible to a child. Not visible to you.”

Berryman was a shrewd observer, a singular writer, and, after all, a poet. He is extraordinary on the subject of alcoholic dissociation: “I found myself wondering whether I would turn off right towards the University and the bus home or whether I would just continue right on to the Circle and up right one block to the main bar I use there, and have a few. Wondering. My whole fate depending on pure chance…. as if one were not even one’s own actor but only a spectator.”

Berryman puts it all together in a horrific capsule description of the “irresistible descent, for the person incomprehensibly determined.”

Relief drinking occasional then constant, increase in alcohol tolerance, first blackouts, surreptitious drinking, growing dependence, urgency of FIRST drinks, guilt spreading, unable to bear discussion of the problem, blackout crescendo, failure of ability to stop along with others (the evening really begins after you leave the party)… grandiose and aggressive behavior, remorse without respite, controls fail, resolutions fail, decline of other interests, avoidance of wife and friends and colleagues, work troubles, irrational resentments, inability to eat, erosion of the ordinary will, tremor and sweating… injuries, moral deterioration, impaired and delusional thinking, low bars and witless cronies….

Berryman had no illusions about his failed attempt to hide behind the mask of a social drinker: “It seems to be loss of control. Unpredictability. That’s all. A social drinker knows when he can stop. Also, in a general way, his life-style does not arrange itself around the chemical, as ours does. For instance, he does not go on the wagon…”

In the end, he was "pleading the universal case of hope for abnormal drinkers, for all despairing and deluded sufferers fighting for their sanity in a world not much less insane itself and similarly half-bent on self-destruction…”

As the head nurse in the facility tells the group: “You are all suffering from the lack of self-confidence… often so powerful that it leads to consideration of suicide, a plan which if adopted will leave you really invulnerable, quite safe at last.”

And as Saul Bellow wrote in the introduction to Recovery: “At last there was no more. Reinforcements failed to arrive. Forces were not joined. The cycle of resolution, reform and relapse had become a bad joke which could not continue.” Berryman agreed. Toward the end, he wrote: “I certainly don’t think I’ll last much longer.”

“There’s hope until you’re dead,” a woman tells him during his final stay in rehab. Sadly, that hope ended a few months later.


Photo posted by Tom Sutpen for the series: Poets are both clean and warm

What Do We Mean When We Talk About Craving?

An essay on drug addiction and need.

For years, craving was represented by the tortured tremors and sweaty nightmares of extreme heroin and alcohol withdrawal. Significantly, however, the one symptom common to all forms of withdrawal and craving is anxiety. This prominent manifestation of craving plays out along a common set of axes: depression/dysphoria, anger/irritability, and anxiety/panic. These biochemical states are the result of the “spiraling distress” (George Koob’s term) and “incomprehensible demoralization” (AA’s term) produced by the addictive cycle. The mechanism driving this distress and demoralization is the progressive dysregulation of brain reward systems, leading to biologically based craving. The chemistry of excess drives the engine of addiction, which in turn drives the body and the brain to seek more of the drug.

Whatever the neuroscientists wanted to call it, addicts know it as “jonesing,” from the verb “to jones,” meaning to go without, to crave, to suffer the rigors of withdrawal. Spiraling distress, to say the least—a spiraling rollercoaster to hell, sometimes. Most doctors don’t get it, and neither do a lot of the therapists, and least of all the public policy makers. Drug craving is ineffable to the outsider.

As most people know, behavior can be conditioned. From maze-running rats to the “brain-washed” prisoners of the Korean War, from hypnotism to trance states and beyond, psychologists have produced a large body of evidence about behavior change—how it is accomplished, how it can be reinforced, and how it is linked to the matter of reward.

