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

 

 

 

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

 

 

What recovers in Recovery? – Cognitive Control over emotions?

 In recent blogs we have called for an increase in research into the neurobiology of recovery to add to the extensive research already published on the neurobiology of the addiction cycle.
There has been extensive research into the neurobiology of addiction, most of this has focused on reward and motivation networks of the brain.  In effect this suggests there is a pathological wanting in addicts, an excessive motivation towards drug taking over all other rewarding activities.
This view does not fully consider that this pathological wanting is in itself a product of dysregulated stress systems in the brain, many the product of neglect, abuse and maltreatment in childhood. These stress factors are also reflective of the role of emotional distress in the addiction cycle . This distress is we feel a product of the emotion processing and regulation deficits commonly seen in all addictive behaviours such as alcohol and substance addiction, eating and gambling disorders and sex addiction etc (and often reflective of childhood maltreatment).
In fact , this emotion processing and  regulation deficit is also apparent in certain children of alcoholics and may be a vulnerability to later alcoholism as these children demonstrate a deficit in impulsivity (common to alcoholics and addicts) and a decision making profile based on choosing now over later (short term gains based) and which recruits more subcortical and motor expressive (compulsive) parts of the brain rather than cortical and reflective/evaluative parts of the brain.
This means they make decisions to alleviate the distress of decisions (as undifferentiated emotions appear to be distressing) not via evaluative processes). This has obvious consequence for decision making over a life span.
This emotion dysregulation is also seen in active addicts and alcoholics and at the endpoint of addiction there is a fairly complete reliance of this compulsive decision making profile, which begs the question, does the decision making deficits seen in at risk children simply get worse in the addiction cycle via the neuro toxic effects of substance abuse?
This emotion (and stress) dysregulation also potentiates reward (makes things more rewarding) so alcohol is seen as more stimulating than for non risk children. This vulnerability may lead to the need  to regulate, especially negative, emotions ( and low self esteem ) via the stimulating and highly rewarding effects of alcohol make perpetuate the addiction cycle to it’s chronic endpoint where chronic emotional distress acts as a compulsive stimulus to the responding of chronic alcohol and drug use.
This emotion dysregulation also seems to play a huge part in relapse – so it begs the question does this emotion regulation improve in time via recovery, particularly long term recovery?
In the next two blogs we look at how the emotion regulation areas of the brain become reinforced, strengthened by the process of recovery or in other words we appear to develop the brain capacity for controlling and regulating our emotions more adaptively and this reduces the stress/distress which often prompts relapse.
Personally, I can wholeheartedly say, that the one main aspect I have developed in my recovery has been the awareness and skills in regulating/controlling emotions. Via recovery I have learnt to identify, label, describe by verbalising and sharing with others how I feel. This processes and regulates the emotions that used to cause me so much distress.
I have also developed a more acute awareness of the the emotional expression and needs of yours. These were previously aspects of my life which were completely lacking and frustrating/confusing as a result.
By emotionally engaging in with the world, by becoming more emotionally literate, I can converse with the world in a way that was previously beyond my capabilities.
The research we look at in the next two blogs asks the question – is cognitive control over emotions, lacking in active addiction, one of the main brain functions that improve in recovery?
A core aspect of alcohol dependence is poor regulation of behavior and emotion.
Alcohol dependent individuals show an inability to manage the appropriate experience and expression of emotion (e.g., extremes in emotional responsiveness to social situations, negative affect, mood swings) (1,2). Dysfunctional emotion regulation has been considered a primary trigger for relapse (1,3) and has been associated with prefrontal dysfunction.
While current alcohol dependence is associated with exaggerated bottom-up (sub-cortical) and compromised top-down (prefrontal cortex) neural network functioning, there is evidence suggesting that abstinent individuals may have overcome these dysfunctional patterns of network functioning (4) .
Neuro-imaging studies showing chronic alcohol abuse to be associated with stress neuroadaptations in the medial prefrontal and anterior cingulate regions of the brain (5 ), which are strongly implicated in the self-regulation of emotion and behavioral self-control (6).
One study (2) looking at how emotional dysregulation related to relapse, showed compared with social drinkers, alcohol-dependent patients reported significant differences in emotional awareness and impulse control during week 1 of treatment. Significant improvements in awareness and clarity of emotion were observed following 5 weeks of protracted abstinence.
Another study (7) which did not look specifically at emotional regulation but rather on the recovering of prefrontal areas of the brain known to be involved also in the inhibition of  impulsive behaviour and emotional regulation showed that differences between the short- and long-abstinence groups in the patterns of functional recruitment suggest different cognitive control demands at different stages in abstinence.

