Month: March 2015

Alcoholics Anonymous Effectiveness: Faith Meets Science

There has much, if not too much, talk of the effectiveness of AA in recent weeks,months and year. Whether there is a concerted controlled drinking agenda is for you to decide.

Controlled drinking for an alcoholic, for me and particularly a chronic alcoholic, is a mirage. Period.

Once you have been pickled to a gherkin you never return to being a cucumber again!

Check the methodology of studies that state it is possible as I have yet to come across a single study that has not been refuted years later by  follow up study.

In order to address this complicated area of studying the effectiveness of a group which does not lend itself easily to being studied we will refer to cite and choose excerpts from an excellent study on AA from a number of years ago (1).

This is the most definitive study of how and why AA works. If you are a newcomer read well.

Given the amount of dubious journalism and studies cited recently it is hugely important to put a study out there which gives those seeking recovery a true picture of how and why AA works.

Another point – if you are reading about recovery in glossy magazines, even if they purport to be aiding those in recovery, think twice about these journalistic pieces.  If it is controversial it sells. Common sense and diligent, unbiased experimental studies which give a fair appraisal of all points don’t sell in the same way.

I even wonder if this glossy recovery mags do more harm than good? Put it this way, an alcoholic could leave these sites thinking of a drink just as much as thinking about recovery.

 

 

“Research on the effectiveness of Alcoholics Anonymous (AA) is controversial and is subject to widely divergent interpretations. The goal of this paper is to provide a focused review of the literature on AA effectiveness that will allow readers to judge the evidence for AA effectiveness themselves.

The review organizes the research on AA effectiveness according to six criterion required for establishing causation: (1) magnitude of effect; (2) dose response effect; (3) consistent effect; (4) temporally accurate effects; (5) specific effects; (6) plausibility.

The evidence for criteria 1, 2, 3, 4 and 6 is very strong: Rates of abstinence are about twice as high among those who attend AA (criteria 1, magnitude); higher levels of attendance are related to higher rates of abstinence (criteria 2, dose-response); these relationships are found for different samples and follow-up periods (criteria 3, consistency); prior AA attendance is predictive of subsequent abstinence (criteria 4, temporal); and mechanisms of action predicted by theories of behavior change are present in AA (criteria 6, plausibility).

The Cochrane Group  [1] review recommended that people considering attending AA or a twelve step facilation (TSF) should be made aware that there is a lack of experimental evidence on the effectiveness of such programs [1]. This is despite optimal outcomes for TSF at 1 and 3 years for outpatients in the Project MATCH trial [2, 3].

At the other end of the spectrum, 12-step scholar Rudy Moos has recommended that referral agencies should consider referring people to AA first, rather than to treatment first. This is based on his own observational studies which have found that longer duration of AA attendance is associated with less drinking at 8 and 16 years [4], and that those who attend AA before attending treatment tend to attend AA longer than those who attend treatment first [5].

Prior efforts to summarize the findings on AA effectiveness have included literature reviews [6, 7] and meta analyses [8–10]. The most recent meta analysis [10] concluded that attending AA led to worse outcomes than no treatment at all. An earlier meta analysis focusing on moderating effects found that the evidence for AA effectiveness was stronger in outpatient samples, and that poorer quality studies (based on volunteers, self-selection rather than random assignment, no corroboration of self-report, etc.) somewhat inflated the case for AA effectiveness [9].

A review summarizing the state of the literature 7 years later [7] argued that there was a consistent, rigorous body of evidence supporting AA effectiveness. Again, there seems to be something for everybody, and the literature really does seem to be widely subject to interpretation. This may stem from the criterion being used to judge effectiveness.”

At the heart of the debate is the quality of the evidence. Their concern is well-founded. As will be evident from this review, experimental studies represent the weakest of the available evidence.

“However, the review also will highlight other categories of evidence that are overwhelmingly convincing with respect to AA effectiveness, including the consistency with established mechanisms of behavior change.

This review will organize the research on AA effectiveness according to six formal criterion for establishing causation [12], which should help readers to integrate the sometimes conflicting conclusions discussed above.

These criterion were first introduced to assist policymakers evaluate the totality of the evidence of a causal effect for smoking on lung cancer in the absence of experimental data [13, 14].

The criterion offer a framework for judging the “totality” of the evidence [12 p.191], implicitly acknowledging that the evidence may not be strong for all criteria, and leaving the final decision to the individual evaluator. These are the criterion:

  • The relationship between an exposure (here, exposure to AA) and the outcome (abstinence, as AA does not recommend any drinking for alcoholics) must be strong. According to this criteria, weak relationships between AA and abstinence would not be as convincing of causality as strong ones
  • There should be a dose-response relationship, such that more involvement in AA relates to higher levels of abstinence.
  • The consistency of the association matters. If some studies find a strong relationship between number of AA meetings attended and rate of abstinence, but many do not, this would call into question whether the dose-response relationship should be trusted, as evidence goes.
  • The timing of the purported influence must be correct. This means that the measurement of AA exposure must be prior to the period of abstinence that is being studied; otherwise, it could mean that abstinent people tend to go to AA, rather than AA causing people to be abstinent.
  • The specificity of the association must be demonstrated. One must be able to rule out other explanations than AA exposure for having led to abstinence. This addresses the concern that those who attend AA are a select sample who would be sober anyway, without ever going to AA. For example, if those who attend AA are highly motivated to do something about their drinking, it could be that this motivation is the cause of their abstinence; it would be unfair to credit AA for their successful outcome. Evidence of specificity ideally requires experimental manipulation of exposure to AA. For example, individuals in a study might be randomized to attend AA or to attend psychotherapy; they do not select their treatment. Because of randomization, motivated people would end up being randomized both to psychotherapy and to AA, so it would not be the case that the “deck was stacked” in favor of AA. If those randomized to attend AA were more likely than those randomized to psychotherapy to be abstinent 2 years later, this would demonstrate an effect specific to AA that could not be due to a selection bias in which only motivated people attend AA.
  • Coherence with existing knowledge is needed to establish causation. The notion of theoretical plausibility is suggested as a way of addressing coherence with existing knowledge; that is, are the mechanisms of action that explain behavior change present in AA? Several theories and different aspects of AA exposure will be considered in addressing this final criterion.

Figure 1

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Criterion:-

Criterion 1 – strength of association

.  As shown in Figure 1, which draws on a longitudinal study of male inpatients in Veterans Administration programs, rates of abstinence are about twice as high for those who attended a 12-step group such as AA following treatment… The rates of abstinence were about twice as high among those who had attended AA or another 12-step group (but no other form of aftercare).

Criterion 2 – dose response relationship

.  Do higher levels of AA attendance or involvement relate to higher levels of abstinence? There is evidence of a dose response relationship for number of 12-step meetings (Figure 2a), frequency of 12-step meetings (Figure 2b), and duration of AA meeting attendance (Figure 2c).

Figure 2a

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Again studying male residential patients in the VA system, and considering AA meeting attendance for the 90 days prior to the 1-year follow-up, the dose response curve looks almost linear (Figure 2a), with more 12-step meetings associated with higher rates of alcohol and drug abstinence [4]

In a smaller outpatient sample, over 70% of those attending 12-step groups weekly for the 6 months prior to the 2-year follow-up were alcohol abstainers, while alcohol abstinence rates among those attending less than weekly were the same as those who never attended during that period [18]; this suggests a threshold dose-response effect for weekly attendance at 12-step groups (Figure 2b).

Figure 2b

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In a longitudinal study of previously untreated problem drinkers, 70% of those with 27 weeks or more of sustained AA meeting attendance any given year (whether at year 1, at years 2–3, or at years 4–8) were abstinent from alcohol at the 16-year follow-up [4]; those with shorter duration of attendance had lower rates of abstinence, with the dose response most evident for AA attendance years 1 and years 4–8 (figure 2c). This study is the reason for Moos’ recommendation to send people to AA first, because those who went to AA first were more likely to be involved in AA for longer duration [5].

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Criterion 3 – consistency of association

The similarities in abstinence rates between the weekly or near-weekly AA attenders (70%) in these two latter studies with different populations and follow-up periods is relevant to this criteria, consistency of association.

Another example is shown in Figure 3, which presents rates of abstinence for those who attended AA but no other treatment (third bar, labeled ‘AA only’), in two different samples (VA inpatients, and previously untreated problem drinkers in the general population), with different follow-up periods (1, 3, and 8 years).