It is pointless to maintain that drug craving is “all in the mind,” as if it were some novel form of hypochondria. Hard-core addicts display all the earmarks of the classical behavioral conditioning first highlighted almost a century ago by Ivan Pavlov, the Russian physiologist. Pavlov demonstrated that animals respond in measurable and repeatable ways to the anticipation of stimuli, once they have been conditioned by the stimuli. In his famous experiment, Pavlov rang a bell before feeding a group of dogs. After sufficient conditioning, the dogs would salivate in anticipation of the food whenever Pavlov rang the bell. This conditioned response extended to drugs, as Pavlov showed. When Pavlov sounded a tone before injecting the dogs with morphine, for example, the animals began to exhibit strong physiological signs associated with morphine use at the sound of the tone alone. Over time, if the bell continued to sound, but no food was presented, or no drugs were injected, the conditioned response gradually lost its force. This process is called extinction.

Physical cravings are easy to demonstrate. Abstinent heroin addicts, exposed to pictures of syringes, needles, or spoons, sometimes exhibit withdrawal symptoms such as runny noses, tears, and body aches. Cravings can suddenly assail a person months—or even years—after discontinuing abusive drug use. Drug-seeking behavior is a sobering lesson in the degree to which the human mind can be manipulated by itself. The remarkable tenacity of behavioral conditioning has been demonstrated in recent animal studies as well. When monkeys are injected with morphine while recorded music is played, the music alone will bring on withdrawal symptoms months after the discontinuation of the injections.  When alcoholics get the shakes, when benzodiazepine addicts go into convulsions, when heroin addicts start to sweat and twitch, the body is craving the drug, and there is not much doubt about it. But that is not the end of the matter.

“Craving is a very misunderstood word,” said Dr. Ed Sellers, now with the Centre for Addiction and Mental Health in Toronto. “It’s a shorthand for describing a behavior, but the behavior is more complicated and interesting than that. It’s thought to be some intrinsic property of the individual that drives them in an almost compulsive, mad way. But in fact when you try to pin it down—when you ask people in a general context when they’re exposed to drugs about their desire to use drugs, they generally give rather low assessments of how important it really is.”

While cravings can sometimes drive addicts in an almost autonomic way, drug-seeking urges are often closely related to context, setting, and the expectancy effect. It has become commonplace to hear recovering addicts report that they were sailing through abstinence without major problems, until one day, confronted with a beer commercial on television, or a photograph of a crack pipe, or a pack of rolling papers—or, in one memorable case of cocaine addiction, a small mound of baking powder left on a shelf—they were suddenly overpowered by an onrush of cravings which they could not successfully combat. “If you put them in a setting where the drug is not available, but the cues are,” said Sellers, “it will evoke a conditioned response, and you can show that the desire to use goes up.” Most people have experienced a mild approximation of this phenomenon with regard to appetite. When people are hungry, a picture of a cherry pie, or even the internal picture of food in the mind’s eye, is enough to cause salivation and stomach rumblings. Given the chemical grip which addiction can exert, imagine the inner turmoil that the sight of a beer commercial on television can sometimes elicit in a newly abstinent alcoholic.

When addicts start to use drugs again after a period of going without, they are able to regain their former level of abuse within a matter of days, or even hours. Some sort of metabolic template in the body, once activated, seems to remain dormant during abstinence, and springs back to life during relapse, allowing addicts to escalate to their former levels of abuse with astonishing speed. This fact, and no other, is behind the 12-Step notion of referring to oneself as a “recovering,” rather than recovered, addict—a semantic twist that infuriates some people, since it seems to imply that an addict is never well, never cured, for a lifetime.

Relapse sometimes seems to happen even before addicts have had a chance to consciously consider the ramifications of what they are about to do. In A.A., this is often referred to as forgetting why you can’t drink. It sounds absurd, but it is a relatively accurate way of viewing relapse. Addiction, as one addict explained, “is the only disease that tells you you ain’t got it.”

Graphics Credit: http://www.aapsj.org/

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What Does Harm Reduction Mean?

A rift in the addiction treatment community over abstinence.

What is harm reduction? How does it differ from the approaches traditionally associated with drug recovery and rehab?

