factors in recovery

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.

 

 

 

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.

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 Research, 37(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 dependence, 121(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 one, 8(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.

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: can you feel “Better than Well!”?

Degrees of Recovery?

Better than Well – I love this concept and reality and relate to it myself. This is a reality for many recovery people who feel they had an amplified recovery or in simple terms, people who got better than well!

This people did not simply have the pathology of addiction extracted from their lives. These people did not only go on to recover but went on to live incredibly rich lives in terms of the quality of their lives and the service to their communities.

These are people who talk about addiction and recovery as a blessing! These are individuals who suggest that what they achieved after recovery was not in spite of their recovery but because of the strength they drew out from their addiction recovery.

Their fulfillment of life was greater perhaps than if they had never been addicted and suffered from addiction. Their recovery from addiction gave them a meaning that they may not have had, if they had not been addicts.

I believe I am 25% smarter in recovery (can be proved in terms of exam grades), I understand people now in recovery, I am a more empathetic human being in recovery. My life is immeasurably better than it was before. I have a contentment unknown to me previously. A peace of mind I thought impossible.

My roots grasp a new soil! I feel like I have been reborn.

This kinda fits in also with Bill White’s description of recovery as a method of transcending the self or “getting out of self”. This idea and reality relates to various previous blogs on why we need to live “outside” self regulation” systems of the brain as these appear to have been hijacked by the effects of drug and behavioural addiction.

One way of doing this is by using our self in a different way, to use self to serve others. This way we can use our stories to help others in recovery and improve our own self regulation as it strengthens areas of the brain like the ventromedial pre frontal cortex used in self referential information and emotional regulation.

We can get reward not from drugs or behaviour but by helping others which supplants the depleted dopamine, natural opioids, oxytocin of increased attachment and bonding and the serotonin of well being. It improves our orbitofrontal cortex as we become more empathetic, begin to become emotional literate, reading emotional expression in other’s faces.  It reduces stress and distress. Lowers glutamate and increases GABA. We become less fearful and more serene.

Helping others helps us so profoundly.  It changes the neurobiology and hence neuroplasticity of our brains.

The video ends with a brief look at the “hot flash” spiritual awakening of recovery a la Bill Wilson and  the slower more incremental or “educational” variety of spiritual awakening. For me, spiritual awakening can mean emotional catharsis, sometimes so dramatic that it immediately changes how we think and feel about the world and our place in it or the more experiential, where our views and attitudes to the world gradually change. Each leads to the same goal of long term recovery. The latter being, by far, the most common.

 

The Road to Recovery

Following on from our recent blog on “So what is Recovery?” we now look at the process of recovery itself and important changes that contribute to successful recovery.

Many recovering persons report quitting drugs because they are ‘sick and tired’ of the drug life. Recovery is the path to a better life but that path is often challenging and stressful.

However, the main message from this study (1) is that those individuals who manage to get to 5 or more years abstinence have an 86% chance of long term recovery !

Not only do the recovering persons benefit in many ways but families and societies also see major benefits of recovery too. The initial cost of recovery, i.e. if via treatment facilities, is offset by increased employment, less penal costs, financial contributions to society of recovering persons etc.

Not only does it make ethical, moral and medical sense to spend much more on treatment facilities it makes makes very obvious financial sense.

“Although substance use disorders are increasingly recognized as chronic relapsing conditions that often span decades and require multiple episodes of treatment and/or self-help (Anglin, Hser, and Grella 1997; Anglin et al. 2001; Dennis, Scott et al. 2003; Dennis and Scott [in press]; Hser et al. 1997; Hser et al. 2001; McAweeney et al. 2005; McLellan et al. 2000; Moos and Moos 2005, 2006; Scott, Foss, and Dennis 2005a, 2005b; Simpson, Joe, and Broome 2002; Vaillant 1988; Weisner, Matzger, and Kaskutas 2003; White 1996), approximately 60% of the people with lifetime substance disorders do eventually reach a state of sustained abstinence (Cunningham 1999a, 1999b; Dawson 1996; Dennis et al. 2005; Kessler 1994; Robins and Regier 1991).

This has led to multiple calls to define and better understand and study “recovery” in terms of not only abstinence but improvements in health, mental health, coping, housing, social and spiritual support, illegal activity, and vocational engagement (Betty Ford Consensus Panel [in press]; Laudet, Morgen, and White 2006; Laudet, White, and Storey [in press]; White 2005).

Using data from 1,162 adults living in a large metropolitan area who sought substance abuse treatment in 1998 and who were subsequently interviewed annually between Years 2 and 8 (greater than 94% follow-up rate each year), this study addresses the following four questions:

1. How do health, mental health, and coping vary by duration of abstinence?

2. How do illegal activity, incarceration, employment, and family income vary by duration of abstinence?

3. How do housing, clean and sober friends, recovery environment, self-efficacy to resist relapse, and social and spiritual support vary by duration of abstinence?

4. How does the likelihood of sustaining abstinence another year vary by the duration of abstinence?

Health, mental health, and coping. Abstinence is generally associated with better health, mental health, and coping. Among people in the community, less substance use is associated with lower rates of chronic health and psychiatric problems, which are in turn associated with high societal costs and death (Mokdad et al. 2004).

Abstinence is also associated with less “avoidance” coping styles, such as cognitive avoidance and emotional discharge, as well as more “approach” coping styles, such as logical analysis, seeking guidance, problem solving, seeking alternative rewards, and positive reappraisal (Carpenter and Hasin 1999; Chung et al. 2001; Finney and Moos 1995; Holahan et al. 2003; Moggi et al. 1999; Moos and Moos 2005).