The 1-year study considered alcohol and drug abstinence as a function of 12-step group attendance, while the 3- and 8-year data focused specifically on AA attendance and alcohol abstinence. About 50% of those who had attended AA/12-step meetings only were abstinent at 1 year [15] and at 3 and 8 years [19]; and about one-fifth of those who did not attend AA/12-step meetings or treatment were abstinent at the parallel follow-up interviews.

Another study of the general population [20] found that individuals with lifetime alcohol dependence who went to 12-step meetings but no formal treatment were more likely to be abstinent than those who did nothing (not shown).

Figure 3

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Criterion 4-  temporally correct association

Moos’ work that studied 16-year alcohol abstinence in a previously untreated problem drinking sample as a function of AA during years 2–3 and years 4–8 [4] (Figure 2c) and met the 4th criterion for evidence of causality.

Criterion 5 – specificity

We will return to this issue in the conclusion as it concerns the mixed results among experimental evidence that has considered evidence of specificity. It is here that methodological differences play a role in clouding the results.

Criterion 6, coherence with existing knowledge

To evaluate the literature on AA effectiveness according to this criterion, theoretical plausibility will be discussed; that is, does AA work in a way that is consistent with major theoretical perspectives on health behavior and behavior change?

For example, a recent interpretation of contemporary psychodynamic theory has characterized alcoholism as an interaction between one’s abilities to express feelings and self-regulate one’s behavior [27]. The theory argues that despite low self esteem, many alcoholics have a narcissistic personality [28] and a sense of omnipotence. They drink to self-medicate, as a way of addressing unmet needs and uncomfortable psychological states.

AA solutions consistent with this characterization of the problem are evident at meetings, in the AA steps, and through people in the AA fellowship.

Meetings provide an opportunity to share one’s own struggles (and learn how to talk about one’s feelings), to increase one’s motivation to abstain, and to get outside of one’s self (and change one’s mood) by hearing others talk about their problems and how AA helped them.

The steps help with self-governance, narcissism and omnipotence: accepting powerlessness over alcohol (step 1); recognizing that one cannot do it alone (but that a higher power, which can be operationalized as the AA group, is there to help; steps 2–3); realizing how one’s behavior affected and affects others (step 4–9); treating other people better (step 10); finding meaning in life (step 11); and relinquishing one’s negative self-focus by helping others (step 12). Through the people in AA, one learns how to live a sober life, and how to regulate one’s behavior one day at a time.

Bandura’s social learning theory [29] adds to the psychodynamic perspective (noting the problem) of  social influences and from self-efficacy: if everyone around you drinks, and if you don’t think it is within your ability to not drink, you will be unable to abstain. The antidote includes changing environmental cues (such as staying away from bars), role modeling (seeing others succeed at not drinking), and self-efficacy (believing you can abstain).

AA meetings, and spending time with people in AA, represent changes in environmental cues; that is, you’re not at a bar, seeing alcohol and seeing people drink alcohol, when you’re at a meeting or out with AA friends.

At an AA meeting, you are exposed to successful role models, instead of current drinkers, who suggest a new approach to abstinence: not drinking 1 day at a time (instead of saying you are “quitting forever”). Seeing yourself able to abstain for one day begins to build self-efficacy, which accumulates with the passage of every sober day.

Spending time at AA meetings and with people in AA also leads to relapse prevention mechanisms put forward by standard behavioral modification techniques. These include learning how to say no to a drink when offered, having a plan of action when confronted with likely drinking conditions, and choosing alternative behaviors to take the place of drinking.

Several studies offer empirical support for these mechanisms. The positive relationship between AA involvement and abstinence has been shown to be partially mediated (explained) by (a) psychological and spiritual mechanisms including finding meaning in life [30], greater motivation for abstinence [31], and changes in religious beliefs and spiritual experiences [32]; (b) social influences such as fewer pro-drinking influences [33], more friends in general [34], having AA friends supportive of abstinence [35], and enhanced friendship networks [36]; and (c) social learning and behavioral mechanisms including improved self-efficacy [31, 37] and effective coping and relapse prevention skills [34, 36] to abstain. These mechanisms (and theories) are inter-related. For example, AA friends represent a particularly effective source of social support, because they provide expertise in preventing relapse.

Conclusions

The goal was not to provide an exhaustive review of the evidence, but rather to present representative studies that address AA effectiveness according to six accepted criterion for establishing scientific causation. This framework may be especially appropriate for considering AA effectiveness, because it acknowledges the value and limitations of experimental evidence in the context of other criterion for determining treatment effectiveness.

As stated at the outset, the experimental evidence for AA effectiveness (addressing specificity) is the weakest among the six criteria considered crucial for establishing causation. Only two studies provided strong proof of a specific AA or TSF effect: the outpatient arm of Project MATCH (with effects at 1 and 3 years) [2, 3], and the intensive referral condition in Timko’s trial (with effects for abstinence at 6 months and 1 year) [24]. The effect sizes were similar, with the TSF/Intensive referral conditions having a 5-10% advantage in abstinence rates. It is noteworthy that neither of these studies attempted to randomize patients to AA per se; instead, they focused on interventions intended to facilitate AA involvement.

One reason that several of the other trials may not have found positive effects for AA/ TSF is because many individuals randomized to the non-AA/non-TSF conditions also attended AA; thus, the AA or TSF condition ended up being compared to a condition consisting of an alternative treatment plus AA.

This was the case in Walsh’s hospital inpatient treatment vs. AA study [23] and in the aftercare arm of Project MATCH [22], and arose because the patients in the non-AA/non-TSF conditions also had attended 12-step-based inpatient treatment, which in turn engendered strong participation in AA. Thus, AA attendance levels were high in the inpatient hospital condition in the former study, and in the CBT and MET conditions among the Project MATCH aftercare subjects. In fact, CBT and MET aftercare patients attended more meetings than the TSF outpatients, and the aftercare patients overall attended twice the number of meetings at every follow-up compared to the outpatients [22, see pp.191–192].

As for the scorecard for the other criteria, the evidence for AA effectiveness is quite strong: Rates of abstinence are about twice as high among those who attend AA (criteria 1, magnitude); higher levels of attendance are related to higher rates of abstinence (criteria 2, dose-response); these relationships are found for different samples and follow-up periods (criteria 3, consistency); prior AA attendance is predictive of subsequent abstinence (criteria 4, temporal); and mechanisms of action predicted by theories of behavior change are evident at AA meetings and through the AA steps and fellowship (criteria 6, plausibility).”

Reference

Kaskutas, L. A. (2009). Alcoholics Anonymous effectiveness: Faith meets science. Journal of addictive diseases, 28(2), 145-157.

A Brief History of Controlled Drinking – the Irrationality of Science

In a recent blog a few days ago I challenged some of Gabrielle Glaser’s “evidence” in her article   “The Irrationality of Alcoholics Anonymous “, which purported to demonstrate the so-called effectiveness of “controlling drinking”.

Glaser cited the following in her article

“ To many, though, the idea of non-abstinent recovery is anathema. No one knows that better than Mark and Linda Sobell, who are both psychologists. In the 1970s, the couple conducted a study with a group of 20 patients in Southern California who had been diagnosed with alcohol dependence.

Over the course of 17 sessions, they taught the patients how to identify their triggers, how to refuse drinks, and other strategies to help them drink safely. In a follow-up study two years later, the patients had fewer days of heavy drinking, and more days of no drinking, than did a group of 20 alcohol-dependent patients who were told to abstain from drinking entirely.”

I responded to this as follows

” What Glaser failed to mention was that in a subsequent study (4) 10-year follow-up of the original 20 experimental subjects showed that only one, who apparently had not experienced physical withdrawal symptoms (thus possibly not alcoholic), maintained a pattern of controlled drinking;

eight continued to drink excessively–regularly or intermittently–despite repeated damaging consequences;

six abandoned their efforts to engage in controlled drinking and became abstinent;

four died from alcohol-related causes;

and one, certified about a year after discharge from the research project as gravely disabled because of drinking, was missing.

Why did Glaser failed to mention this research, a follow up study to the one she mentions and cites?”