Originally, I became interested in harm reduction because its advocates were highlighting the folly of prison terms over treatment for drug addicts—a sentiment with which I wholeheartedly agree. Also, the various harm reduction organizations worldwide were fastened tenaciously to the issue of clean needle exchanges as a means of reducing HIV transmission—another approach I heartily support. And at its core, harm reduction has always been about reducing the number of deaths by drug overdose. At its essence, harm reduction is sensible and necessary, given the failures of the drug war, and the inability to make a significant dent in addiction statistics by traditional socioeconomic approaches.

Harm reduction, as formally defined by Harm Reduction International, concerns itself with “policies, programs and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families, and the community.” It’s a hopeful mission statement. But reducing harm without necessarily reducing drug consumption? What does that mean, exactly?

Lately, activists in the harm reduction movement have been leaning hard on the notion that abstinence is just so much humbug; an archaic admonition that need not be automatically imposed on addicts. Who said addicts have to become abstinent for the rest of their lives? Are we forever hostage to the religious zealotry of the Cambridge Group and it’s successor, Alcoholics Anonymous? If an alcoholic drinks one drink less today than yesterday, or a junkie shoots up a bit less junk today than yesterday, that is harm reduction in action.

But now that harm reduction has become intimately associated with the abstinence debate, egged on by activists like Stanton Peele and Jack Trimpey, the ground underneath the movement has shifted. Many harm reductionists are becoming wary, and sometimes completely hostile, to the notion of addiction as a disease syndrome with a distinct, lifelong, and incurable timeline beyond the reach of notions like “Rational” or “Smart” recovery. “Your best thinking got you here,” AA likes to say, reminding alcoholics that “being smart” or feeling full of “will power” often have less to do with recovery than one might suppose.

But in order to free themselves of the need for abstinence, extreme harm reductionists often deny that addiction is in any meaningful way a medical disorder. This has created a rift in the treatment community, and complicated the mission of recovery programs based on abstinence. Kenneth Anderson, a harm reduction advocate and the author of How to Change Your Drinking, framed it this way for me in an email exchange: “The more alcohol related problems you have, the more you need to practice harm reduction by planning safe drinking strategies, until you resolve your alcohol related problems by quitting or developing a non-problematic drinking pattern.” Like many harm reductionists, Anderson is no fan of Alcoholics Anonymous. One of the book’s sections is headed: “Everything You Always Wanted to Know About Alcohol—But you got told to go to AA and not ask.”

Anderson said that the National Institute on Alcohol Abuse and Alcoholism (NIAAA) “tells us that about half of people who overcome alcohol dependence do so by quitting, the other half overcome it by cutting back.” If even the nation’s premier scientific agency for researching alcoholism doesn’t seem so sure about whether alcoholics need to strive for abstinence, why should abstinence be a stated goal at the outset of treatment at all? Said Anderson: "When abstinence is forced on people against their will, it often backfires and leads to more drug or alcohol use."
 
A few weeks ago, on Denise Krochta’s excellent podcast, Addicted to Addicts, I suggested that part of the argument over abstinence vs. controlled drinking stemmed from a confused bundling of “problem drinkers” and “alcoholics”—a move that the National Institute on Alcohol Abuse and Alcoholism, whose very name is a testimony to the institute’s fundamental ambivalence, has been championing lately. This has helped harm reductionists center the battle precisely where the definitions are fuzziest: at the point on the spectrum where “problem drinking” becomes “alcoholism.” Nonetheless, by focusing on this imprecise edge, harm reductionists make a legitimate point: Culture and environment are major influences on the course of heavy drinking.

“I do not use the word alcoholism [in the book], because it has no scientific definition in the current day and is not found in the DSM IV” Anderson told me. “Although there is some heritability of alcohol dependence, it is a great error to overlook the importance of environmental factors. Alcohol dependence is not located on a single gene--currently there are dozens of genes implicated in alcohol dependence.” And he’s right. These are legitimate caveats that apply to many of the disease models of addiction now at play in the scientific community.

