12 steps

How Far Have We Come In Understanding this “Spiritual Malady” of Alcoholism?

In our previous blog we wondered if some commentators, who have co-occurring disorders may be puzzled at how having a “spiritual malady” could be related in any way to have a co-occurring condition?

This is a pretty valid question?

In fact this may be at the heart of the issue in many cases  of feeling the need to take medication  for so-called co-occurring conditions?

Seeing alcoholism as partly the product of a spiritual malady, instead of the affective disorder I believe it to be, may influence certain AAs to seek additional help for supposed additional conditions when the manifestation of these conditions may actually be part of the emotional disorder of alcoholism?

It is at least worth considering?

For me sometimes there is a confusion with what is perceived to be a spiritual malady?

I do not believe I have the same type of spiritual malady as my wife for example who is an normie, earthling, normal person (whatever that is?) I believe, if any thing I have a super enhanced, at times turbo-charged,  spiritual malady, often fuelled by stress/distress, as the result of my alcoholism.

I do not believe I have the same spiritual malady as other normal people such as those people who were in the Oxford Group.

That is not to say that normal people cannot be full of sin –  a cursory look around the work and it’s events will soon confirm this is the case. What I am saying is that they do not have the emotion dysregulation or fear based responding that I seem to have which often prompts “sin”.

By sin I mean negative emotions that cause distress to me and others.

For example, false pride, intolerance, impatience, arrogance, shame, lust, gluttony, greed. Yes these all create distress.

The spiritual principles of AA and the 12 steps in particular were drawn from the 4 absolutes of the Oxford group, via initially the 6 steps  and the idea of a spiritual malady is also borrowed from the Oxford group.

I have for several years wondered if the spiritual malady described in the Big Book adequate or accurate enough in describing what I suffer from.

I believe others have difficulties in reconciling the spiritual malady of the Big Book with their own alcoholism, addiction and  co-occurring conditions?

Part of the problem may lie in not being specific enough about what   alcoholism is.

It may be that research and the world have not progressed far enough to give a comprehensive account of what alcoholism is. Also the spiritual malady concept of AA has for 80 years helped millions of people recover from this most profound of conditions? So why change it if it’s not broke?

That is a good point? I am not advocating changing anything, I hope AA recovery remains as it is for 80 more years and much more years. I would not change one word in the first 164 pages of the BB.

However, many AAs ignore the spiritual malady thing completely, or do not do the steps, so, in my opinion, they often do not properly understand what they suffer from?

The magic of the the steps is that they seem to reveal  the patterns of behaviour that our actions have prompted over the course of our lives.  Maladaptive behaviours I should add. It helps us see ourselves and our condition of alcoholism and how it effects us and others.

It shows the areas of behaviour and attitudes that can be treated by working the steps. It shows us how our approach to life can possibly be transformed for the better.

For me personally it often showed a pattern of emotional responding to events that do not go my way!!?

As Bill Wilson once wrote we suffer when we cannot not get what we want or others seem to prevent us getting what we want.

My inventory of steps 4/5 showed me that my long lists of resentments were mainly the product of emotional immaturity and responding in an immature manner to not getting my way.

My inventory showed me also that I did not seem to have the facility previously to emotionally respond to the world in a mature way. As the world dominated me.

My recovery has thus since been about “growing up” a bit, however unsuccessful I am in this pursuit on occasion.

I have often written that this inherent emotional immaturity may even be linked to the possibility that the areas of my brain that regulate emotions have not matured properly  as alcoholic seem to have different connectivity, functionality and morphology (size/volume)  in this emotion regulation  circuit/network to healthy normal people.

Alcoholics seem not to be able to fully process emotional information externally, i.e reading emotion expression of faces accurately, or internally reading what emotions we are having, or even whether we are hungry or tired!

So we have issues with emotions and somatic/body feeling states. This is perhaps compounded by most of us having experienced abuse or maltreatment which can also lead to alexithymic characteristics such as not being able to label or describe, verbally, emotional states we are experiencing – although we can be good at intellectualising these emotions – which is not the same as processing them.

Alcoholics and children of alcoholics have a tendency to avoid emotions (use avoidant coping strategies) in fact and to use emotional reasoning when arguing a point.

These emotion processing deficits also appear to make us more impulsive, and to choose lesser short term gain over greater long term gain in decision making. It can lead to a distress feeling state that can make us fear based, perfectionist, have catastrophic thoughts, intolerance of uncertainty, low frustration and distress tolerance, be reactionary, moody, and immature in our emotional responding.

But how has any of this got anything to do with the so-called spiritual malady we are suppose to suffer from?

I believe the spiritual malady mixed with the ancedotal evidence throughout the BiG Book hints at these emotional difficulties as being an intrinsic part of our alcoholism, “We were having trouble with personal relationships, we couldn’t control our emotional natures, we were a prey to misery and depression, we couldn’t make a living, we had a feeling of uselessness, we were full of fear, we were unhappy…”

It was 80 years ago, so our knowledge base has moved on greatly from when the Big Book was written. Hence I believe we should appreciate that this definition of our condition has been updated by research into emotions especially in the last 20 years.

I am happy to say a spiritual malady is what we suffer from, as the steps provide a solution to my emotion disorder by treating it as a spiritual malady but  I do not think it is the straightforward spiritual malady adopted by AA from the Oxford Group, mainly because in the majority of situations I do not choose to sin, the sinning seems to happen to me. In other words it is the consequence of my fear based condition, this affective disorder.

The Oxford Group explain a general spiritual malady that all people can have. I do not think alcoholics are like all people. We are human beings, but extreme versions of human beings. I believe, even when I try my best to be virtuous and holy, I could sin at the sinning Olympics for my country. I am that naturally good at it!

I sin so naturally, effortlessly  and usually without even trying. I believe my so-called defects of character are linked to my underlying emotional disorder of alcoholism.

Sins I believe are the poisoned fruit of fear, often  helped along in alcoholics by false pride, shame and guilt. These defects are related to me being an alcoholic, they are intrinsic to my condition.

In order to illustrate how I believe my spiritual malady is the consequence of my emotional disorder, called alcoholism/addiction first let’s  go back to where this idea of spiritual malady came from.

According to a wonderful pamphlet “What is the Oxford Group”   written by The Layman With a Notebook ” Sin can kill not only the soul but mind, talents, and happiness as surely as a malignant physical disease can kill the body…

Sin is a disease with consequences we cannot foretell or judge; it is as contagious as any contagious disease our bodies may suffer from. The sin we commit within this hour may have unforeseen dire consequences even after we have long ceased to draw living breath…

…Like physical disease Sin needs antiseptics to prevent it from spreading; the soul needs cleaning as much as the body needs it…

Unhappiness to us and others, discontent, and, frequently, mental and bodily ill health are the direct results of Sin.