The authors attempted to justify this choice in a statement that seems to clearly demonstrate their bias: “we are addressing the question of whether controlled drinking is itself a desirable treatment goal, not the question of whether the patients directed towards that goal fared better or worse than a control group.. .” (Pendery et al., 1982, 172-173)

The interesting aspect about her article for me (and most worrying) was that it highlighted a controversy that goes back to the 1960s – can alcoholics ever control their drinking?

In this blog we will address the origins of this “controlled drinking debate” and demonstrated how it is a castle built on sand.

The original study which supposedly demonstrated so-called controlled drinking or asymptomatic drinking in it’s alcoholic participants did no such thing.

So we now have an ongoing debate about controlled drinking when it has continuously been based on dubious research, bogus findings and bad science.

It is the researchers that Glaser champions that could be accused of irrationality.

The methodological madness started way back in the 1960s.

 While scattered reports of controlled drinking outcomes had occasionally appeared in the scientific literature before 1962, most commentators date the beginning of the controlled drinking controversy to the publication that year of a paper entitled “Normal Drinking in Recovered Alcohol Addicts.” In this paper, D.L. Davies, a British psychiatrist, reports that, in the course of long-term follow-up of patients treated for “alcohol addiction” at Maudsley Hospital in London, 7 of the 93 patients investigated “have subsequently been able to drink normally for periods of 7 to 11 years after discharge from the hospital.” (Davies, 1962, p. 94).

At least two different studies have challenged the findings of Davies:-

“Evidence suggests that five subjects experienced significant drinking problems both during Davies’s original follow-up period and subsequently, that three of these five at some time also used psychotropic drugs heavily, and that the two remaining subjects (one of whom was never severely dependent on alcohol) engaged in trouble-free drinking over the total period”

http://www.ncbi.nlm.nih.gov/pubmed/4010292

“A subsequent follow-up of these cases suggested that Davies had been substantially mislead”

http://www.ncbi.nlm.nih.gov/pubmed/7956756

So four decades of research into controlled drinking were inspired by a study which did not actually demonstrate controlled drinking in the first place!

In addition to the Sobells, Glaser also mentioned the Rand Report of the 1970s.

“In 1976, for instance, the Rand Corporation released a study of more than 2,000 men who had been patients at 44 different NIAAA-funded treatment centers. The report noted that 18 months after treatment, 22 percent of the men were drinking moderately. The authors concluded that it was possible for some alcohol-dependent men to return to controlled drinking. Researchers at the National Council on Alcoholism charged that the news would lead alcoholics to falsely believe they could drink safely. The NIAAA, which had funded the research, repudiated it. Rand repeated the study, this time looking over a four-year period. The results were similar.”

The first Rand Report was attacked as being methodologically weak  – e.g  it suffered from sample bias (80% of subject dropped out).

The Rand Corporation did a follow up 4 years later.  This time they reported that a smaller figure of 14% of the sample  continued to drink in an unproblematic manner  but other researchers reanalyzing the data arrived at a corrected estimate of 3-4% of the sample were drinking in a nonproblematic manner.

3% is somewhat less than the 22% – why does Glaser not cite these other follow up studies again?  It is difficult to accept any of her arguments as  she picks only studies that support her biased arguments.

jaywalker-t-shirt-men-s_design

It was also noted that alcoholics can often be expected to drink in a non problematic manner for brief periods. In my own experience, I have often heard of alcoholics share about a relapse and state that they thought they had their alcoholic problem licked as they started off drinking in what appeared to be a controlled manner only to find in a matter of weeks that their alcoholism had progressed far beyond it’s original severity prior to the relapse. In other words it can take a relapse some weeks to kick start into even more profound alcoholism than previously.

Researchers need to spend more time around alcoholics to observe what we have learnt through very painful experience, instead of theorising about this reality from academic ivory towers.

As the Big Book of Alcoholics Anonymous states in Chapter 3  “Most of us have been unwilling to admit we were real alcoholics. No person likes to think he is bodily and mentally different from his fellows. Therefore, it is not surprising that our drinking careers have been characterized by countless vain attempts to prove we could drink like other people. The idea that somehow, someday he will control and enjoy his drinking is the great obsession of every abnormal drinker. The persistence of this illusion is astonishing. Many pursue it into the gates of insanity or death. We learned that we had to fully concede to our innermost selves that we were alcoholics. This is the first step in recovery. The delusion that we are like other people, or presently may be, has to be smashed. We alcoholics are men and women who have lost the ability to control our drinking. We know that no real alcoholic ever recovers control. All of us felt at times that we were regaining control, but such intervals –usually brief—were inevitably followed by still less control, which led in time to pitiful and incomprehensible demoralization. We are convinced to a man that alcoholics of our type are in the grip of a progressive illness. Over any considerable period we get worse, never better.”

 

Why Alcoholics Anonymous Works

A journalistic piece entitled,  “The Irrationality of Alcoholics Anonymous “, written by  Gabrielle Glaser, also harshly criticizes Alcoholics Anonymous. AA and similar 12-step programs.

I cite a blog on her criticisms here (1)

Why Alcoholics Anonymous Works

“Glaser’s central claim is that there’s no rigorous scientific evidence that AA and other 12-step programs work.

First, she writes that “Unlike Alcoholics Anonymous, [other methods for treating alcohol dependence] are based on modern science and have been proved, in randomized, controlled studies, to work.” In other words, “modern science” hasn’t shown AA to work.”

Glaser appears to lessen her argument by suggesting that AA is difficult to study (so how can she be so sure it is not effective then?).

” Alcoholics Anonymous is famously difficult to study. By necessity, it keeps no records of who attends meetings; members come and go and are, of course, anonymous. No conclusive data exist on how well it works.”

Equally there, in her world view, would also be no conclusive data to suggest if doesn’t work? So why make bold claims either way?

” In 2006, the Cochrane Collaboration, a health-care research group, reviewed studies going back to the 1960s and found that “no experimental studies unequivocally demonstrated the effectiveness of AA or [12-step] approaches for reducing alcohol dependence or problems.”

According to (1), Glaser is simply ignoring a decade’s worth of science, not only here but throughout the piece.

“No, that’s not true,” said Dr. John Kelly, a clinical psychologist and addiction specialist at Massachusetts General Hospital and Harvard Medical School. “There’s quite a bit of evidence now, actually, that’s shown that AA works.”

Kelly, alongside Dr. Marica Ferri and Dr. Keith Humphreys of Stanford, is currently at work updating the Cochrane Collaboration guidelines (he said they expect to publish their results in August).

” Kelly said that in recent years, researchers have begun ramping up rigorous research on what are known as “12-step facilitation” (TSF) programs, which are “clinical interventions designed to link people with AA.”

Dr. Lee Ann Kaskutas, a senior scientist at the Alcohol Research Group who has conducted TSF studies, suggest that TSF outperforms many alternatives.

“They show about a 10 to 20 percent advantage over more standard treatment like cognitive behavioral therapy in terms of days abstinent, and typically also what we find is that when people are engaged in a 12-step-oriented treatment and go to AA, they have about 30 percent to 50 percent higher rates of continuous abstinence,” said Kelly.”

The original Cochrane paper that Glaser cites came out before the latest round of studies did, so that research wasn’t factored into the conclusion that there’s a lack of evidence for AA’s efficacy. In a followup email, Kelly said he expects the next round of recommendations to be significantly different:

Although we cannot as yet say definitively what the final results will bring in the updated Cochrane Review, as it is still in progress, we are seeing positive results in favor of Twelve-Step Facilitation treatments that have emerged from the numerous NIH-sponsored randomized clinical trials completed since the original review published in 2006. We can confirm that TSF is an empirically-supported treatment, showing clinical efficacy, and is likely to result also in lowered health care costs relative to alternative treatments that do not link patients with these freely available recovery peer support services. Another emerging finding is that a central reason why TSF shows benefit is because it helps patients become actively involved with groups like AA and NA, which in turn, have been shown to enhance addiction recovery coping skills, confidence, and motivation, similar to professional interventions, but AA and NA are able to do this in the communities in which people live for free, and over the long-term.

In other words, the most comprehensive piece of research Glaser is using to support her argument will, once it takes into account the latest findings, likely reverse itself.”

In other words, it will also help contradict Glaser’s arguments.

“In an email and phone call, Glaser said that TSF programs are not the same thing as AA and the two can’t be compared. But this argument doesn’t quite hold up: For one thing, the Cochrane report she herself cites in her piece relied in part on a review of TSF studies, so it doesn’t make sense for TSF studies to be acceptable to her when they support her argument and unacceptable when they don’t.