The counter-argument here is that genuine alcoholics do not have, and cannot develop, a “non-problematic drinking pattern,” any more than a serious diabetic is likely to develop a non-problematic sugar doughnut strategy. What alcoholic hasn’t tried controlled drinking? Again and again? And failed? Where are the legions of former drunk-tank alcoholics who have rationally transformed themselves into social drinkers?

These are some of the terms of the current debate in the addiction recovery community. But we do a disservice by concentrating solely on points of departure. The harm reduction movement, at street level, has some very sound contributions to make regarding addiction and public policy. Anderson, in his book, drives home the overlooked but essential point that there is no one-size-fits-all treatment for destructive drinking:

• “Harm reduction never forces people to change in ways which they do not choose for themselves.”
• “Harm reduction recognizes that each of us is a unique human being different from all others.”
• “Harm reduction recognizes the need for ‘different strokes for different folks.’”
• “Harm reduction supports every positive change.”

I fervently hope that 12-Step Groups and Harm Reduction Groups can work their way toward a rapprochement. And so does Kenneth Anderson. But what stands in the way of this is, I fear, is the disease model of addiction—and medical addiction researchers aren’t likely to turn their backs on that premise any time soon. Still, we cannot say what future research will reveal. And I agree with harm reductionists that the best attitude we can bring to the subject of addiction and recovery is open-mindedness, and a willingness to treat each case as unique, in order to forestall “metabolic chauvinism.”

Graphics Credit: http://hamsnetwork.org 

Bill Manville’s Booze Book

A “professional bar fly” who flirted with death and Helen Gurley Brown.

"From the drinking man's classic, Saloon Society, back in the Sixties, to his sadder but wiser Cool, Hip and Sober, Bill Manville has consistently provided an honest, insightful first-person account of where alcoholism begins--and where it ends.”  So said the respected Keith Humphreys of Stanford University’s School of Medicine, when Manville’s account of beating booze was published some years ago. What makes his book unique in the annals of addiction books, so far as I know, is the additional blurb on Cool, Hip and Sober from none other than Cosmopolitan Magazine founder and Sex and the Single Girl author Helen Gurley Brown, who wrote: “I never read anything like this and am thrilled to recommend the book to anybody with the problem himself or with a suffering family member.”

That represents a pretty wide spectrum of opinion makers, so I took a look—and had fun with it. Written in a breezy, question-and-answer style based on his call-in radio show in Sonora, California, Manville represents an older generation of addicts whose distilled experience is as timely now as ever. Novelist, newspaper journalist, radio host, and a self-confessed “professional bar fly” on the New York City circuit who has been sober now for more than twenty years, Manville has been in the game long enough as a professional writer and practicing alcoholic to have seen a thing or two. “Those were the days when I was living on the Five-Martini Diet—writing for Helen Gurley Brown at Cosmopolitan Magazine by day, and passing out before dinner more nights than I like to remember,” Manville wrote in a recent piece for TheFix.com.

“Addictions and Answers,” the widely-read column he currently co-authors for the New York Daily News, takes personal questions and gives out useful, straightforward, evidence-based advice. So does his book. Some excerpts follow:
----------

--“Take an alcoholic or drug addict without a penny in his pocket. Deposit him, friendless and alone, in a bluenose town. Dump him there at 6AM Sunday morning, broke and hungover, the bars and liquor stores closed.  He’ll find a way to get high before noon. That’s will power.”

--"In vino veritas?  No. ‘In vino bullshit,’ says John A. Mac Dougall, D. Min., a United Methodist Minister who is also Manager of Spiritual Guidance for Hazelden in Center City, Minnesota.”

-- “‘Each time your addiction brings you smack up against trouble or grief,’ says Brian Halstead, a Program Director at the Caron Foundation, ‘you are being presented with a choice. Do you want this to be your bottom, or do you want to be hit harder?’”