In one study, the long-term abstinent group (n=9) had not consumed cocaine for on average 69 weeks, the short-term abstinent (SA) group (n=9) had an average 0f 2.4 weeks.

Relative to controls, abstinent cocaine abusers have been shown to have reduced metabolism in left anterior cingulate cortex (ACC) and right dorsolateral prefrontal cortex (DLPFC), and greater activation in right ACC.
In this study  the abstinent groups of cocaine addicts showed more elevated activity in the DLPFC ; a finding that has also been observed in abstinent marijuana users (8).
The elevation of frontal activity also appears to undergo a shift from the left to right hemisphere over the course of abstinence.  The right is used more in processing (labelling/identifying) of emotion.
Furthermore, the left inferior frontal gyrus (IFG) has recently been shown to be important for response inhibition (9) and in a task similar to that described here, older adults have been shown to rely more on left PFC (10). Activity observed in these regions is therefore likely to be response inhibition related.
The reliance of the SA group on this region suggests that early in abstinence users may adopt an alternative cognitive strategy in that they may recruit the LIFG in a manner akin to children and older adults to achieve behavioral results similar to the other groups.
In longer,  prolonged abstinence a pattern topographically typical of normal, healthy controls may emerge.
In short-term abstinence there was an increased inhibition-related dorsolateral and inferior frontal activity indicative of the need for increased inhibitory control over behaviour,  while long-term abstinence showed increased error-related ACC activity indicative of heightened behavioral monitoring.
The results suggest that the improvements in prefrontal systems that underlie cognitive control functions may be an important characteristic of successful long-term abstinence.
Another study (11) noted the loss of grey matter 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 (12 -14).
It has been suggested cocaine abuse blunts responses in regions important to emotional regulation (15)
Given that emotional reactivity has been implicated as a factor in vulnerability to drug abuse (16)  this may be a preexisting factor that  increased the likelihood of the development and prolonging of drug abuse
If addiction can be characterized as a loss of self-directed volitional control (17),  then abstinence (recovery) and its maintenance may be characterized by a reassertion of these aspects of executive function (18)  as cocaine use has been shown to reduce grey matter in brain regions critical to executive function, such as the anterior cingulate, lateral prefrontal, orbitofrontal and insular cortices (19-24) .
The group of abstinent cocaine addicts (11) reported here show elevations in  (increased) grey matter in abstinence exceeded those of the healthy control in this study 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.
Reassertion of behavioral control may produce a expansion (25)  in grey matter  in regions such as the anterior insula, anterior cingulate, cerebellum, and dorsolateral prefrontal cortex .
All brain regions implicated in the processing and regulating of emotion. 
References
1. Berking M, Margraf M, Ebert D, Wupperman P, Hofmann SG, Junghanns K. Deficits in emotion-regulation skills predict alcohol use during and after cognitive-behavioral therapy for alcohol dependence. J Consult Clin Psychol. 2011;79:307–318.
2.  Fox HC, Hong KA, Sinha R. Difficulties in emotion regulation and impulse control in recently abstinent alcoholics compared with social drinkers. Alcohol Clin Exp Res. 2008;33:388–394.
3..Cooper ML, Frone MR, Russell M, Mudar P. Drinking to regulate positive and negative emotions: A motivational model of alcohol use. J Pers Soc Psychol. 1995;69:990
4. Camchong, J., Stenger, A., & Fein, G. (2013). Resting‐State Synchrony in Long‐Term Abstinent Alcoholics. Alcoholism: Clinical and Experimental Research37(1), 75-85.
5. Sinha, R., & Li, C. S. (2007). Imaging stress- and cue-induced drug and alcohol craving: Association with relapse and clinical
implications. Drug and Alcohol Review, 26(1), 25−31.