For another, Kelly, Katsukas, and Humphreys, while acknowledging that TSF programs and AA are not exactly the same thing, all said that the available evidence suggests that it’s the 12-step programs themselves that are likely the primary cause of the effects being observed (the National Institutes of Health, given the many studies into TSF programs it has sponsored, would appear to agree).”

“It’s worth pointing out that while critics of AA point it as a bit cultlike…to the researchers who believe in its efficacy, there’s actually very little mystery to the process. “We have been able to determine WHY these 12-step facilitation interventions work,” said Kaskutas in an email. “And we have also been able to determine WHY AA works.”

Simply put, “People who self-select to attend AA, or people who are randomized to a 12-step facilitation intervention, end up having people in their social network who are supportive of their abstinence,” she said.

Reams of research show that social networks…are powerful drivers of behavior, so to Kaskutas — who noted that she is an atheist — the focus on AA’s quirks and spiritual undertones misses the point.

“When you think about a mechanism like supportive social networks, or the psychological benefit of helping others… they have to do with the reality of what goes on in AA, with people meeting others in the same boat as they are in, and with helping other people (are but two examples of these mechanisms of action),” she said.”

At the heart of recovery via 12 step groups may be because it “works for a lot of people, simply by connecting them to others going through the same struggles.”

 

 

France - Alcoholic Anonymous celebrates its 75th year

 

 

 

The Irrationality of Controlled Drinking?

The Irrationality of Controlled Drinking?

by alcoholicsguide

“Most of us have been unwilling to admit we were real alcoholics…Therefore, it is not surprising that our drinking careers have been characterized by countless vain attempts to prove we could drink like other people. The idea that somehow, someday, he will control and enjoy his drinking is the great obsession of every abnormal drinker. The persistence of this illusion is astonishing. Many pursue it into the gates of insanity or death.” (Alcoholics Anonymous, 1976, p. 30)

 

A number of very concerned people, people in recovery and family members of people in recovery have sent me a link to a journalistic piece entitled,  “The Irrationality of Alcoholics Anonymous “, written by  Gabrielle Glaser, who has moved onto writing about the highly emotive issue of alcoholism and so-called “controlled drinking” after having previously written on such diverse subjects as health and beauty, and interfaith marriage and appeared in magazines like Mademoiselle, Glamour, The Washington Post, and Health, among other publications.

They worry about the effect of this article may have on vulnerable alcoholics and new comers to recovery in particular.

In order to help newcomers and those out there in active addiction make an informed decision about an abstinence based recovery path, which is what I would strongly suggest for alcoholics, I will pick certain studies Glaser cites as being good example of research that demonstrate a return to controlled drinking in alcoholics and  why they are not.

I will then address many of her arguments  over the next series of blogs.

I believe there is no such phenomenon as a return to controlled drinking in alcoholics. To suggest otherwise is highly dangerous.

The Natural History of Alcoholism Revisited (1995) is a book by psychiatrist George E. Vaillant that describes two multi-decade studies of the lives of 600 American males, non-alcoholics at the outset, focusing on their lifelong drinking behaviours. By following the men from youth to old age it was possible to chart their drinking patterns and what factors may have contributed to alcoholism.

In other words, this studies show the “progression” of the disease of alcoholism.

The National Review hailed the first edition (1983) as “a genuine revolution in the field of alcoholism research” and said that “Vaillant has combined clinical experience with an unprecedented amount of empirical data to produce what may ultimately come to be viewed as the single most important contribution to the literature of alcoholism since the first edition of AA’s Big Book.”[1] Some of the main conclusions of Vaillant’s book are:

“Alcoholism can simultaneously reflect both a conditioned habit and a disease.”

That alcoholism was generally the cause of co-occurring depression, anxiety …not the result.

… it is therapeutically effective to explain it as a disease to patients. The disease concept encourages patients to take responsibility for their drinking, without debilitating guilt.

That there is as yet no cure for alcoholism…

That for most alcoholics, attempts at controlled drinking in the long term end in either abstinence or a return to alcoholism.

Successful return to controlled drinking is…just  a rare and unstable outcome that in the long term usually ends in relapse or abstinence, especially for the more severe cases.[48]

“by the time an alcoholic is ill enough to require clinic treatment, return to asymptomatic drinking is the exception not the rule.”[47]

Vaillant, when asked whether controlled drinkingis advisable as a therapeutic goal, he concluded that “training alcohol-dependent individuals to achieve stable return to controlled drinking is a mirage.”[47]

Glaser struggles with this concept of progression of alcoholism I feel in her article. She describes alcoholism as a spectrum when it is in fact more accurately a continuum – it not a static disorder but a disorder which has transitory phases, most commonly called use, abuse and addiction. If one does not understand this progression then they could be saying that abusers and not alcoholics can return to controlled drinking which is different. If that is even the case.

Some people can also  meet a diagnostic criteria for alcohol dependence for certain periods of time in their lives but are not alcoholic per se.  For example, they may be drinking heavily for a period of time due to a bereavement over the loss of a loved one.

As I will go into later in other blogs, neuroscience can certainly give us a good indication of the progression to chronic alcoholism in terms of brain imaging regions of the brain. A classic example is the switch in reward – motivation processing from the ventral to dorsal striatum in the brain of chronic alcoholics.

The dorsal striatum is more involved in compulsive behaviour common to endpoint addiction.

Other diagnostic help in assessing alcoholism in terms of chronicity is the severity of automatically occurring thoughts about alcohol related subject matter or obsessive thinking about drinking as measured by the Obsessive Compulsive Drinking Scale which also shows that more chronic alcoholics activate not only the dorsal striatum when viewing alcohol related cues but also obsessively think about these cues more also.

This the shift to dorsal regions of the striatum is reflected in cognitive terms and is also reflective of affective mechanisms such as a low heart rate variability which is a measure of emotion regulation in the face of these cues.

Alcoholics simply react differently to alcohol cues, salivate more etc than those who are not alcoholic. These measures are reflective to “that invisible line” alcoholics cross in switching for abusive to alcoholic drinking.

Unless scientific enquiry starts using these and other biomarkers of alcoholism it will be impossible for them to conclude that their studies are actually observing the behaviour of alcoholics. You can not predict behaviour accurately unless you have accurately defined what it is you are observing?

This is basic Science.

Glaser determines whether the people she is talking about are or were actual alcoholics by relying on self reports.

She also takes these people on face value although she may have heeded Vaillant when he suggests alcoholics present special challenges for researchers because they are good at concealing their drunkenness.[16] Vaillant asserts that “Alcoholics are expert forgetters,”[17] have inaccurate memories,[18] and give persuasive denials[16] that manifest “an extraordinary ability to deny the consequences of their drinking.”[19]

For the above reasons we have to be especially skeptical of studies supposedly about alcoholics. Most studies on alcoholics showing the markers I have mentioned above have no chance of returning to asymptomatic drinking whatsoever, to do so would lead to relapse and possible early death. This highlights the importance of detailed research, mainly because superficial research can have terrible if not life threatening effect on vulnerable alcoholics looking for help.

I will give an example of this by looking more closely at a study by certain researchers cited by Glaser in her article. To directly quote from Glaser’s article,

“ To many, though, the idea of non-abstinent recovery is anathema. No one knows that better than Mark and Linda Sobell, who are both psychologists. In the 1970s, the couple conducted a study with a group of 20 patients in Southern California who had been diagnosed with alcohol dependence.

Over the course of 17 sessions, they taught the patients how to identify their triggers, how to refuse drinks, and other strategies to help them drink safely. In a follow-up study two years later, the patients had fewer days of heavy drinking, and more days of no drinking, than did a group of 20 alcohol-dependent patients who were told to abstain from drinking entirely. (Both groups were given a standard hospital treatment, which included group therapy, AA meetings, and medications.) The Sobells published their findings in peer-reviewed journals.

In 1980, the University of Toronto recruited the couple to conduct research at its prestigious Addiction Research Foundation. “We didn’t set out to challenge tradition,” Mark Sobell told me. “We just set out to do good research.”

The Sobells returned to the United States in the mid-1990s to teach and conduct research at Nova Southeastern University, in Fort Lauderdale, Florida. They also run a clinic.”