--“Sobriety makes you a more competent player; it does not guarantee you will be a winner. You’re still a dress size too large, and your husband is going bald. Your wife doesn’t understand you, and you’re in a dead end job. You’ll be able to address these problems with a cool, sober brain, yes… with a bit of detachment, yes… but they are still there. You’ve discovered that even glorious sobriety has realistic limits. The pink cloud begins to float down, closer to earth. Very dangerous time.”

--“The essence of addiction is: it SPEEDS up. That’s why it’s called progressive.

--"The phrase I like is that the genetic type of alcoholic was born two drinks behind."

--“Says Scott Munson, Executive Director, Sundown M Ranch, one of the top rehabs in the country, ‘I think it is important for psychologists and psychiatrists to understand the mistrust of those professions by many people in AA. Chemical dependency is a primary illness, not the result of another disorder.’" 

 --“There are pharmaceuticals, like insulin, that correct a deficiency in the body's mechanism. When the patient takes them, he does not get high… any diabetes sufferer will tell you that is a small price. And if taking a daily pill will end your enthrallment to addiction, that's not a high price either."

--Let me end with this, a kind of self-test I heard during a lecture when I was a facilitator at Scripps McDonald: Do you remember your first drink?  How did it make you feel? If you reply, ‘For the first time in my life it made me feel normal, like other people’--take it as a warning bell. In the UC Berkeley "Alcohol & Drug Abuse Studies" catalog, it estimates "that more than one half of clients in alcohol and drug treatment have coexisting psychiatric disorders."

Photo Credit: http://www.sabredesign.net 

Love, Loss, and Addiction

Review of “This River” by James Brown.

James Brown, author of “The L.A. Diaries,” has offered up another candid and courageous memoir in his new book, “This River.” In a series of related vignettes, the book amplifies and extends the basic story of Brown’s life as chronicled in “L.A. Diaries,”--a harrowing tale of genetic fate and social failure; a dysfunctional family riven by alcoholism and drug addiction, culminating in the suicide of the author’s brother, followed by the suicide of his  sister.

Throughout his descents into hard drug use, his ups and downs along the alcoholic’s rehab trail, Brown remains a fierce observer of his own behavior, and, heartbreakingly, its effect on those around him: “Worrying, damaging, terrorizing those closest to us, intentionally or not, is what alcoholics, addicts, and the mentally ill do best.” As was true of “The L.A. Diaries,” Brown writes in a spare, direct, unflinching style—a bracing antidote to the Stuart Smalleys of the world.  His observations on A.A., anti-craving medications, and antipsychotic drugs are those of a man unwilling to let prior prejudices and built-in excuses deter him from a search for the true nuts and bolts of his condition.

Reaching that point of understanding, and comprehending the need for action—none of it typically comes fast, cheap, or easy. Brown, who teaches in the MFA program at Cal State San Bernardino, masterfully captures the internal monologues of the addictive mind:

"Getting hooked is for weaklings, the idiots who can’t control themselves, those losers who end up broke and penniless, wandering the streets at night like zombies, like the walking dead…. For the budding addict, the supply is never enough, but your only regret, at least to date, is that you didn’t come across this miracle potion sooner."

The internal dialog eventually becomes an existential struggle: “True or not, I resist the idea that mental illness and alcoholism are somehow inborn. Accepting that premise means embracing the notion of fate, and I don’t. I prefer to believe that I’m in full control.”

As who among us does not. And although none of us are truly in full control—we are all a conflicting welter of “I”s, of shifting identities and roles—it is through the dissociations characteristic of addictive illness that the Jekyll and Hyde nature of these changes, which are somehow “in the blood,” sometimes manifest themselves most graphically.