…Morbidity of mind must affect the physical health. If we can be absolutely truthful to ourselves we can analyse our sins for ourselves and trace their mental and physical effects. Sins can dominate us mentally and physically until we are their abject slaves. We cannot get rid of them by deciding to think no more about them; they never leave us of their own accord, and unless they are cut out by a decided surgical spiritual operation which will destroy them, roots and all, and set us free from their killing obsession, they grow in time like a deadly moss within us until we become warped in outlook not only towards others but towards ourselves….”

One can see how this concept of sin disease or in other words spiritual malady could be and was applied to early AA and incorporated into the Big Book of AA.

However, it is equally stating, I believe, that alcoholics suffer from the same spiritual malady as other people but our spiritual malady has led to chronic alcoholism, this is the manner in which sin has dominated  “mentally and physically until we are their abject slaves”.

In fact the Big book’s first chapters look more at the manifestation of this malady, problem drinking,    than the malady.  It suggests that there is more than this malady, there is also a physical reason for alcoholism- an allergy (or abnormal reaction) to alcohol. So this is a departure from the Oxford Group as it clearly states that alcoholism is more than a spiritual malady.   It is not simply the consequence of this spiritual malady although this malady may contribute.  So is this saying some of us are spiritually ill while also having an abnormal reaction to alcohol?

In the foreword The Doctor’s Opinion suggests  that “the body of the alcoholic is quite as abnormal as his mind.” and  a first mention of a disorder more than “spiritual” is suggested, “It did not satisfy us to be told that we could not control our drinking just because we were maladjusted to life, that we were in full flight from reality, or were outright mental defectives. These things were true to some extent, in fact, to a considerable extent with some of us. (my emphasis)

“The doctor’s theory that we have an allergy to alcohol interests us…as ex-problem drinkers, we can say that his explanation makes good sense. It explains many things for which we cannot otherwise account.”

“the action of alcohol on these chronic alcoholics is a manifestation of an allergy; that the phenomenon of craving is limited to this class and never occurs in the average temperate drinker.”

Here we have an abnormal reaction to alcohol and for some alcoholics a maladjustment to life.

For me this maladjustment to life is not exactly the same as the spiritual disease mentioned in the Oxford Group pamphlet.

All of my academic research in the last 6 years has explored the possibility that this “maladjustment to life” is more than a spiritual malady, i.e. it is not simply the consequence of Sin but the result of abnormal responding, emotionally (which has obvious consequences for sinning) to life.

This emotion dysregulation, as I name it, has consequences for how we feel about ourselves, how we interact with people, how much we feel we belong, how rewarding alcohol and drugs are, how much these substances make us feel better about ourselves (fix our feelings ) and how they turn off the internal critic of maladaptive and negative self schemas.

 

In fact our first “spiritual” wakening was probably the result of drinking as it transformed how we felt about ourselves and the world in which we lived. I know it did for me. In fact, I felt “more me” when I drank, it was like I escaped a restrictive sense of self to be a more expansive, people loving self.  I had a connection with the world I could not generate myself, when sober.

I was a “spirit awakening” if nothing else? It is interesting that a common definition of “spiritual” as it relates to AA, is a sense of connection with others.

As the BB states “Men and women drink essentially because they like the effect produced by alcohol. The sensation is so elusive that, while they admit it is injurious, they cannot after a time differentiate the true from the false. To them, their alcoholic life seems the only normal one. They are restless, irritable and discontented, unless they can again experience the sense of ease and comfort which comes at once by taking a few drinks—”

For me this section is saying our emotion dysregulation leads to feelings of being “restless, irritable and discontented” which prompt a return to drinking.

The Doctor’s Opinion even offers some classifications of alcoholics “The classification of alcoholics seems most difficult, and in much detail is outside the scope of this book. There are, of course, the psychopaths who are emotionally unstable… the manic-depressive type, who is, perhaps, the least understood by his friends, and about whom a whole chapter could be written.”

This section would appear to be stating clearly that there alcoholics who have other (co-occurring) conditions or conditions appearing as co-occurring?

I contend that alcoholism is an emotional disorder which results in chemical dependency on the substance of alcohol. However in order to treat it we have to first contend with the symptomatic manifestation of this disorder, chronic alcohol use, as it is the most life threatening aspect of this disorder when we present our selves at AA.

What we used once to regulate negative emotions and a sense of self has eventually come to regulate our emotions to such an extent that any distress leads to the compulsive response of drinking. Alcoholics had become a compulsive disorder to relief distress not to induce pleasure.

The “spiritual malady” of the Oxford group seems enhanced in me, I believe I sin more than normal people because of my emotional immaturity and reactivity. My “loss of control” over drinking is also linked to emotion processing difficulties as it prompted  impulsive, uninhibited drinking.

This emotional immaturity is referenced throughout the Big Book I believe.

“… He begins to think life doesn’t treat him right. He decides to exert himself more. He becomes, on the next occasion, still more demanding or gracious, as the case may be. Still the play does not suit him. Admitting he may be somewhat at fault, he is sure that other people are more to blame. He becomes angry, indignant, self-pitying. ”

“Whatever our protestations, are not most of us concerned with ourselves, our resentments, or our self-pity? Selfishness—self-centeredness! That, we think, is the root of our troubles. Driven by a hundred forms of fear, self-delusion, self-seeking, and self-pity, we step on the toes of our fellows and they retaliate. ”

“So our troubles, we think, are basically of our own making. They arise out of ourselves…”

“…Our liquor was but a symptom…”

“Resentment is the ”number one“ offender. It destroys more alcoholics than anything else. From it stem all forms of spiritual disease, for we have been not only mentally and physically ill, we have been spiritually sick.”

For me this is saying that out of my emotion dysregulation  “stem all forms of spiritual disease”.

It then talks of the fear that “was an evil and corroding thread; the fabric of our existence was shot through with it. ”

The list of emotional difficulties continues throughout the Big book’s first 164 pages.

One of the earliest studies on AA members concluded that  they were linked in commonality by two variables, emotional immaturity and grandiosity! I would contend that grandiosity is a part of emotional immaturity. I also contend that our “maladjustment to life” is based on emotional immaturity which is in itself a function of emotion regulation and processing deficits.

A book titled Matt Talbot by Morgan Costelloe has cites this reference –  “American authorities on alcoholism hold that the following psychological traits are commonly found in alcoholics:

> 1. A high level of anxiety in interpersonal relations
> 2. Emotional immaturity
> 3. Ambivalence towards authority
> 4. Low frustration tolerance
> 5. Low self-esteem
> 6. Perfectionism
> 7. Guilt
> 8. Feelings of isolation”

The list is  almost word-for-word identical with one in Howard Clinebell’s
“Understanding and Counseling the Alcoholic” p 53 of the revised edition of 1968 (the original edition appeared in 1956), the only difference being that Clinebell included grandiosity and compulsiveness.