What Glaser failed to mention was that in a subsequent study (4) 10-year follow-up of the original 20 experimental subjects showed that only one, who apparently had not experienced physical withdrawal symptoms (thus possibly not alcoholic), maintained a pattern of controlled drinking;

eight continued to drink excessively–regularly or intermittently–despite repeated damaging consequences;

six abandoned their efforts to engage in controlled drinking and became abstinent;

four died from alcohol-related causes;

and one, certified about a year after discharge from the research project as gravely disabled because of drinking, was missing.

Why did Glaser failed to mention this research, a follow up study to the one she mentions and cites?

Also why has Glaser not mentioned either that the the Sobells have stated since that it is those with less severe problems who often improve by moderating their drinking. Alcoholic abusers.

The Sobells’ implication – that the focus on non-dependent problem drinkers and on harm reduction could take the teeth out of the controlled drinking controversy – was again strangely also not mentioned by Glaser?

It is worth noting that some supporters of controlled or moderation drinking have also hidden their own difficulties with the drink. Audrey Kishline, the founder of Moderation Management (MM), a non-abstinence-oriented self-help group for individuals whose alcohol problems stop short of dependence, killed two people in a head-on vehicular collision with a not very moderate blood alcohol content measured at .26.

She started attending AA soon afterwards.

I will be dissecting the Glaser over the next few weeks – next up will be a blog on the infamous Rand Report of the 1970s and other studies which have purportedly demonstrated a return of controlled drinking in a small minority of so-called alcoholics?

 

Until then, all I can say is  a very heart felt but at the same time sad thank you to those friends in AA who were chronic alcoholics like me, who showed me what I need to know about this disease. They all relapsed and died,  to never become abstinent and in recovery again?

This was, is and will always be proof enough for me! Ultimately when it comes down to it, my experience and what my eyes see will always outrank academic theorising.

The BB states clearly ” If anyone who is showing inability to control his drinking can do the right-about- face and drink like a gentleman, our hats are off to him. Heaven knows, we have tried hard enough and long enough to drink like other people!”

What I am trying to do and will continue to do is demonstrate where research  is often inaccurate and sometimes downright dangerous.

Also, to end, these studies and diagnostic criteria all seem to focus on alcohol not the underlying condition of alcoholism. If alcohol was my only problem I would simply have stopped drinking as I stopped smoking, stopped taking drugs, stopped eating meat.

Going to an AA meeting and subsequently has shown me that I needed to accept first my alcoholism before accepting that alcoholism is more than alcohol, that I need a solution to my every day living problem.

I have a stress and emotional dysregulation problem, which precedes alcohol and which remains after alcohol.

Until we grasp, finally, what is wrong with alcoholics, we may be destined to go around in the same circuitous fashion.

AA has taught me how to live with others in this world, in a way I never previously could, and no amount of words can never convey how grateful I am for that blessing.

 

References

1. Alcoholics Anonymous. (2001). Alcoholics Anonymous, 4th Edition. New York: A.A. World Service

2.Vaillant, George E. (1995). The Natural History of Alcoholism Revisited. Cambridge, Massachusetts: Harvard University Press. ISBN 0-674-60378-8.

Vaillant, George E. (2003). “A 60-year follow-up of alcoholic men”. Addiction, 98, 1043–1051.

4. Pendery, M. L., Maltzman, I. M., & West, L. J. (1982). Controlled drinking by alcoholics? New findings and a reevaluation of a major affirmative study.Science, 217(4555), 169-175.

 

 

Childhood Maltreatment and later Alcoholism/Addiction

One old timer I know often says two things that I often take issue with – 1. there are as many alcoholisms as alcoholics and that 2. we all come to AA in different boats but end up in the same dock.

Thanks to having a wife in Al Anon I have had the benefit of her insight and from other al-anons who state how remarkably similar we alcoholics are in our behaviour, particularly in dealing/coping with distress and stress, our emotional reactivity and at times immaturity (or so-called defects of character), I disagree that we are so different in our addictive behaviours.

All addictive behaviours from alcoholism, substance addiction, eating disorders to hypersexual disorder seem to be based on an inherent problem with emotion and stress dysregulation.

I believe I have a distress based condition. It results in what appear to be distress based reactions such as perfectionism, distress intolerance and frustration intolerance, normally exemplified in my shouting at my PC when it doesn’t work quickly enough or crashes!

I also believe I have distress based impulsivity, I want that thing, whatever it is, NOW. That anything!

In fact I have noticed when I want something, anything, I end up pathological wanting it in no time at all! It seems then like I NEED it. I too think this is based on distress and heighten stress reactivity.

In fact it is through this pathological wanting that my so-called defects of character that my examples  of emotional dysregulation appear.

If I can’t get what I want, all range of negative emotions spill forth such as intolerance, impatience, arrogance, pride, shame, selfishness etc .  They only appear when I want something and you are getting in the way of me having it!!

So there is a link between my motivation (which is dysregulated due to the effects of chronic stress which turns simple wanting into something more akin to “needing”) and my subsequent emotional dysregulation.

So where does this distress come from? Is it purely the effects of chronic stress dysregulation caused by years of neuro toxic brain damage or does it go back further, into childhood?

I do not think we all have separate alcoholisms, I feel we have remarkably similar reactions to life and these centre on an inherent difficulty regulating stress and emotion.

I also believe we have come to recovery in similar boats. In fact the majority of us have come to recovery in a remarkable similar boat so much so that it would resemble a gigantic ship rather than a boat. That boat is the ship of childhood maltreatment.

Child maltreatment has been frequently identified in the life histories of adolescents and adults in treatment for substance use disorders, as well as in epidemiological studies of risk factors for substance use and abuse.

 Child Maltreatment

One study (1) suggests there is ample evidence exists for higher rates of substance abuse and dependence among maltreated individuals.

In clinical samples undergoing treatment for substance use disorders, between one third and two thirds evince child abuse and neglect histories (Dembo, Dertke, Borders, Washburn, & Schmeidler, 1988; Edwall, Hoffman, & Harrison, 1989; Pribor & DiWiddie, 1992; Schaefer, Sobieragi, & Hollyfield, 1988).

In the US a survey of over 100,000 youth in 6th though 12th grade, Harrison, Fulkerson, and Beebe (1997) Harrison, Fulkerson, and Beebe (1997) found that those reporting either physical or sexual abuse in childhood were from 2 to 4 times more likely to be using drugs than those not reporting abuse; the rates were even higher for youth reporting multiple forms of child maltreatment. Similar findings have been reported by Rodgers et al. (2004) and Moran, Vuchinich, and Hall (2004).

Among youth with Child Protective Services documented maltreatment, Kelly, Thornberry, and Smith (1999) reported one-third higher risk for drug use among those with an abuse history. In a large epidemiological study, Fergusson, Boden, and Horwood (2008) have shown physical abuse and particularly sexual abuse to be related to illicit drug use, as well as abuse and dependence.

Another Study (2) study would suggest the figures are much higher –   data were collected on 178 patients–101 in the United States and 77 in Australia–in treatment for drug/alcohol addiction. The purpose of the study was to determine the degree to which a correlation exists between child abuse/neglect and the later onset of drug/alcohol addiction patterns in the abuse victims. The questionnaire explored such issues as family intactness, parental violence/abuse/neglect, parental drug abuse, sibling relationships and personal physical/sexual abuse histories, including incest and rape. The study determined that 84% of the sample reported a history of child abuse/neglect.

A third study (1) stated that, using the Childhood Trauma Questionnaire-Short Form (CTQ-SF; Bernstein & Fink, 1998; Bernstein et al., 2003) to assess childhood maltreatment in a community sample of active drug users, Medrano, Hatch, Zule, and Desmond (2002) found that 53% of women and 23% of men were sexually abused, 53% of women and 43% of men were physically abused, 58% of women and 39% of men were emotionally abused, 52% of women and 50% of men were physically neglected, and 65% of women and 52% of men were emotionally neglected.

Substance abusers, in addition to having higher rates of childhood maltreatment than members of the general population, have been found to have levels of psychological distress that increase with increasing severity of all types of childhood maltreatment (Medrano et al., 2002). This association is important considering that stress increases an individual’s vulnerability to addiction and addiction relapse (Goeders, 2003; Sinha, 2001;Wills & Hirky, 1996).