Does the author prevail? He does, for now, and that is how we must leave it:

Things are changing deep inside you and have been for some time: hormones, genes, brain chemistry, all of it adapts to the alcohol and drugs you continually dump into your body. The cells habituate. The cells literally mutate to accommodate your cravings and now they crave too. Now your addiction has more to do with physiology than psychology. Now it’s the body that robs the mind of its power to choose, and it’s not long before you’ll wish you never came across that miracle potion, those powders and pills.

With suberb jacket reviews from the likes of Tim O’Brien, Robert Olmstead, and Duff Brenna, “This River” is a short read that will lodge itself firmly in your memory.  I read it in one sitting, and I bet you do, too.

Photo Credit: http://radaris.com/p/James/Rivers/

Book Review: Thinking Simply About Addiction

Of bicycles, swimming, and drugs.

Back when I first became interested in the science of addiction, I was fascinated by an article in Parabola magazine by Dr. Richard Sandor, a Los Angeles psychiatrist with many years of experience treating alcoholics and other drug addicts. In the article, Sandor suggested that a good deal of addictive behavior could profitably be viewed as a form of dissociation. I quoted from that article in my book about addiction, and now he has published a book of his own.

Thinking Simply About Addiction: A Handbook for Recovery, focuses on the current controversy over Alcoholics Anonymous and its 12-Step variants, and takes a reasoned, thoughtful approach to the so-called spiritual aspects of recovery.

Happily, this is not another southern California feel-good self-help tome, though the author does not shy away from tweaking the neuroscience establishment for “delving deeper and deeper into the biochemistry of the alcoholic and drug-addicted brain, endless promising a ‘cure’ and yet never quite delivering the goods.”

While acknowledging that addiction is “correctly understood as a disease,” Sandor diverges a bit from the mainstream disease theory of addiction, believing that addictions are “diseases of automaticity—automatisms—developments in the central nervous system that cannot be eliminated but can be rendered dormant.”

As examples of simple automatisms, Sandor cites bicycle riding and swimming, two behaviors it is impossible to “unlearn.” Consider swimming: If, for some reason, it became extremely dangerous for you to swim (pollution, a heart condition, sharks), the problem is that “you literally cannot choose not to swim. Your only reliable choice is to stay out of the water, to become abstinent.”

Much of the confusion over addiction, the author maintains, is that “we miss the essential quality that defines addiction as a disease: Something someone has rather than something they’re doing.”

What his addicted patients frequently tell him, Sandor writes, is that “the core experience of being addicted is powerlessness, the experience of having lost control over the use of alcohol or a drug.” As one addiction expert put it, addicts “have lost the freedom to abstain.” Like other forms of rehabilitation, says Sandor, “treatment doesn’t work or not work. The patient works. It seems obvious. If the very nature of addiction is automaticity—the loss of control—then recovery is the restoration of choice, not handing choices over to someone else.”

On controlled drinking, or a return to social drinking, Sandor writes that “studies that have followed reliably diagnosed alcoholics for long enough periods of time reveal what clinicians and AAs have known for a long time: Abstinence is necessary for recovery…. If you follow true alcoholics for years, you discover that those who continue to drink get worse and those who remain abstinent don’t. Presumably, the same is true for all other addictions.”

Problem drinkers who do return to moderate drinking “were people who had had enough problems with drinking to land in treatment but who were never physically addicted and therefore didn’t have to become abstinent in order to stop the progression of the disease.”

Where does the “Higher Power” concept fit into all this? Sandor endorses the wider view taken by many psychologists and thinkers, from Gregory Bateson to C.G. Jung. In line with his theme of keeping it simple, Sandor suggests that thinking about a Higher Power may mean coming to realize that “the body’s capacity to restore itself is part of something much larger than our operations and medications… If you like, it comes from God. If you don’t like, it comes from a Higher Power, from Nature, from five billion years of the evolution of life on Earth, from the created universe, from whatever you want to call it.”

It is the simplest of simple ideas: “We all belong to something beyond ourselves.”