6. Beauregard, M., Lévesque, J., & Bourgouin, P. (2001). Neural correlates of conscious self-regulation of emotion. Journal of
Neuroscience, 21(18), RC165
7. Connolly, C. G., Foxe, J. J., Nierenberg, J., Shpaner, M., & Garavan, H. (2012). The neurobiology of cognitive control in successful cocaine abstinence. Drug and alcohol dependence121(1), 45-53.
8.  Tapert SF, Schweinsburg AD, Drummond SP, Paulus MP, Brown SA, Yang TT, Frank LR. Functional MRI of inhibitory processing in abstinent adolescent marijuana users.Psychopharmacology (Berl.) 2007;194:173–183.[PMC free article]
9. Swick D, Ashley V, Turken AU. Left inferior frontal gyrus is critical for response inhibition. BMC Neurosci. 2008;9:102.[PMC free article]
10. Garavan H, Hester R, Murphy K, Fassbender C, Kelly C. Individual differences in the functional neuroanatomy of inhibitory control. Brain Res. 2006;1105:130–142
11. 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 one8(3), e59645.
12. Chanraud S, Pitel A-L, Rohlfing T, Pfefferbaum A, Sullivan EV (2010) Dual Tasking and Working Memory in Alcoholism: Relation to Frontocerebellar Circuitry. Neuropsychopharmacol 35: 1868–1878 doi:10.1038/npp.2010.56.
13.  Wobrock T, Falkai P, Schneider-Axmann T, Frommann N, Woelwer W, et al. (2009) Effects of abstinence on brain morphology in alcoholism. Eur Arch Psy Clin N 259: 143–150 doi:10.1007/s00406-008-0846-3.
14.  Makris N, Oscar-Berman M, Jaffin SK, Hodge SM, Kennedy DN, et al. (2008) Decreased volume of the brain reward system in alcoholism. Biol Psychiatry 64: 192–202 doi:10.1016/j.biopsych.2008.01.018.
15, Bolla K, Ernst M, Kiehl K, Mouratidis M, Eldreth D, et al. (2004) Prefrontal cortical dysfunction in abstinent cocaine abusers. J Neuropsychiatry Clin Neurosci 16: 456–464 doi:10.1176/appi.neuropsych.16.4.456.
16.  Piazza PV, Maccari S, Deminière JM, Le Moal M, Mormède P, et al. (1991) Corticosterone levels determine individual vulnerability to amphetamine self-administration. Proc Natl Acad Sci USA 88: 2088–2092. doi: 10.1073/pnas.88.6.2088
17.  Goldstein RZ, Volkow ND (2002) Drug addiction and its underlying neurobiological basis: neuroimaging evidence for the involvement of the frontal cortex. Am J Psychiatry 159: 1642–1652. doi: 10.1176/appi.ajp.159.10.1642
18. Connolly CG, Foxe JJ, Nierenberg J, Shpaner M, Garavan H (2012) The neurobiology of cognitive control in successful cocaine abstinence. Drug Alcohol Depend 121: 45–53 doi:10.1016/j.drugalcdep.2011.08.007.
19.  Liu X, Matochik JA, Cadet JL, London ED (1998) Smaller volume of prefrontal lobe in polysubstance abusers: a magnetic resonance imaging study. Neuropsychopharmacol 18: 243–252 doi:10.1016/S0893-133X(97)00143-7.
20.  Bartzokis G, Beckson M, Lu P, Nuechterlein K, Edwards N, et al. (2001) Age-related changes in frontal and temporal lobe volumes in men – A magnetic resonance imaging study. Arch Gen Psychiatry 58: 461–465. doi: 10.1001/archpsyc.58.5.461
21. Franklin TR, Acton PD, Maldjian JA, Gray JD, Croft JR, et al. (2002) Decreased gray matter concentration in the insular, orbitofrontal, cingulate, and temporal cortices of cocaine patients. Biol Psychiatry 51: 134–142. doi: 10.1016/s0006-3223(01)01269-0
22.  Matochik JA, London ED, Eldreth DA, Cadet J-L, Bolla KI (2003) Frontal cortical tissue composition in abstinent cocaine abusers: a magnetic resonance imaging study. NeuroImage 19: 1095–1102. doi: 10.1016/s1053-8119(03)00244-1
23.  Lim KO, Wozniak JR, Mueller BA, Franc DT, Specker SM, et al. (2008) Brain macrostructural and microstructural abnormalities in cocaine dependence. Drug Alcohol Depend 92: 164–172 doi:10.1016/j.drugalcdep.2007.07.019.
24.  Ersche KD, Barnes A, Jones PS, Morein-Zamir S, Robbins TW, et al. (2011) Abnormal structure of frontostriatal brain systems is associated with aspects of impulsivity and compulsivity in cocaine dependence. Brain 134: 2013–2024 doi:10.1093/brain/awr138.
25.  Ilg R, Wohlschlaeger AM, Gaser C, Liebau Y, Dauner R, et al. (2008) Gray matter increase induced by practice correlates with task-specific activation: A combined functional and morphometric magnetic resonance Imaging study. J Neurosci 28: 4210–4215 doi:10.1523/JNEUROSCI.5722-07.2008.