There is also evidence that the way in which people cope with stress is related to substance use. For example, researchers have found that greater use of avoidance stress-coping strategies (i.e., disengaging from investing effort to cope with a problem) is related to a greater likelihood of drug use initiation, higher levels of ongoing drug use, and a greater probability of relapse, whereas greater use of active stress-coping strategies (i.e., taking steps to deal with a problem) most consistently functions to protect individuals from substance use initiation and relapse (Wagner, Myers, & McIninch, 1999; Wills & Hirky, 1996).

Childhood maltreatment may influence substance use behavior through its effect on stress and coping. There is emerging evidence that childhood maltreatment may negatively affect the maturation of self-regulatory systems that enable an individual to modulate and tolerate aversive emotional states (Cicchetti & Toth, 2005; Hein, Cohen, & Campbell, 2005). Childhood maltreatment may disrupt neurobiological development and elevate subjective stress by biologically altering the brain’s response to stress (Bugental, 2004;DeBellis, 2002; Heim & Nemeroff, 2001; Heim et al., 2000; Sinha, 2005; Wills & Hirky, 1996). Childhood maltreatment may also affect an individual’s characteristic style of coping with stress so that he or she may be more likely to rely upon maladaptive strategies, such as avoidance of problems, wishful thinking, and social withdrawal, rather than active strategies, such as seeking information and advice from others (Bal, Crombez, Van Oost, & Debourdeaudhuij, 2003; Futa, Nash, Hansen, & Garbin, 2003; Krause, Mendelson, & Lynch, 2003; Leitenberg, Gibson, & Novy, 2004; Thabet, Tischler, & Vostanis, 2004).

Elevated stress and maladaptive coping related to childhood maltreatment may translate to greater substance use behavior by making the coping motives of substance use appear more attractive (Wills & Hirky, 1996). Indeed, substance users commonly report using psychoactive substances such as alcohol, cannabis, and cocaine to cope with stress and regulate affect (Boys, Marsden, & Strang, 2001)

Most cocaine dependent inpatients reported multiple types of childhood maltreatment, and only 15% reported no maltreatment at all, (similar figures to study 2).

“Our findings suggest that the severity of overall childhood maltreatment experienced by recently abstinent cocaine dependent adults has a significant relationship with perceived stress and avoidance coping in adulthood.

Our findings suggest that having a more severe childhood maltreatment history may result in a greater sensitivity to stress…basic coping skills training may not be adequate in decreasing distress and avoidant coping in order to decrease substance use and relapse. Additional interventions that focus on stress tolerance, altering appraisals of stress, stress desensitization, and affect and emotion regulation skills may be of particular benefit to patients with childhood maltreatment histories.

The fact that childhood maltreatment is a preventable phenomenon that occurs early in life and affects psychological functioning well into adulthood makes our findings relevant to clinical practice with children as well. Early identification and treatment of maltreated children may help prevent stress sensitivity or the development of a less adaptive style of coping. Assessment of coping ability and the implementation of coping skills and stress tolerance training may also be indicated for maltreated children in an effort to increase their coping efficacy and decrease their vulnerability to stress later in life.”

I may have been in recovery for a number of years now but coping with stress/distress is still central to my recovery. Dealing with the effects of childhood maltreatment not only via negative self esteem and self schema but in the real sense of coping with every day stress/distress, mainly prompted in my interpersonal relationships (other people!) and with my PC!

 

References

1. Rogosch, F. A., Oshri, A., & Cicchetti, D. (2010). From child maltreatment to adolescent cannabis abuse and dependence: A developmental cascade model.Development and psychopathology, 22(04), 883-897.

2. Cohen, F. S., & Densen-Gerber, J. (1982). A study of the relationship between child abuse and drug addiction in 178 patients: Preliminary results. Child Abuse & Neglect, 6(4), 383-387.

3.  Hyman, S. M., Paliwal, P., & Sinha, R. (2007). Childhood maltreatment, perceived stress, and stress-related coping in recently abstinent cocaine dependent adults. Psychology of Addictive Behaviors, 21(2), 233.

Your Heart is in Your Own Hands!

Easy Does it…on yourself!

I give myself a hard time,  it is a habitual response I have when things go “wrong” or don’t go my way. One of the first words  that pop into my head is “idiot!”. It is a lack of distress tolerance borne out of a reducee ability to deal with fristration. This appears in the brain as a distress signal prompting an automatic response rather than an evaluative response. A reaction rather than a reflective action.

It is the consequence of a distress state and in itself distressing. It can also be distressing for those around me. It seems like perfectionism which is also a product of distress.

I believe it is also the product of my upbringing, trauma and insecure attachment which has led to a low self esteem and a lack of self soothing combined with the reality that chronic alcoholism leaves us with an allostatic brain, i.e. the stress systems in the brain are impaired.

It is only recently in recovery, after some years of recovery, that I have started to feel real compassion for myself as someone recovering from alcoholism and various addictive behaviours.

When I look at photos of me in active addiction and in the first years of recovery my heart goes out to that younger, more distressed version of myself.

Compassion is a Latin word that which can be translated as meaning suffer together with. It can also be described as a feeling of empathy for the suffering of other people.

I have always found it easier to have compassion for others more than myself. I practiced Buddhist mediation for a number of years and have often felt at one with the world and it’s people. I have nonetheless always struggled with being compassionate towards myself.

I have somehow found myself undeserving of a compassionate attitude towards my own struggles. I know my God loves me but I have often felt it difficult to love this person that God loves.

Again, this could be a legacy of how ambivalent attachment and how my mother saw and reacted. I sometimes have more time and consideration for others rather than myself.

Ultimately however, how react to the world is a function of how I treat myself and the attitudes I have collected in my negative self schema or the neural responses ingrained in my brain over decades. As the image below shows, my heart is in my own hands, by this I mean the distress I experience in life is the consequence of my own attitudes towards me and my fellow human beings.

Self-Compassion-680x513

 

I can change my brain and behaviour via neuroplasticity by behaving differently towards myself!

Here we look at one study on self compassion in relation to those who have alcohol  use disorders.

It will be a first in a series of blogs about the role of the heart in addiction and recovery.

Why the heart?

I thought this blog was about neuroscience and the brain which is the head? Not completely true. The heart has a role to play in stress and emotion regulation and in craving and helps prompt neuro transmission of various brain chemicals. The heart has a reciprocal relationship with the brain as we will see in later blogs.

We have had a neuroscientific “decade of the brain” so perhaps we need a “decade of the heart”? As we say in recovery circles, recovery is a journey from the head to the heart, which is so true whatever way you care to look at it.

This study (1)  looked at “Self-Compassion Amongst Clients with Problematic Alcohol Use”.

“Self-compassion is a topic of growing research interest and is represented by six facets including selfkindness, self-judgement, mindfulness, over-identification, common humanity and isolation. Recent research interest has begun to examine the use of self-focused compassion and mindfulness as a way of alleviating the distress associated with psychological disorders.

Recent research interest has begun to examine the use of self-focused compassion and mindfulness as a way of alleviating the distress associated with psychological disorders.

The self medication hypothesis (Khantzian 2003) suggests that substance addiction functions to self-soothe and to modulate the effects of distressful psychological states (Suh et al. 2008).

Other research has found that experiencing stressful life events significantly predicts the amount and frequency of alcohol consumed (Dawson et al. 2005) and the onset of alcohol dependence (Lloyd and Turner 2008) indicating that stress plays a key part in the development of alcohol use disorders.

Low self-esteem has also been found to pose a high risk for substance abuse (Baumeister 1993; Bushman and Baumeister 1998) and alcohol dependence (Chaudhury et al. 2010,).

Self-compassion does not involve an unrealistic self view, it should be stable unlike self-esteem, which often fluctuates (Kernis et al. 1993). Self-compassion involves being kind and understanding to oneself, awareness that pain and failures are unavoidable common experiences among humanity and a balanced awareness of one’s emotions (Neff, Rude and Kirkpatrick 2007).

Kelly et al. (2010) suggested that the trait of self-compassion promotes adaptive functioning and appears to provide a buffer from emotional distress. Neff (2003a) has also reported that self-compassion was strongly inversely related to psychological health such as depression, anxiety, rumination, thought suppression, self-criticism and neurotic perfectionism. Neff, Kirkpatrick and Rude (2007) found that increased self compassion resulted in reduced depression, anxiety, thought suppression, rumination and self-criticism.