Graphics Credit: www.thesecondroad.org

Alcoholism: The Genetic Puzzle

Fathers and Sons.

The hunt for genetic influences on alcoholism derives largely from the work of Dr. Donald W. Goodwin, chair of the Department of Psychiatry at the University of Kansas Medical Center. Starting in the early 1970s, Dr. Goodwin and co-workers, using computer technology and a detailed database of Scandinavian health records, scrutinized the results of 5,000 adoption cases in Copenhagen. The results of the initial study stunned alcoholism experts around the world. The sons of alcoholics were more likely to become alcoholics themselves, as many had expected. But the relationship held true even when the children of alcoholics were separated from their natural parents shortly after birth, and subsequently raised by foster parents.

In Phase 2 of the Danish studies, Goodwin selected only alcoholic families in which one son had been raised by his biological parents, while the other son had been adopted away early in life. Raised in separate environments, twins of this sort are highly prized for genetic research. Goodwin compared the sons who had been raised by their alcoholic birth parents to their adopted-away brothers. It didn’t seem to make any difference: Rates of alcoholism were roughly the same. Environmental factors alone did not seem to account for it.

“By their late twenties or earlier,” Goodwin wrote, “the offspring of alcoholics had nearly twice the number of alcohol problems and four times the rate of alcoholism as the children whose parents had no record of hospitalization for alcoholism.” It did not look like family environment was the primary determinant.

Perhaps some of the children simply ended up with less effective foster parents, detractors pointed out. Alternatively, some unknown trauma might have been inflicted in the womb. Maybe the pregnant mother drank. Environmental factors can never be ruled out. Nonetheless, the basic implications of Goodwin’s work could not be shaken off. The Danish adoption studies were the first major scientific papers to establish a firm link between heredity and alcoholism.

Beginning in the 1980s, Dr. C. Robert Cloninger, professor of psychiatry and genetics at Washington University in St. Louis, and Michael Bohman, a Swedish pediatrician, began a broader series of adoption studies. The Stockholm Adoption Study scrutinized the records of more than 3,000 adopted individuals, and confirmed the Danish studies: The children of alcoholics, when compared with the children of non-alcoholic parents, were far more likely to become alcoholics themselves—even if they were adopted away. 

Moreover, “Alcohol abuse in the adoptive parents was not associated with an increased risk of abuse in the children they reared,” Cloninger later reported in the journal Science, “so there was no evidence that alcoholism is familial because children imitate their [non-biological] parents.”  

Adapted from The Chemical Carousel: What Science Tells Us About Beating Addiction by Dirk Hanson © 2008.

Graphics Credit: http://www.3dscience.com/

My Name is Roger

A famed movie critic tells his story.

Excerpted from :
“My Name is Roger, and I'm an alcoholic.”
By Roger Ebert, Chicago Sun Times
Posted on “Roger Ebert’s Journal,”
August 25, 2009.
© Sun-Times News Group

In August 1979, I took my last drink. It was about four o'clock on a Saturday afternoon, the hot sun streaming through the windows of my little carriage house on Dickens. I put a glass of scotch and soda down on the living room table, went to bed, and pulled the blankets over my head. I couldn't take it any more.
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At about this time I was reading The Art of Eating, by M. F. K. Fisher, who wrote: "One martini is just right. Two martinis are too many. Three martinis are never enough."
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In my case, I haven't taken a drink for 30 years, and this is God's truth: Since the first A.A. meeting I attended, I have never wanted to. Since surgery in July of 2006 I have literally not been able to drink at all. Unless I go insane and start pouring booze into my g-tube, I believe I'm reasonably safe. So consider this blog entry what A.A. calls a "12th step," which means sharing the program with others. There's a chance somebody will read this and take the steps toward sobriety.
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I know from the comments on an earlier blog that there are some who have problems with Alcoholics Anonymous. They don't like the spiritual side, or they think it's a "cult," or they'll do fine on their own, thank you very much. The last thing I want to do is start an argument about A.A.. Don't go if you don't want to. It's there if you need it. In most cities, there's a meeting starting in an hour fairly close to you. It works for me. That's all I know. I don't want to argue with you about it.
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I've been to meetings in Cape Town, Venice, Paris, Cannes, Edinburgh, Honolulu and London, where an Oscar-winning actor told his story. In Ireland, where a woman remembered, "Often came the nights I would measure my length in the road." I heard many, many stories from "functioning alcoholics." I guess I was one myself. I worked every day while I was drinking, and my reviews weren't half bad. I've improved since then.
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The God word. The critics never quote the words "as we understood God." Nobody in A.A. cares how you understand him, and would never tell you how you should understand him. I went to a few meetings of "4A" ("Alcoholics and Agnostics in A.A."), but they spent too much time talking about God. The important thing is not how you define a Higher Power. The important thing is that you don't consider yourself to be your own Higher Power, because your own best thinking found your bottom for you.