Life in Recovery

The cost of addiction and the benefits of recovery are clearly illustrated in this survey from last year.

“Faces & Voices first-ever nationwide survey of persons in recovery from addiction to alcohol and other drugs was conducted by Alexandre Laudet, PhD.  The survey documented dramatic improvements in all areas of life for people in recovery from addiction and documents the heavy costs of addiction.

During their active addiction, 50 percent of respondents had been fired or suspended once or more from jobs, 50 percent had been arrested at least once and a third had been incarcerated at least once…

The dramatic improvements associated with recovery affected all areas of life including a 50 percent increase in participation in family activities and in paying taxes compared with their lives in active addiction.

Well the many costs of active addition are well documented, very little is known about the changes in key life areas as a function of entering and sustaining recovery, or when they occur. The survey measures and quantifies the recovery experience over time — less than 3 years; 3 to 10 years; and 10 years or more.

ADDICTION RECOVERY IS ASSOCIATED WITH DRAMATIC IMPROVEMENTS IN ALL AREAS OF LIFE

  • Involvement in illegal acts and involvement with the criminal justice system (e.g., arrests, incarceration ) decreases by about ten-fold
  • Steady employment in addiction recovery increases by over 50% greater relative to active addiction
  • Frequent use of costly Emergency Room departments decreases ten-fold
  • Paying bills on time and paying back personal debt doubles
  • Planning for the future (e.g., saving for retirement) increases nearly three-fold
  • Involvement in domestic violence (as victim or perpetrator) decreases dramatically
  • Participation in family activities increases by 50%
  • Volunteering in the community increases nearly three-fold compared to in active addiction
  • Voting increases significantly
  • Reports of untreated emotional/mental health problems decrease over four-fold
  • Twice as many participants further their education or training than in active addiction

 

THE BENEFITS OF ADDICTION RECOVERY OVER TIME

  • The percentage of people owing back taxes decreases as recovery gets longer while a greater number of people in longer recovery report paying taxes, having good credit, making financial plans for the future and paying back debts.
  • Civic involvement increases dramatically as recovery progresses in such areas as voting and volunteering in the community
  • People increasingly engage in healthy behaviors such as taking care of their health, having a healthy diet, getting regular exercise and dental checkups, as recovery progresses
  • As recovery duration increases, a greater number of people go back to school or get additional job training
  • Rates of steady employment increase gradually as recovery duration increases
  • More and more people start their own business as recovery duration increases
  • Participation in family activities increases from 68% to 95%.

ABOUT THE SURVEY

The online survey was developed, conducted and analyzed in collaboration with Alexandre Laudet, Ph.D., Director of the Center for the Study of Addictions and Recovery at the National Development and Research Institutes, Inc.  It was conducted between November 1 and December 31, 2012 and collected information on 3,228 participants’ sociodemographics, physical/mental health, substance use, and recovery history, and 44 items representing experiences and indices of functioning in work, finances, legal, family, social and citizenship domains…”

This survey help us see that recovery studies help us a societies to look beyond the illness to the recovery of the illness. It helps change our views.There is active addiction and recovery from addiction. We need to keep doing research into this wonderful new world of recovery.

It all helps de-stigmatise this condition so that many more can join us on the road to recovery.

I am not just the disease of addiction, I am the recovery from it.  

Reference

http://www.facesandvoicesofrecovery.org/resources/life-recovery-survey

 

 

Healing Communities via Recovery

Recovery is healing. From the personal to the communal. Here is a great example of recovering in recovery communities. It illustrates how recovery is a gradual move from isolation from,  to commune with other people.

We recover via communal contact and interaction with others. It is the new “secure attachment” with others which helps heal and also repair the neurobiology impaired by addictive behaviours.  It helps heal not only us but also our families and the communities we belong to. Love is the drug for me (and us).

The Healing Power of Recovery – Connecticut  Community of Recovery – how community recovery also helps individuals overcome feeling stigmatised by their condition and can feel more encouraged to seek treatment for their addictive behaviours.  So in a sense we can see recovery communities are passing the message of recovery on to others by putting a “face on recovery” acting as role models of recovery. Attraction and promotion.

For me this recovery community is showing the world “how it works” in a sense, the collective wisdom of recovery we often share among ourselves in recovery meetings but now share this with the wider society; this is what we got and what you can have.   We will help you get it too if you want it. This is how we all get better, recovering together.