Neff (2003a, b) suggests that there are three main components to self-compassion including self-kindness versus self-judgement, common humanity versus isolation and mindfulness versus over-identification. Self-kindness is being kind to oneself rather than judging harshly or being self– critical. Common humanity is viewing one’s experiences as part of larger human experience and not viewing them as isolating or separating. Mindfulness is paying attention in a particular way involving a conscious direction of awareness (Kabat-Zinn 1994). Neff (2003a, b) describes mindfulness as taking a balanced approach to negative emotions and neither suppressing not exaggerating emotions.

The self-kindness facet represents an alternative to rumination, blaming, self-condemnation and self-criticism.

Common humanity appears to be related to general well-being and Mindfulness represents a state of mental balance with a stance of composure towards difficult and painful thoughts and feelings, therefore suggesting mindfulness may play an important role in adaptive and maladaptive emotion regulation (Van Dam et al. 2011). Self-compassion can be thought of a coping strategy that assists one to remain emotionally balanced when in a stressful situation (Rendon 2007) and provides emotional resilience (Neff 2011).

This study is among the first to examine the self-compassion of people with alcohol dependence, who were currently using alcohol at hazardous levels.

The results indicated that the (alcohol dependnet) participants in this study were significantly lower in mindfulness, common humanity and self-kindness than what would be expected in the general population.

Participants were also significantly higher in over-identification, perceived isolation and self judgement than the norms for general population.

Stress was found to be significantly negatively correlated to the overall score for self-compassion (e.g., the higher the level of stress reported by the individual, the lower the self compassion). Stressed individuals judged themselves more harshly, felt more isolated from others and felt overly responsible for negative events that occurred in their lives.

The results ,taken together, indicated that participants in this study reported a significant increase in self-compassion, mindfulness, common humanity and self-kindness between baseline and 15-week follow-up and involvement in treatment with a Drug and Alcohol Clinical Service.

Additionally, there was a significant decrease in self-judgement, isolation and over-identification. The reduction in self-judgement and isolation was such that at the 15-week follow-up stage, participant scores for these subscales were equivalent to what other research has suggested is representative of the general population.

The change in participant’s stress was found to be significantly associated with self- kindness, self-judgement, isolation and the number of sessions in which meditative practice (which may have incorporated mindfulness-based approaches) was used by clinicians. These results provide support for the notion that significant increases in participant’s overall self-compassion, self-kindness, mindfulness and common humanity can be observed in people with alcohol dependence over a 3-month treatment period.”

 

This study is useful in that it shows how the emotional distress at the heart of addiction, itself a manifestation of altered stress responding or heightened stress responses in alcoholics, was greatly reduced by self compassion or simply have a more compassionate view of one’s suffering.

It is in taming the distress of the heart that lowers stress chemicals swirling around the brain and which influences our subsequent attitudes and behaviour.

Recovery is in the heart, in the now, in not reacting but acting. Even if that action is just of observing, paying attention to, having compassion for.

After years of being our own worst enemy, perhaps recovery is the process of becoming our own best friend. 

References

1. Brooks, M., Kay-Lambkin, F., Bowman, J., & Childs, S. (2012). Self-compassion amongst clients with problematic alcohol use. Mindfulness, 3(4), 308-317.

 

 

Abstinence is getting Sober, Recovery is getting Emotionally Sober.

A very interesting concept in recovery is the idea of Emotional Sobriety which originated with Bill Wilson who found that after 20 years of recovery he suffered badly from  depression. His decades long association with Dr Tiebout, his psycho-analyst, led him to conclude that this was partly due to how he reacted to people. He found he either tried to dominate them or emotionally depend on them.

This emotional immaturity is something we have discussed in previous blogs and may be related to an overall problem regulating our emotional behaviour.

Our emotional responses may be related to an inherent brain allostasis which seems to affect pathological wanting in various aspects of life (not just substances or behaviours – the illness of “more”), to the common emotional and stress dysregulation seen in addicts in active use and in recovery or to habitualized, maladaptive emotional responding which is the legacy of our previous active addiction, which in themselves may have been the consequence also of maladaptive self schemata borne out of childhood maltreatment, or insecure attachment or all these in combination.

As we grow older in recovery, hopefully we also emotionally  mature or become more adaptive or healthy in regulating our emotions and in our decision making and subsequent behaviour.

Ultimately how we deal with our emotions (or how they deal with us!) depends on our motivations.

Roger B offers some great insights into how to overcome this emotional neediness and live in a more emotionally sober way.

Forgiving Others is the Number One Healer!?

“Resentment is the “number one” offender. It destroys more alcoholics than anything else… In dealing with resentments, we set them on paper. We listed people, institutions or principles with whom we were angry… The first thing apparent was that this world and its people were often quite wrong. To conclude that others were wrong was as far as most of us ever got. The usual outcome was that people continued to wrong us and we stayed sore. Sometimes it was remorse and then we were sore at ourselves. But the more we fought and tried to have our own way, the worse matters got…It is plain that a life which includes deep resentment leads only to futility and unhappiness…If we were to live, we had to be free of anger. The grouch and the brainstorm were not for us. They may be the dubious luxury of normal men, but for alcoholics these things are poison…We saw that these resentments must be mastered, but how?… (1)”

Later, p.77, it suggests  “a helpful and forgiving spirit.”

In the 12 Steps and 12  Traditions, p.78, in reference to step 8 it suggests “why shouldn’t we start out by forgiving them, one and all?

These truncated passages from the Big Book (1)  and the 12 and 12 (3) illustrates how resentments cause relapse and that they need to by treated with the antidote of forgiveness.

We suggest also that the myriad of resentments which swirl around our minds in early recovery are also negative emotions unprocessed and thus unregulated from the past. They continually haunt us because we have not put them “to bed” in long term memory.

We have not dealt with them, by clearly identifying, labelling, sharing via verbalising them with others and then by letting go of them via forgiveness. “Letting go” is another emotional regulatory strategy that healthy people use.

res images (42)

Instead of constantly holding on to memories and incidents from the past, endlessly ruminating on them we maturely face up to them and consign them to the past.

We were thus interested in a study which was not using 12 step recovery but which came to the same conclusion but via another route (2).

“Anger and related emotions have been identified as triggers in substance use. Forgiveness therapy (FT) targets anger, anxiety, and depression as foci of treatment. Fourteen patients with substance dependence from a local residential treatment facility were randomly assigned to and completed either 12 approximately twice-weekly sessions of individual FT or 12 approximately twice-weekly sessions of an alternative individual treatment based. Participants who completed FT had significantly more improvement in total and trait anger, depression, total and trait anxiety, self-esteem, forgiveness, and vulnerability to drug use than did the alternative treatment group. Most benefits of FT remained significant at 4-month follow-up.

The levels of anger and violence observed among alcohol and other substance abusers are far higher than the levels found in the general population.

Alcohol and other substance abusers administered the State-Trait Anger Expression Inventory typically have been shown to have higher state and trait anger, to be more likely to express anger to others, and to have less control of their anger.

Reducing levels of anger and its related emotions is now seen as an important feature of recovery programs. For example, according to the Project Match 12-step facilitation therapy manual, “Anger and resentment are pivotal emotions for most recovering alcoholics. Anger that evokes anxiety drives the alcoholic to drink in order to anesthetize it. Resentment, which comes from unexpressed (denied) anger, represents a constant threat to sobriety for the same reason” (Nowinski, Baker, & Carroll, 1999, p. 83).

Marlatt (1985) emphasized the importance of anger and frustration as triggers for relapse in both the intrapersonal and interpersonal domains. He noted that 29% of relapses are related to intrapersonal frustration and anger and that 16% are related to interpersonal conflict and associated anger and frustration.

Litt, Cooney, and Morse (2000) reported that those alcoholics who had urges to use after treatment had higher degrees of alcohol dependence, anxiety, and trait anger than those without such urges.

Forgiveness is an important way to resolve anger and restore hope (Enright & Fitzgibbons, 2000). In helping clients move toward forgiveness, it is essential to differentiate forgiving from condoning, pardoning, reconciling, or forgetting.

Forgiveness is a personal decision to give up resentment and to respond with beneficence toward the person responsible for a severe injustice that caused deep, lasting hurt. FT helps the wronged person examine the injustice, consider forgiveness as an option, make a decision to forgive or not, and learn the skills to forgive.