Photo Credit: chicagoist.com


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Addiction Assumptions: Denial

Is denial always part of the deal?

Maybe denial really IS just a river in Egypt. Lorraine T. Midanik, dean of the School of Social Welfare at the University of California in Berkeley, is convinced that the contemporary concept of denial as applied to alcoholism represents a weak link in the disease model of addiction.

Neither the founding fathers of Alcoholics Anonymous, nor the foremost early proponent of the disease model—E.M. Jellinek—specifically identified denial as a core concept of alcoholism, according to Midanik. In “The Philosophy of Denial in Alcohol Studies: Implications for Research,” which appears as a chapter in The Praeger International Collection on Addictions, Midanik highlights the conclusion that often results from making a strict association between alcoholism and denial: “There is no room in this perspective for truth telling from the drinker himself.”

The more often and the more energetically a drinker protests against the hypothesis that he is drinking alcoholically, the more telling the proof that the drinker is “in denial” and therefore incapable of rational decision-making about drinking. Clearly, this is exactly the case in many instances. Denial exists. However, Midanik argues that “the definition of denial in alcohol studies has been expanded well beyond its original meaning” to include a host of vaguely Freudian defense mechanisms, including hostility and other forms of negative behavior. Midanik, who is openly skeptical regarding many aspects of the disease model, complains that denial has been broadened into a catchall category “for any behavior that prevents the adoption of the disease model system.”

As the “disease model system” is often presented to patients in various rehab centers around the country, I would tend to agree. But Midanik also questions whether there really exists anything beyond what she labels “tactical denial,” meaning “deceptive maneuvers used by alcoholics to conceal the extent of their drinking.” In such cases, the drinker is obviously aware of what he or she is doing, so the more appropriate term might be “lying.” Nonetheless, I firmly believe that denial, in the sense of lack of self-awareness, or dissociation, is often an acute part of the presenting symptoms of alcoholism, if not quite the “central core of alcoholism treatment,” as Midanik sees it.

Midanik describes something like a cabal of interests helping to foster and inflate the denial concept—AA, Al-Anon, and various codependency groups in particular—even though “study after study and review after review report that alcoholics give valid self-reports....” Here Midanik is onto something interesting. As she intriguingly relates, the near-universal presumption guiding “interventions” or “structured encounters” with supposed alcoholics is that “there is a continuum with denial on one end and truth telling on the other. Overreporting rarely if ever exists.”

Yet overreporting is a well-known issue in clinical research. Midanik refers to the “hello-goodbye effect,” in which patients tend to overemphasize their symptoms when entering treatment, and to minimize them at the end of treatment. If new patients overreport their alcohol consumption, “there are important implications for treatment personnel who base treatment decisions on these self-reports.” Moreover, overreporting may also bias clinical studies “by inflating success rates (presuming there was an opposite bias after treatment). Yet despite the implications of these findings, little interest has been shown by researchers in the alcohol field to explore this area.”

Photo Credit: shatteringdenial.com

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