Years after the Big Book Bill Wilson wrote about this emotion immaturity in the guise of discussing emotional sobriety, for me what he is saying that our emotional difficulties are present in long term recovery and need to be addressed – in other words there is more to alcoholism than sinning and drinking. What we are left with after the steps is ongoing and underlying difficulties with living life on life’s terms because we are emotionally immature. This I believe also preceded our drinking, for many of us anyway?

For many recovering alcoholics this may be another unpalatable truth, that they have issues with emotional responding, with being emotionally mature. If further validation is required I suggest a frank conversation with  a loved one, wife, husband, child, parent, etc.

Here is what Bill Wilson wrote ” Those adolescent urges that so many of us have for top approval, perfect security, and perfect romance—urges quite appropriate to age seventeen—prove to be an impossible way of life when we are at age forty-seven or fifty-seven.      Since AA began, I’ve taken immense wallops in all these areas because of my failure to grow up, emotionally and spiritually”. (my emphasis) 

Bill continues “Suddenly I realized what the matter was. My basic flaw had always been dependence – almost absolute dependence – on people or circumstances to supply me with prestige, security, and the like. Failing to get these things according to my perfectionist dreams and specifications, I had fought for them. And when defeat came, so did my depression.”

” Emotional and instinctual satisfactions, I saw, were really the extra dividends of having love, offering love, and expressing a love appropriate to each relation of life… I was victimized by false dependencies…       For my dependency meant demand—a demand for the possession and control of the people and the conditions surrounding me.”

For me this is emotional immaturity, regulating ones emotions and distress via external dependencies on others, demanding in an immature manner that others do one’s bidding?

I would suggest in relation to the issue of co-morbidities that one try to deal with these alcoholism related issues and then see if there are any other to deal with afterwards. For me, as someone who has been treated for anxiety and depression prior to recovery the 12 steps appear to have treated these as emotional consequences of my underlying condition of emotion dysregulation which I call alcoholism.

I think part of the issue is whether doctors, who know in my experience often know next to nothing generally about alcoholism,  can always properly diagnose depression and anxiety in someone suffering from alcoholism?

I also think the issues are complicate because alcoholism have some many similarities to GAD, MDD, OCD, and so on. They all may be similar but different.

This is why we need a satisfactory definition of what alcoholism and addition is? Rather than describing these conditions in terms of the manifest symptoms, i.e chronic substance abuse or, at times, vague “spiritual maladies”.

For example, one variable I believe is slightly different in alcoholism  to other affective disorders is distress based impulsivity which leads to maladaptive decision making, it leads to always wanting more of that…that anything.

These may be specific to addictive behaviours.

It may also be that we feel we have a co-occurring disorder because the underlying distress states prompt similar reactions in various differing disorders.

My distress feeds perfectionism, and catastrophic thinking as with other anxiety disorders like OCD, does that mean I have OCD too?

Maybe or maybe not? My tendency to not  regulate emotions has caused a distress state since childhood, it feeds into perfectionism and many other manifestations like always wanting just one more…?

It is the always wanting one more that makes my affective disorder that of addiction and not another disorder.

My affective disorder via various neural and cognitive – affective mechanisms leads to chronic substance use and dependency of these substances.

GAD, MDD, OCD have different manifestations and different mechanisms.

If we start by trying to recover from alcoholism and addiction and find we still have other issues then obviously address these with outside professional and specialist help.

I believe we can unwittingly complicate our treatment of alcoholism by believing we have (and treating) other conditions we see as distinct from alcoholism but which are in fact part of this condition called alcoholism.

I never fully knew what alcoholsim was until I did the 12 steps. Only then did it become clear what I suffered from?

I have suggested clearly in previous blogs how I think AA’s 12 recovery programme helps specifically with problems of emotion dysregulation.

How the Alcoholics Anonymous-12-step-program of recovery helps with emotional dysregulation

Maintaining Emotional Sobriety (and sanity) via the steps 10-12.

These illustrate how the 12 step programme can help with an emotion dysregulation disorder.

I end, however, with some words from a doctor who seems to be suggesting that AA works because it makes us more emotionally healthy.  For me she is saying how AA treats emotional illness.

An article by Dr. Jacqueline Chang’s paper given to the National Workshop for Health Liaison in York in 1998 and published in the Winter 1999 edition of the AA News suggests that

“The principles of the programme of Alcoholics Anonymous are scientific and closely follow all the helping therapies which lead people to emotional well-being.

AA proposes living “ One Day at a Time”. It is emotionally healthy to live in the day … in the here and now. Professional therapists teach people to live in the present.  AA encourages members to share their experience, strength and hope with other members. It is emotionally healthy to accept our past experiences, however painful, as past events and move on to a richer, more fulfilling future.

Step 1 in the AA programme is “ We admitted we were powerless over alcohol – that our lives had become unmanageable”. It is emotionally healthy to surrender and accept things over which we have no control.
“God grant us the serenity to accept the things we cannot change, courage to change the things we can and the wisdom to know the difference” is the Serenity Prayer used at every AA meeting. It is emotionally healthy to prioritise problems. The Serenity Prayer is the greatest exercise in prioritisation.

It is emotionally healthy to accept that we cannot change a particular situation but we can change the way we react to it.

It is emotionally healthy to accept yourself as you are.
It is emotionally healthy to recognise your environment and interact with it as it is, not as you wish it would be.  It is emotionally healthy to associate or be in contact with other human beings.

It is emotionally healthy to be altruistic – to help others without question or expectation.
It is emotionally healthy to anticipate – to plan for future discomfort or crises. This is the function of the AA Step programme. ”

 

AA provides many ways of becoming more emotionally well, which ultimately means more emotionally mature.

 

 

 

Impulsivity is an Independent Predictor of 15-Year Mortality Risk among Individuals Seeking Help for Alcohol-Related Problems

In yesterday’s blog we looked at how AA membership and the 12 step program of recovery helped reduce impulsivity in recovering alcoholics.

We mentioned also that impulsivity was present as a pathomechanism of alcoholism from vulnerability in “at risk” children from families, were there was a history of alcoholism, right the way through to recovering alcoholics in long term recovery (i.e. many years of recovery).

We cited and used excerpts from a study written by the same authors as the study we cite now (1).

This study shows and highlights how, if untreated, by recovery programs such as AA’s 12 steps, that “trait” impulsivity can lead to increased mortality in alcoholics.

This study interestingly shows there is a difference from “state-like” impulsivity in early recovery when recovering people are still distressed and “trait-like” which is after Year 1 of recovery when some of the severity of withdrawal from alcohol has long since abated and some recovery tools have been learnt.

The fact that this impulsivity continues to contribute to relapse and mortality may suggest it is a trait state in alcoholics and possibly a vulnerability to later alcoholism also.

In effect, it illustrates the role impulsivity plays as a pathomechanism in alcoholism, i.e. it is a psychological mechanism that drives addiction and alcoholism forward to it’s chronic endpoint.

Again research shows us how we can learn about a pathology from the recovery from it!