 

Recovery is Contagious

In our final blogs on the invaluable insights into the Recovery process given by the research and experience of William White we finish by looking at the rise of recovery communities in the US in particular and discuss whether this “New Recovery Advocacy Movement” is the future of recovery (treatment) which is much more long term recovery orientated rather than simply treating this chronic condition of addiction as an acute disorder which is generally what treatment centres do.

We may have to move away from a narrow neurobiology of addiction (disease model) to a wider neurobiology of recovery (recovery model). We may have to make it more plain to the world that recovery happens all the time and that millions upon millions around the world are in long term recovery, and have a very high chance of remaining so.

That is not to say we should not continue to look within the brains of addicts to learn which neural and affective mechanisms propel this disorder forward but that research into addiction needs to be much less lopsided and negative. It needs to look at vulnerability and the progression of this condition but it also needs to more fully address the recovery stage too. It is like reading a page turning novel only to find the riveting denouncement has pretty much been omitted. Research needs to move from diagnosis of the problem to prognosis of the solution, i.e. recovery.

The shares of a 12 step meeting are some of the greatest stories of redemption you are likely to hear. The outside world needs to know how these stories are created, yes, but also how they are resolved via recovery. The outside world needs to hear the story does not end with recovery, in some ways this is where the story really gets interesting. The spiritual voyage of recovery is a story those suffering from addictive behaviour need to hear. Otherwise, research demoralises, rather than encourages. It perpetuates a unnecessarily negative view and a false picture about the reality of long term recovery for many millions of people, their families and communities.

Clinical neuroscience, in particular, needs to show the images to go with these stories otherwise it is falling down on it’s obligations to society and the greater world.

Science has not sufficiently shown us how the brain is altered in a positive, adaptive, healthy manner by behavioural changes associated with long term recovery. The major role of science is to predict behaviour. It needs to start demonstrating and confirming that if an addict starts doing certain behaviours, certain positive outcomes will follow. It needs to illustrate the neuroplasticity so that suffering people can clearly chart, in a rational manner, the course of wellness ahead.

I remember seeing the Jellinek Curve in treatment and was re-assured that this was a disease that one could clearly recover from and within a defined trajectory. It showed me rationally how others had done this recovery thing and how I could and would if I wanted to achieve what they had achieved.

Rather than the constant search for a “magic pill” should we not be celebrating in research this wonderful success story called long term recovery. Isn’t this one of the greatest stories out there?

Anyway, back to William White and his powerful advocacy of recovery communities which as he suggests may make students of us all when some of use thought we were teachers.

The story moves on, becoming more enriching and inspiring.

There is a movement towards the management of long term recovery from an acute treatment model. There have been new developments like recovery coaches which show an increasing focus on long term recovery.

There is also an emergence of a recovery movement that has not historically existed before. “Recovery is everywhere” campaigns organised not by treatment centres but by local, grass-root, recovery community organisations. They are not mutual aid or treatment based. They have never had a category to put them in until now.

We are seeing the mobilisation of people in recovery. We are seeing a number of New Recovery Support Institutions such as Recovery Community Centres, offering non clinical recovery support services for individuals and families in long term recovery, Recovery Homes, Recovery Schools movement, Collegiate recovery programs, recovery industries who realise that people in recovery make the best and most hard working employees, recovery ministries, religious base recovery communities like including Celebrate Recovery which is attached to over 10,000 churches throughout the US, Recovery Cafes, and an ever increasingly elaborate interconnection of recovery resources.

William White ends with an intriguing suggestion that we may, via these increase recovery support organisation and via our own long term recovery be able to break the chain of dependence in our own children.

This way seem somewhat far fetched to some but equally it may be possible to identify the ways genes are expressed by certain behaviours in certain environments and for these to be altered by a change in these behaviours as the result of recovery and for environments to be changed too.

If, as we have suggested, addiction is at heart an emotion processing and regulation disorder, we could intervene to shore up these skills in those vulnerable to alter addiction by teaching sharing emotions, identifying and labeling of emotions, verbalisng of emotions etc, because we are attacking the pathomechanism of addiction, the mechanism by which addiction is propelled.

In doing so we may have a fighting chance of altering the course of possible addiction. So what has always been seen as inevitable (drunks beget drunkards) may for the first time in history not be so straight forward, so inevitable. This pathomechanism may be malleable and be susceptible to us changing the course of a likely disorder. In doing so, it will affect the chain of genetic inheritance from one generation to the next?

Fanciful or possible?

We discuss our ideas and William White’s ideas on this in another blog.