Findings – Our clients came to the program with trait anxiety and trait anger scores substantially above the published norms for adults; after treatment, however, FT participants exhibited scores comparable to the average.  In other words, the treatment did not lead simply to a change in anxiety and anger (particularly the reportedly more stable trait anxiety) but to a change toward normal profiles. In contrast, patients in the alternative treatment condition had anxiety scores well above average, especially in terms of trait anxiety, which showed little change at post test and only minimal improvement at follow-up.

FT did not focus on drug vulnerabilities, whereas the alternative treatment did. Urges to use substances are not necessary for relapse, they are important indicators.

FT  treatment is centered more on clients’ thoughts, feelings, and behaviors about someone other than themselves: an offender who hurt them deeply and unfairly. In FT, a potential reason for substance use is examined, that of avoiding painful memories of betrayal, violence, or abuse. When patients are allowed to heal, their motivation to abuse substances may be substantially reduced…(it) is worth considering as a way to address core issues of emotional pain.

resentment

 

This can lead to a reduction in negative emotions and increases in self-esteem and forgiveness… it moves to the heart of the matter for some clients. Deep hurts borne out of unfair treatment seem to play a part in substance use and abuse. Even when clients have many people to forgive…we find that they seem to know which person is most crucial to forgive first before moving to other offenders. Substance use, from this perspective, is a symptom of underlying resentments and related emotional disruptions.

If we fail to realize this, we may end up treating only symptoms rather than underlying causes. ”

 

This process seems practically the same as the inventory of Step 4 and the forgiveness implicit to steps 8 and 9. This study also highlights that we through forgiveness we actually tackle the underlying condition of emotional dysregulation. It is this emotion dysregulation (or spiritual disease) which appears to drive addiction so needs to be fundamentally addressed. By addressing these issues via the steps especially step 4 we begin to see how it works!

It was interesting that forgiveness led to higher self esteem, as if being tied to the past was akin to being tied to a former negative self schema, that people from our pained past did actually have the power to control us! Especially how we feel about ourselves. We change how we feel about ourselves and our past by simply forgiving, it is such a powerful tool in recovery.

Importantly by viewing studies like this (2)  we get beyond negative views of 12 step recovery to show that the recovery program’s effectiveness is clearly highlighted by the success of other psychological treatments getting the same positive results by using exactly the same strategies.

12 step groups provide a battery of the most profoundly effective psychological therapies for addiction ever contained within one treatment philosophy.

Don’t we all need to re-appraise how we see 12 step recovery?

Can’t we all benefit from stepping to one side and looking via a different angle to see why 12 step recovery is effective?

 

Reference

1. Alcoholics Anonymous. (2001). Alcoholics Anonymous, 4th Edition. New York: A.A. World Services.

2. Lin, W. F., Mack, D., Enright, R. D., Krahn, D., & Baskin, T. W. (2004). Effects of forgiveness therapy on anger, mood, and vulnerability to substance use among inpatient substance-dependent clients. Journal of consulting and clinical psychology, 72(6), 1114.

3.   Twelve steps and twelve traditions. (1989). New York, NY: Alcoholics Anonymous World Services

How the Brain Recovers in Abstinence and Recovery

If addiction is characterized by loss of control over the use of substances and behaviour and a severely diminished self control or volitional control over behaviour is recovery the regaining over control over behaviours?

 

This study (1)  looked at the recovery of grey matter (and brain function in cocaine addicts (CD).  This study used a brain imaging technique called voxel based morphometry (VBM) to assess how local grey matter (GM) volume varies with years of drug use and length of abstinence in a cross-sectional study of cocaine users (presently or formerly inpatients or outpatients at treatment centres) with various durations of abstinence (1–102 weeks) and years of use (0.3–24 years).

“Extensive evidence indicates that current and recently abstinent cocaine abusers compared to drug-naïve controls have decreased grey matter in regions such as the anterior cingulate, lateral prefrontal and insular cortex. Relatively little is known, however, about the persistence of these deficits in long-term abstinence despite the implications this has for recovery and relapse.

Lower grey matter volume associated with years of use was observed for several regions including anterior cingulate, inferior frontal gyrus and insular cortex. Conversely, higher grey matter volumes associated with abstinence duration were seen in regions that included the anterior and posterior cingulate, insular, right ventral and left dorsal prefrontal cortex. Grey matter volumes in cocaine dependent individuals crossed those of drug-naïve controls after 35 weeks of abstinence, with greater than normal volumes in users with longer abstinence.

The asymmetry between the regions showing alterations with extended years of use and prolonged abstinence suggest that recovery involves distinct neurobiological processes rather than being a reversal of disease-related changes. Specifically, the results suggest that regions critical to behavioral control may be important to prolonged, successful, abstinence.

Findings suggest a cumulative effect of cocaine use wherein the longer the period of substance use the lower the grey matter volume [22]. That these effects were observed in abstinent users is consistent with prior reports of GM deficits in alcoholism that last from 6–9 months to more than a year or, in some reports, up to at least 6 years following abstinence [42]–[44].

Similarly, decreased GM as a function of years of use of heroin [6], [45], [46] and cocaine [15] have previously been reported. in regions important to emotional regulation…given that emotional reactivity has been implicated as a factor modulating vulnerability to drug abuse [49], this may have been a preexisting factor that served to increase the likelihood of the development and prolongation of drug abuse.

If addiction can be characterized as a loss of self-directed volitional control [22], abstinence and its maintenance may be characterized by a reassertion of these aspects of executive function [24]

Current cocaine users demonstrate reduced GM in brain regions critical to executive function, such as the anterior cingulate, lateral prefrontal, orbitofrontal and insular cortices [6]–[11]. In contrast, the group of abstinent CD users reported here show elevations in GM as a function of abstinence duration that exceeds control levels after 36 weeks, on average, of abstinence. One possible explanation for this is that abstinence may require reassertion of cognitive control and behavior monitoring that is diminished during current cocaine dependence [11], [50], [51].

 

We, and others, have previously hypothesized that drug abusers may develop increased cerebellar activity to compensate for reduced prefrontal activity in tasks demanding elevated levels of cognitive control [52], [53] and that this may play a role in maintaining abstinence [24]. Reassertion of behavioral control may produce a practice-related expansion [54] in GM regions such as the anterior insula, anterior cingulate, cerebellum, and dorsolateral prefrontal cortex and is consistent with our previous reports of elevated activity levels, compared to controls, in long-term abstinent substance users [24], [55].

 

It should be noted that we also observed regions displaying increased GM with abstinence in bilateral cingulate gyri that did not overlap with those showing decreased GM with years of use. This suggests that the brain is capable of compensating in response to changes in demands, such as the maintenance of abstinence [54], [76].”

It would have been interesting to correlate the findings of this type of research with more information on the treatment undertaken, e.g. was it a 12 step facilitation treatment, to assess the nature of this behaviour-based neuro-plasticity. We need more research into translating the elements of “how it works” into the areas of the brain to observe where it works. In other words how do new attitudes and behaviours shape the brain literally. How does the brain recover volume, connectivity, functionality via behavioural change?

The brain areas which regain volume are implicated also in emotion regulation. It is interesting that the authors point to a possibility that the decreased brain volume in certain areas regulating emotion may also be a pre-existing condition, or in other words, a vulnerability to later addiction risk.

It may be that in recovery some of us learn to master or at least attempt to manage and control emotions in a way we could not previously.

For us this is an essential part of the pathomechanism of addictive  behaviours,  this emotion processing and regulation deficit; a deficit we learn to overcome in recovery. An unmanageability that we learn to manage in recovery.

In our next blog we will look at how these emotional factors drive the addiction cycle to it’s chronic endpoint.

We will look at how emotional dysregulation around forgiveness has contributed to a need to continually distance ourselves chemically from the incidents that needed our forgiveness. It will also look at how forgiveness itself is a emotional regulation strategy in itself, just like “letting go” is. We learn so many emotion regulation strategies in recovery and these appear essential to long term recovery.

References

1. Connolly, C. G., Bell, R. P., Foxe, J. J., & Garavan, H. (2013). Dissociated Grey Matter Changes with Prolonged Addiction and Extended Abstinence in Cocaine Users. PLoS ONE, 8(3), e59645. doi:10.1371/journal.pone.0059645