 

impulse control.preview

“Abstract

Background

Although past research has found impulsivity to be a significant predictor of mortality, no studies have tested this association in samples of individuals with alcohol-related problems or examined moderation of this effect via socio-contextual processes. The current study addressed these issues in a mixed-gender sample of individuals seeking help for alcohol-related problems.

Results

…higher impulsivity at baseline was associated with an increased risk of mortality from Years 1 to 16; higher impulsivity at Year 1 was associated with an increased risk of mortality from Years 1 to 16, and remained significant when accounting for the severity of alcohol use, as well as physical health problems, emotional discharge coping, and interpersonal stress and support at Year 1. In addition, the association between Year 1 impulsivity and 15-year mortality risk was moderated by interpersonal support at Year 1, such that individuals high on impulsivity had a lower mortality risk when peer/friend support was high than when it was low.

Conclusions

The findings highlight impulsivity as a robust and independent predictor of mortality.

Introduction

…personality traits related to impulsivity (e.g., low conscientiousness) have been identified as significant predictors of poor health-related outcomes including mortality (Bogg and Roberts, 2004; Roberts et al., 2007). Although there is a well-established association between disinhibitory traits and alcohol use disorders (AUDs) (Labouvie and McGee, 1986; McGue et al., 1999;Sher et al., 2000), to our knowledge, no studies have tested these traits as predictors of mortality among individuals with alcohol-related problems or examined moderation of this effect via socio-contextual processes.

Predictors of Mortality Risk among Individuals with Alcohol Use Disorders

Relative to the general population, individuals with AUDs are more likely to die prematurely (Finney et al., 1999; Johnson et al., 2005; Valliant, 1996). Accordingly, several longitudinal studies have aimed to identify the most salient risk factors for mortality in this population (for a review, see Liskow et al., 2000)

…more reliance on avoidance coping, less social support, and more stress from interpersonal relationships increase the risk of mortality among individuals with AUDs (Finney and Moos, 1992; Holahan et al., 2010; Mertens et al., 1996; Moos et al., 1990).

Impulsivity and Risk for Mortality: Relevance for Individuals with Alcohol Use Disorders

Despite the litany of variables that have been examined as predictors of mortality among individuals with AUDs, tests of the significance of individual differences in personality are noticeably absent from this literature. In the clinical and health psychology literatures, however, personality traits have long been identified as possible risk factors for mortality (Friedman and Rosenman, 1959), with low conscientiousness emerging as one of the most consistent, trait-based predictors of poor health and reduced longevity (Kern and Friedman, 2008; Roberts et al., 2007). Conscientiousness is a broad domain of personality reflecting individual differences in the propensity to control one’s impulses, be planful, and adhere to socially-prescribed norms (John et al., 2008).

(previously) no studies in this literature have tested impulsivity as an independent predictor of mortality in a sample of individuals with alcohol-related problems. This is a surprising omission, given that impulsivity is a well-established risk factor for alcohol misuse (Elkins et al., 2006; McGue et al., 1999; Sher et al., 2000) and therefore may be an especially potent predictor of mortality among individuals with AUDs. Furthermore, the role of impulsivity as an independent predictor of mortality risk among individuals with AUDs is relevant from the standpoint of the stage of the alcohol recovery process.

Thus, we sought to examine the impulsivity-mortality link at baseline and one year after participants had initiated help-seeking for their alcohol use problems. At baseline, participants were in a state of distress due to their problematic alcohol use, whereas at Year 1 most participants had obtained help for their alcohol-related problems and reduced their drinking (Finney and Moos, 1995).

Given prior research on acute clinical states and self-report assessments of personality (e.g., Brown et al., 1991; Peselow et al., 1994;Reich et al., 1987), we hypothesized that individuals’ self-reports of impulsivity at Year 1 would be less a reflection of their alcohol problems – and therefore more likely to be independently linked to mortality risk – than their reports at baseline, which may be more closely associated with concurrent alcohol use and problems (i.e., state effects).

Discussion

…impulsivity at baseline was a significant predictor of mortality risk from Years 1 to 16; however, this effect was accounted for by the severity of alcohol use at baseline. In contrast, impulsivity at Year 1 was associated with an increased risk of mortality over the subsequent 15 years…

In addition, a significant interaction was observed between impulsivity and peer/friend support at Year 1, which suggested that, among individuals high on impulsivity, the mortality risk may be reduced for those high on support from peers/friends. Collectively, these findings highlight impulsivity as an independent risk factor for mortality in AUD samples…

…It is also conceivable that, given participants were in a state of crisis at baseline, their reports of their impulsive tendencies at that time partly captured “state” effects (e.g., psychiatric distress from concurrent substance use; withdrawal symptoms) and therefore were less an indication of their typical or “characterological” pattern of impulsivity, independent of alcohol use. However, at Year 1, most participants had reduced their drinking and were not in a state of crisis; thus, their reports at that time may have been a better reflection of their “trait-like” pattern of impulsivity, which in turn may be a more robust independent predictor of long-term outcomes such as mortality. Accordingly, future studies that seek to test impulsivity as an independent predictor of mortality among individuals with AUDs should consider the stage of the alcohol recovery process.

Moderation of the Impulsivity-Mortality Link via the Social Context

The results of the moderator analyses suggest that the effects of impulsivity on mortality may become manifest through interactions between traits and socio-contextual process (Friedman, 2000). That is, the dire effects of impulsivity on risk for mortality may not reach fruition for individuals who are able to maintain a strong peer support network. Conceivably, by virtue of their strong bond with a high-risk individual, such peers may have sufficient leverage to discourage expression of the individual’s impulsive tendencies and encourage consideration of the long-term consequences of his/her actions.

Such a perspective is consistent with evidence from the AUD treatment-outcome literature that social support networks are a key mechanism by which Alcoholics Anonymous (AA) and other psychosocial treatments can improve long-term drinking-related outcomes (Humphreys and Noke, 1997; Kaskutas et al., 2002).

Furthermore, from the standpoint of treatment, the present findings suggest that interventions for AUDs may benefit from an ecological perspective that considers the contexts in which dispositional tendencies, such as impulsivity, become expressed in individuals’ everyday lives. Notably, based on prior work with this sample, longer duration in AA and alcohol treatment was associated with a decline in impulsivity (Blonigen et al., 2009). In combination with the present findings, it appears that formal and informal help for AUDs may include “active ingredients” that can help curtail expression of impulsive tendencies (e.g., social integration, peer bonding; Moos, 2007,2008) and buffer the otherwise deleterious impact of such tendencies on health and longevity.

References

1. Blonigen, D. M., Timko, C., Moos, B. S., & Moos, R. H. (2011). Impulsivity is an Independent Predictor of 15-Year Mortality Risk among Individuals Seeking Help for Alcohol-Related Problems. Alcoholism, Clinical and Experimental Research, 35(11), 2082–2092. doi:10.1111/j.1530-0277.2011.01560.x

Alcoholics Anonymous and Reduced Impulsivity: A Novel Mechanism of Change

Impulsivity or lack of behaviour inhibition, especially when distressed, is one psychological mechanisms which is implicated in all addictive behaviour from substance addiction to behaviour addiction.

It is, in my view, linked to the impaired emotion processing as I have elucidated upon in various blogs on this site.

This impulsivity is present for example in those vulnerable to later alcoholism, i.e. sons and daughters of alcoholic parents or children  from a family that has a relatively high or concentrated density of alcoholics in the family history, right through to old timers, people who have decades of recovery from alcoholism.

It is an ever present and as a result part of a pathomechanism of alcoholism, that is it is fundamental to driving alcoholism to it’s chronic endpoint.

It partly drives addiction via it’s impact on decision making – research shows people of varying addictive behaviours choose now over later, even if it is a smaller short term gain over a greater long term gain. We seem to react to relieve a distress signal in the brain rather than in response to considering and evaluating the long term consequences of a decision or act.

No doubt this improves in recovery as it has with me. Nonetheless, this tendency for rash action with limited consideration of long term consequence is clearly a part of the addictive profile. Not only do we choose now over then, we appear to have an intolerance of uncertainty, which means we have difficulties coping with uncertain outcomes. In other words we struggle with things in the future particularly if they are worrying or concerning things, like a day in court etc. The future can continually intrude into the present. A thought becomes a near certain action, again similar to the though-action fusion of obsessive compulsive disorder. It is as if the thought and possible future action are almost fused, as if they are happening in unison.

Although simple, less worrying events can also make me struggle with leaving the future to the future instead of endless and fruitlessly ruminating about it in the now. In early recovery  especially I found that I had real difficulty dealing with the uncertainty of future events and always thought they would turn out bad. It is akin to catastrophic thinking.

If a thought of a drink entered into my head it was so distressing, almost as if I was being dragged by some invisible magnet to the nearest bar. It was horrendous. Fortunately I created my own thought action fusion to oppose this.

Any time I felt this distressing lure of the bar like some unavoidable siren call of alcohol I would turn that thought into the action of ringing my sponsor. This is why sponsees should ring sponsors about whatever, whenever in order to habitualize these responses to counteract the automatic responses of the addicted brain.

I think it is again based on an inherent emotion dysregulation. Obsessive thoughts are linked to emotion dysregulation.

My emotions can still sometimes control me and not the other way around.

Apparently we need to recruit the frontal part of the brain to regulate these emotions and this is the area most damaged by chronic alcohol consumption.

As a result we find it difficult to recruit this brain area which not only helps regulate emotion but is instrumental in making reflective, evaluative decisions about future, more long term consequence. As a result addicts of all types appear to use a “bottom up” sub-cortical part of the brain centred on the amgydala region to make responses to decisions instead of a “top down” more cortical part of the brain to make evaluative decisions.

We thus react, and rashly act to relieve the distress of undifferentiated emotions, the result of unprocessed emotion rather than using processed emotions to recruit the more cortical parts of the brain.

Who would have though emotions were so instrumental in us making decisions? Two parts of the brain that hold emotions in check so that they can be used to serve goal directed behaviour are the orbitofrontal cortex and the ventromedial prefrontal cortex.

120px-Orbital_gyrus_animation_small2

 

These areas also keep amgydaloid responding in check. Unfortunately these two areas are impaired in alcoholics and other addictive behaviours so their influence on and regulation of the amgydala is also impaired.

This means the sub cortical areas of the amgydala and related regions are over active and prompt not a goal directed response to decision making but a “fight or flight” response to alleviate distress and not facilitate goal directed behaviour.

128px-Amyg

 

Sorry for so much detail. I have read so much about medication recently which does this or that to reduce craving or to control  drinking but what about the underlying conditions of alcoholism and addictive behaviour? These are rarely mentioned or considered at all.

 

We always in recovery have to deal with alcoholism not just it’s symptomatic manifestation of that which is chronic alcohol consumption. This is a relatively simple point and observation that somehow alludes academics, researchers and so-called commentators on this fascinating subject.

Anyway that is some background to this study which demonstrates that long term AA membership can reduce this impulsivity and perhaps adds validity to the above arguments that improved behaviour inhibition and reducing impulsivity is a very possible mechanism of change brought about by AA membership and the 12 step recovery program.

It shows how we can learn about a pathology from the recovery from it!

Indeed when one looks back at one’s step 4 and 5 how many times was this distress based impulsivity the real reason for “stepping on the toes of others” and for their retaliation?

Were we not partly dominated by the world because we could not keep ourselves in check? Didn’t all our decisions get us to AA because they were inherently based on a decision making weakness? Isn’t this why it is always useful to have a sponsor, someone to discuss possible decisions with?

Weren’t we out of control, regardless of alcohol or substance or behaviour addiction? Isn’t this at the heart of our unmanageability?

I think we can all see how we still are effected by a tendency not to think things through and to act rashly.

The trouble it has caused is quite staggeringly really?

Again we cite a study (1) which has Rudolf H. Moos as a co-author. Moos has authored and co-authored a numbered of fine papers on the effectiveness of AA and is a rationale beacon in a sea of sometimes quite controversial and ignorant studies on AA, and alcoholism in general.

“Abstract

Reduced impulsivity is a novel, yet plausible, mechanism of change associated with the salutary effects of Alcoholics Anonymous (AA). Here, we review our work on links between AA attendance and reduced impulsivity using a 16-year prospective study of men and women with alcohol use disorders (AUD) who were initially untreated for their drinking problems. Across the study period, there were significant mean-level decreases in impulsivity, and longer AA duration was associated with reductions in impulsivity…

Among individuals with alcohol use disorders (AUD), Alcoholics Anonymous (AA) is linked to improved functioning across a number of domains [1, 2]. As the evidence for the effectiveness of AA has accumulated, so too have efforts to identify the mechanisms of change associated with participation in this mutual-help group [3]. To our knowledge, however, there have been no efforts to examine links between AA and reductions in impulsivity-a dimension of personality marked by deficits in self-control and self-regulation, and tendencies to take risks and respond to stimuli with minimal forethought.

In this article, we discuss the conceptual rationale for reduced impulsivity as a mechanism of change associated with AA, review our research on links between AA and reduced impulsivity, and discuss potential implications of the findings for future research on AA and, more broadly, interventions for individuals with AUD.

Impulsivity and related traits of disinhibition are core risk factors for AUD [5, 6]. In cross-sectional research, impulsivity is typically higher among individuals in AUD treatment than among those in the general population [7] and, in prospective studies, impulse control deficits tend to predate the onset of drinking problems [8–11]

Although traditionally viewed as static variables, contemporary research has revealed that traits such as impulsivity can change over time [17]. For example, traits related to impulsivity exhibit significant mean- and individual-level decreases over the lifespan [18], as do symptoms of personality disorders that include impulsivity as an essential feature [21, 22]. Moreover, entry into social roles that press for increased responsibility and self-control predict decreases in impulsivity [16, 23, 24]. Hence, individual levels of impulsivity can be modified by systematic changes in one’s life circumstances [25].

Substance use-focused mutual-help groups may promote such changes, given that they seek to bolster self-efficacy and coping skills aimed at controlling substance use, encourage members to be more structured in their daily lives, and target deficits in self-regulation [26]. Such “active ingredients” may curb the immediate self-gratification characteristic of disinhibition and provide the conceptual grounds to expect that AA participation can press for a reduction in impulsive inclinations.

…the idea of reduced impulsivity as a mechanism of change…it is consistent with contemporary definitions of recovery from substance use disorders that emphasize improved citizenship and global health [31], AA’s vision of recovery as a broad transformation of character [32], and efforts to explore individual differences in emotional and behavioral functioning as potential mechanisms of change (e.g., negative affect [33,34]).

Several findings are notable from our research on associations between AA attendance and reduced impulsivity. First, consistent with the idea of impulsivity as a dynamic construct [18, 19], mean-levels of impulsivity decreased significantly in our AUD sample. Second, consistent with the notion that impulsivity can be modified by contextual factors [25], individuals who participated in AA longer tended to show larger decreases in impulsivity across all assessment intervals.

References

Blonigen, D. M., Timko, C., & Moos, R. H. (2013). Alcoholics anonymous and reduced impulsivity: a novel mechanism of change. Substance abuse, 34(1), 4-12.

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

 

 

 

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

It Works if you Work It!

Alcoholism takes away your life and then kills you.

We look at a study from 8 years ago to show the extent of premature deaths caused by alcoholism and how membership of Alcoholics Anonymous helps in reducing the risk of premature death from alcoholism.

This study (1) of women and men, over 16 years,  observed that those initiating help-seeking careers have better chances of long-term survival. Of the individuals for whom cause of death was known, of the 121 participants known to have died, 76 did so between the 8- and 16-year follow-ups.and 68% died of alcohol-related causes.

Men were more likely to die than were women. When gender was controlled, individuals who were older and unmarried and had more alcohol dependence
symptoms at baseline were more likely to die over the 16-year period.

“It is well documented that the course of alcohol use disorders (AUDs) may end in premature death (Rivara et al., 2004; Room et al., 2005) and …that remission may reduce the risk of premature mortality (Fillmore et al., 2003; Miller, 1999), there is little information about whether an initial course of
professional treatment, or participation in Alcoholics Anonymous (AA), can counteract the connection between AUDs and heightened mortality risk.

To address these issues, we examined mortality in a sample of individuals who had just initiated help-seeking for their AUDs at the start of the study and were followed for 16 years. Specifically, we ascertained the proportions of women and men who died and how these rates compared with matched general population rates…

It Works If You Work It

 

Data on mortality are much more extensive for treated than for untreated individuals with AUDs. Finney and Moos (1991) reviewed long-term studies of mortality among treated individuals. Overall mortality rates ranged from 15% to 42% and were higher when the duration of follow-up was longer (see also Nielsen et al., 2005).

…Among individuals treated for AUDs, mortality rates were higher for men than for women (Feurerlein et al., 1994; Hurt et al., 1996). In addition, in community samples, rates of mortality due to alcohol use were higher in
men than in women (John and Hanke, 2002; Zureik and Ducimetiere, 1996). Premature death due to alcohol abuse or dependence is particularly more likely among men than among women in young and middle-aged groups (Moller-Leimkuhler, 2003)…

…A more severe and longer duration of alcohol abuse predicts premature death (Liskow et al., 2000; Ojesjo, 1981)…. In an 11-year follow-up, Smith et al. (1983) found that women who developed their AUD early and engaged in binge drinking were more likely to die. Consistently, more alcohol consumption and having recognized at a younger age that drinking was a problem were related to more years of life lost to an AUD (Marshall et al., 1994).

…Mackenzie et al. (1986) found that men who were hospitalized for AUDs more frequently were more likely to die over an 8-year follow-up. Inpatient treatment occurring throughout the course of alcoholism may be a marker for a more severe and chronic disorder because such treatment is sought in response to a relapse (Timko et al., 2000). In a study of inpatients with AUDs, de Lint and Levinson (1975) found that death rates were lower in the first 2 years postdischarge than thereafter. They speculated  that intensive outpatient aftercare may delay or prevent the high rate of mortality that often occurs shortly after discharge.

Among individuals treated for AUDs, those who subsequently attended AA were less likely to have died by a 2-year follow-up than those who did not attend (Masudomi et al., 2004)…

… For inpatient care, longer duration appears to be an indicator of greater disorder severity and thus should be associated with higher mortality…However, for outpatient care and help from AA, a longer duration predicts better substance use disorder outcomes and so may  indicate continuing motivation to stop drinking (Moos and Moos, 2003a, 2004a). From this perspective, a longer duration of outpatient treatment or AA affiliation should be associated with lower mortality.

…Furthermore, those who relapsed after treatment were 3 to 5 times more likely to die as those who remained abstinent (Bullock et al., 1992; Feurerlein et al., 1994)…

(This study found)…individuals who are just beginning their help-seeking…have a better chance of long-term survival than do women and men with more chronic disorders.
That is, individuals entering an initial episode of help-seeking may be successful at preventing or reducing the harm associated with excessive drinking that is also potentially causal in death. In contrast, repeated episodes of AUD treatment are often a reflection of the chronic and severe alcoholism known to cause premature death. As other studies have found, men were more likely to die than were women (Feurerlein et al., 1994; Hurt et al., 1996; John and Hanke, 2002; Zureik and Ducimetiere, 1996). Of the individuals who died, over two-thirds died of causes related to alcohol use.

…individuals who were olderand had more alcohol dependence symptoms (Finney and Moos, 1992; Liskow et al., 2000) and were unmarried were
more likely to die over the 16-year observation period.
Alcohol-related mortality tends to be lower among married persons (Agren and Romelsjo, 1992; Lewis et al., 1995)…

keepcomingback

 

…continuous abstinence, had a positive effect on the survival of individuals with AUDs. Studies comparing stable abstinence with reduced frequency and
quantity of abusive drinking found that only stable abstinence prevented a higher mortality risk (Bullock et al., 1992; Gerdner and Berglund, 1997). Our results are consistent with those findings…

 

…Longer duration of AA attendance during the first follow-up year (specifically, attendance for more than 4 months) combined with better 1-year drinking outcomes was associated with a lower likelihood of death in the subsequent 15 years.

Alcoholics Anonymous participation may delay mortality not only by
reducing drinking and drinking-related, including medical,
problems, as outpatient treatment does, but also by increasing social resources and reducing…friendship stressors (Humphreys and Noke, 1997; Kaskutas et al., 2002; Masudomi et al., 2004).

 

References

Timko, C., DeBenedetti, A., Moos, B. S., & Moos, R. H. (2006). Predictors of 16‐year mortality among individuals initiating help‐seeking for an alcoholic use disorder. Alcoholism: Clinical and Experimental Research, 30(10), 1711-1720.

Why a spiritual solution?

The Alcoholics Guide to Alcoholism

In the first in a series of blogs we discuss the topic of why does the solution to one’s alcoholism and addiction require a spiritual recovery.

This is a much asked question within academic research, although the health benefits of meditation are well known and life styles incorporating religious affiliation are known to increase health and span of life.

I guess people are curious as to how the spirit changes matter or material being when it should perhaps be rephrased to how does application of the ephemral mind affect neuroplasticity of the brain. Or in other words how does behaviour linked to a particular faith/belief system alter the functions and structure of the brain. We have discussed these points in two blogs previously and will do so again in later blogs. Here I just want to highlight in a short summary why spiritual practice helps alcoholics and addicts with with…

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AA helps to reduce Impulsivity

 

One constant in studies on addiction and in alcoholism, in particular is the  fundamental role played by impulsivity in these disorders. It is seen to be present in early use but appears to be more distress based (i.e. more negative urgency based) as the addiction cycle becomes more chronic. This impulsivity has obvious consequences for propelling these disorders via impulsive behaviours and decision making difficulties.

Thus it then follows that any treatment of these addictive disorders must have treatment of impulsivity at the core as it appears to a fundamental pathomechanism.

 

Here, we review a study that on links  AA attendance and reduced impulsivity using a 16-year prospective study of men and women, who were initially untreated for their drinking problems. Across the study period, there were significant l decreases in impulsivity, and longer AA duration was associated with reductions in impulsivity.

Alcoholics Anonymous (AA) is linked to improved functioning across a number of domains [2,3]. As the evidence for the effectiveness of AA has accumulated, so too have efforts to identify the mechanisms of change associated with participation in this mutual-help group [4].

This study concluded that help-seeking and exposure to the “active ingredients” of various types of help (i.e., AA principles/practices, sponsors), which, in turn, leads to improvements in reduced impulsivity.

Impulsivity is typically higher among individuals in AUD treatment than among those in the general population [5] and, impulse control deficits tend to predate the onset of drinking problems [6-9].

Contemporary research has revealed that traits such as impulsivity can change over time [10]. Mutual-help groups like AA may promote such changes, given that they seek to bolster self-efficacy and coping skills aimed at controlling substance use, encourage members to be more structured in their daily lives, and target deficits in self-regulation [11].

 

impulse control.preview

 

Such “active ingredients” may curb the immediate self-gratification characteristic of disinhibition and provide the conceptual grounds to expect that AA participation can press for a reduction in impulsive inclinations. In turn, given the range of outcomes related to impulsivity (e.g., legal, alcohol-related, and psychosocial problems), decreases in impulsivity may account for part of the association between AA participation and improvements in these outcomes.

AA’s vision of recovery as a broad transformation of character [12], and  explores individual differences in emotional and behavioural functioning as potential mechanisms of change (13,14).

Such groups encourage members to be more structured and goal-directed, which may translate into greater efforts to delay gratification of one’s impulses and  to improve clients’ general coping skills (e.g., reduce avoidance coping).

Given that impulsivity is a risk factor for a host of problematic behaviors and outcomes beyond drinking-e.g., criminality [15], drug abuse [16], reckless driving and sexual practices [17],  lower quality of interpersonal relationships [18], and poor health [19] this reduced impulsivty is beneficial in other aspects too.

Notably, this effect was buffered by a higher quality of social support-a probable active ingredient of AA. Thus, the impact of reducing impulsivity may be widespread across a range of outcomes that are critical for long-term sobriety.

 

Our main caveat on this study is that it does not distinguish between different types of impulsivity and does not mention negative urgency (or distress-based impulsivity) which is more commonly seen is this sample group.

AA’s “active ingredients” may reduce distress, via a new found emotional regulation gained via the steps and use of a sponsor (acting as an external prefrontal cortex to help us inhibit our impulsive and distress based responses)  which in turns reduces our tendency to impulsive decision making and behaviour.

 

It would have been interesting in this study to have also measure how emotional dysregulation changed in the time span of 16 years (using the DERS scale) and to have used a different impulsivity scale i.e. used the UPPS-P scale which would both have helped more specificallylook  at the interaction of how emotional regulation and impulse control changed over the 16 year period.

 

References

 

1.  Blonigen, D. M., Timko, C., & Moos, R. H. (2013). Alcoholics anonymous and reduced impulsivity: a novel mechanism of change. Substance abuse, 34(1), 4-12.

2. Humphreys, K. Circles of recovery: Self-help organizations for addictions. Cambridge Univ Pr; 2004.

3.. Tonigan JS, Toscova R, Miller WR. Meta-analysis of the literature on Alcoholics Anonymous: Sample and study characteristics moderate findings. Journal of Studies on Alcohol. 1995

4. Kelly JF, Magill M, Stout RL. How do people recover from alcohol dependence? A systematic review of the research on mechanisms of behavior change in Alcoholics Anonymous. Addiction Research & Theory. 2009; 17(3):236–259.

5. Conway KP, et al. Personality, drug of choice, and comorbid psychopathology among substance abusers. Drug and alcohol dependence. 2002; 65(3):225–234. [PubMed: 11841894]

6. Caspi A, et al. Behavioral observations at age 3 years predict adult psychiatric disorders: Longitudinal evidence from a birth cohort. Archives of General Psychiatry. 1996; 53(11):1033. [PubMed: 8911226]

7. Cloninger CR, Sigvardsson S, Bohman M. Childhood personality predicts alcohol abuse in young adults. Alcoholism: Clinical and Experimental Research. 1988; 12(4):494–505.

8. Elkins IJ, et al. Personality traits and the development of nicotine, alcohol, and illicit drug disorders: Prospective links from adolescence to young adulthood. Journal of abnormal psychology. 2006; 115(1):26. [PubMed: 16492093]

9. Sher KJ, Bartholow BD, Wood MD. Personality and substance use disorders: A prospective study. Journal of Consulting and Clinical Psychology. 2000; 68(5):818. [PubMed: 11068968]

10. Caspi A, Roberts BW, Shiner RL. Personality development: Stability and change. Annual Review of Psychology. 2005; 56:453–484

11. Moos RH. Active ingredients of substance use focused self help groups. Addiction. 2008; 103(3):387–396. [PubMed: 18269361]

12. White WL. Commentary on Kelly et al. (2010): Alcoholics Anonymous, alcoholism recovery, global health and quality of life. Addiction. 2010; 205:637–638. [PubMed: 20403015]

13. Kelly JF, et al. Mechanisms of behavior change in alcoholics anonymous: does Alcoholics Anonymous lead to better alcohol use outcomes by reducing depression symptoms? Addiction. 105(4):626–636. [PubMed: 20102345]

14. KELLY JF, et al. Negative Affect, Relapse, and Alcoholics Anonymous (AA): Does AA Work by Reducing Anger? Journal of studies on alcohol and drugs.

15. Krueger RF, et al. Personality traits are linked to crime among men and women: Evidence from a birth cohort. Journal of abnormal psychology. 1994; 103(2):328. [PubMed: 8040502]

16. McGue M, Slutske W, Iacono WG. Personality and substance use disorders: II. Alcoholism versus drug use disorders. Journal of Consulting and Clinical Psychology. 1999; 67(3):394. [PubMed: 10369060]

17. Caspi A, et al. Personality differences predict health-risk behaviors in young adulthood: Evidence from a longitudinal study. Journal of Personality and Social Psychology. 1997; 73(5):1052. [PubMed: 9364760]

18. Ozer DJ, Benet-Martinez V. Personality and the prediction of consequential outcomes. Annu. Rev. Psychol. 2006; 57:401–421. [PubMed: 16318601]

19. Bogg T, Roberts BW. Conscientiousness and Health-Related Behaviors: A Meta-Analysis of the Leading Behavioral Contributors to Mortality. Psychological Bulletin. 2004; 130(6):887. [PubMed: 15535742]

 

 

 

 

 

 

 

 

Why erase addiction memories when they can help others?

According to one UK newspaper The Independent, dated the 9th July 2014 “Substance abusers could have their memories of drug addiction wiped in a bid to stop them using illegal narcotics, an award-winning neuroscientist has said.

According to new research by Cambridge University’s Professor Barry Everitt: disrupting the memory pathways of drug users could weaken powerful “compel” cravings, reduce “drug seeking behaviour” and open a new field of addiction therapy.

Professor Everitt  told this week’s Federation of European Neuroscience Societies (FENS) how his research in rodents had found that targeting “memory plasticity” in rats was able to reduce the impact of maladaptive drug memories.

He added that this knowledge could offer a radical new method of treatment of drug addiction in humans, where researchers have already established that the path to addiction operates by shifting behavioural control from one area of the brain to another. This process sees drug use go from a voluntary act to a goal directed one, before finally becoming an compulsive act.

It was this process that Professor Everitt’s research is trying to “prevent” by targeting “maladaptive drug-related memories” to “prevent them from triggering drug-taking and replaces”.

In humans this could potentially be done by blocking brain chemicals.

“It’s the emotional intrusiveness of drug and fear memoirs that can be diminished, rather than an individual’s episodic memory that they did in the past take drugs or had a traumatic experience,” he told The Independent. “Conscious remembering is intact after consolidation blockade, but the emotional arousal [that] leads to drug seeking or distressing feelings of fear that are diminished.”

His research group discovered that when drug memories are reactivated by retrieval in the brain, they enter a pliable and unstable state. By putting rats in this state Professor Everitt was able to prevent memory reconsolidation by blocking brain chemicals or inactivating key genes.

In one study, the team diminished drug seeking behaviours by obstructing a brain chemical receptor linked to learning and memory, thus erasing memories, while in another study it found they could weaken drug use memories by altering a particular gene in the amygdala, a brain area processing emotional memory.

“Of course, inactivating genes in the brain is not feasible in humans,” the professor told FENS. “So we’re directing our research to better identify the underlying brain mechanisms of memory reconsolidation.”

He added: “We specifically examined how we could target these maladaptive drug-related memories, and prevent them from triggering drug-taking and relapse.”

So to recap, this new treatment is based on altering genes in rats!

There is no need to actually wipe an alcoholics’ addiction memories.

In fact it may be very counter productive to recovery from alcoholism. One 80 year old and hyper ecologically valid experiment into the mnemonics of “treating addiction memories”  has shown that by honestly looking at the consequences of one’s actions as the result of one’s alcoholic drinking that the positive associations of previous drinking were reappraised in light of the damage done to oneself, one’s loved ones and family and society at large.

Addiction memories via this profound reappraisal were then more accurately processed in long term explicit memory. Implicit schematic memory was also altered fro a self schema in which one is a drinking alcoholic to one in which one is a recovering alcoholic.

So-called positive associations in long term episodic and explicit memory were,  when labile via recall, then challenged and replaced by more accurate negative associations in long term memory – no memories needed to be erased just reappraised more accurately.

 

mad scientist

 

This type of ongoing experiment is happening on a daily basis at an AA meeting near you.

AA groups have found that memories need not be erased, with possible deleterious knock on effects on fear processing and amgydaloid performance, but rather memories simply need to be faced up to, and via honesty appraisal reprocessed more adaptively in long term memory.

This also means alcoholics in recovery can use their addiction memories in not only clearing away the wreckage of the past, repairing broken relationships with loved ones and society as a whole by  making amends to those involved in this wreckage and also put the memories of the past to excellent therapeutic use by using it to help others with similar memory difficulties.

In fact even academic researchers have found and have demonstrated that abstinent, treatment seeking individuals also have a different cognitive or/and memory bias to active alcoholics. This has been illustrated in findings that the greater “accessibility” for positive vs. negative alcohol- associations in heavy vs. light drinkers was not found to be generalized to alcoholics in treatment vs. social drinkers (2). Rather, there was a trend for treated inpatients, motivated to attain abstinence, to show greater availability and accessibility for negative alcohol-related information.

This is how to use memories of addiction to the best possible use, instead of erasing them, wiping them our and hoping for the best, memories of our addiction can be used to great purpose in helping others. Also “addiction memory” is often activated by those who have not come to terms with their alcoholism and still want to drink. Unless some one has come to terms with their alcoholism little can be done, by erasing memories or otherwise. These are sticking plasters on a gaping wound. They will be replaced with other “addiction memory” as there an underlying condition to alcoholism ( we believe it to be emotional regulation and processing deficits) and it is this that drives this fear-based condition called alcoholism, memories are the result of this malady. Address the underlying conditions and the rest takes care of itself.

It is not brain regions which are the problem either such as activation of the amgydala, it is how this sometimes errant and overactive brain region in alcoholics is tamed via the serenity found in the AA program of recovery.

The compel parts of the brain, Everitt mentions,  are activated by emotional distress, so treat the distress not the symptom of it. He also confuses implicit, automatic memory, with explicit, conscious memory. Either way they are both activated by stress/distress, and are thus both emotional memories.  Again treat the emotional dysregulation, the primary problem not the secondary manifestation of the problem.

As I mentioned above, there has been an ongoing experiment into recovery from alcoholism going on for nearly 80 years now, there is a lab in most areas of town.

It would benefit the world and science, in particular, if neuroscientists would pop in for a coffee and check our our findings.

 

References

2. McCusker CG  Cognitive biases and addiction: an evolution in theory and method. Addiction 2001;96:47–56.