Abstinence has generally been associated with reductions in illegal activity, incarceration, poverty, and improvements in vocational activity. Reductions in substance use are associated with relatively rapid reductions in illegal activity and illegal income (Dismuke et al. 2004; Scott, Foss et al. 2003).

Although this often involves some period of residential treatment or incarceration, such costs are typically offset by reductions in other costs to society, increased employment, and increased productivity (Bray et al. 2000; French, Salome, and Carney 2002; McCollister and French 2003; Rajkumar and French 1997; Single et al. 1998).

Abstinence is generally associated with being housed and having some friends, fewer problems in the recovery environment, and more personal, family, social, and spiritual support.

Risks (e.g., substance use among family, friends, and victimization) and protective factors (e.g., treatment and self-help participation, peers in recovery) in the recovery environment and self-efficacy to resist relapse were also among the major predictors of transitions from using to recovery and relapse (Humphreys, Moos, and Cohen 1997; Schutte et al. 2001; Scott et al. 2005b).

The general association between relapse and stress has also been found to be moderated by the extent of support one gets from self-perceived personal strengths, family, and social peers (Jessor, Turbin, and Costa 1998, Laudet et al. 2004; Miller 1998; Miller et al. 1996; Procidano and Heller 1983; Schutte et al. 2001).

We found no studies to date using the “duration of abstinence” to predict the likelihood of sustaining abstinence for another year. However, a recent extensive review by Moos and Moos (2007) found one or more of four dozen studies reporting that the odds of sustaining abstinence was positively associated with abstinence self-efficacy, approach coping styles, vocational engagement, income, having clean and sober friends, and having social and spiritual support and inversely related to an avoidance approach coping style.

Findings – This study demonstrates that duration of abstinence is related to changes in other aspects of recovery but at different rates and times.

Use of coping mechanisms started out high and decreased as the number of years of abstinence increased, suggesting that the high rates of these coping strategies previously reported by others (see Moos and Moos 2007) may actually be a characteristic of early abstinence. Mental health problems peaked during 1 to 3 years of abstinence and decreased thereafter.

The rapid decrease in illegal activity and illegal income sustained across varying lengths of abstinence was consistent with the literature given that many of the crimes were drug related. Following 1 year of abstinence, the number of days worked and legal income generated significantly increased and days with financial problems decreased. After 3 years of abstinence, there were also significant reductions in the percentage of families living below the poverty line, which indicates continued gains in financial status.

Consistent with the literature, the duration of abstinence was associated with reduced environmental risks and increased number of clean and sober friends, level of social support, spiritual support, and self-efficacy to resist relapse.

The odds of sustaining abstinence increased dramatically during the first 3 years and then leveled off. Among people with 5 or more years of abstinence, there was still some risk of relapse (14%) – but equally a 86% chance of remaining in recovery!

Consistent with earlier findings by Grella et al. (Grella, Scott, and Foss 2005; Grella et al. 2003; Grella et al. [in press]) that women were more likely to enter and stay in recovery.

Implications for Practice, Policy, and Research

Findings suggest the need for a shift from focusing on acute episodes of treatment to the management of recovery during longer periods of time.

Most of the drug abuse treatment research to date has focused on reducing days of use or abstinence in the first 6 to 12 months after treatment (Dennis and Scott [in press]; Prendergast et al. 2002). More health services research is needed on managing long-term recovery, both in terms of how to deliver it in ways that are both effective and cost effective for multiple years. This includes research on ways to integrate these other kinds of services, minimize some of the negative trends (e.g., the early peak in mental health problems), and accelerate the positive trends (e.g., more positive recovery environment and vocational activity).

Conclusion

Although much of the research on substance abuse treatment outcomes has focused on abstinence in the first 6 to 12 months after treatment, this article suggests that initial abstinence and the initial time period do not fully represent the changes associated with long-term recovery. This research shows that risk of relapse is particularly problematic in the first 3 years of abstinence and never completely goes away, suggesting the need for promoting strategies and programs that support the long-term management of recovery.

References

1. Dennis, M. L., Foss, M. A., & Scott, C. K. (2007). An eight-year perspective on the relationship between the duration of abstinence and other aspects of recovery. Evaluation Review, 31(6), 585-612.

So What is Recovery?

So, what does recovery mean? It is total abstinence? Is recovery strictly a question of substance use or is there more to it than that?

This study (1) addressed two primary research questions: (1) Does recovery require total abstinence from all drugs and alcohol? and (2) Is recovery defined solely in terms of substance use or does it extend to other areas of functioning as well?

Many of those in this study who defined recovery as abstinence went on to express the idea that using any mood altering substance would lead back to full-blown relapse.

Recovery meant  in descending order: a new life (22%), well-being (13%), a process of working on yourself (11.2%), living life on life’s terms (accepting what comes – 9.6%), self-improvement (9%), learning to live drug free (8.3%), recognition of the problem (5.4%), and getting help (5.1%).

“I’m in recovery myself because I want to stay clean. And I want to be a responsible person or responsible human being. To do what I was … what I should do or what God put me here to do. And, you know, I got to – I got to remain sober to do these things.”

“To me recovery means getting back what I lost. Myself. I am not talking about materialistic things. I am talking about me.”

“Recovery, I just.. What is it for me? It’s going back to me…

“My definition of recovery is life. Cause I didn’t have no life before I got into recovery.”

 

Qualitative data on recovery definitions provided by the 20.4% of individuals who did not consider themselves in recovery are particularly noteworthy as they echo some of the popular connotations the term ‘recovery’ carries in the general public. Some of the answers were expected, including those of individuals who may have never considered themselves in recovery (e.g., “I wouldn’t know how to define recovery because I’ve never been in it,” “I’ve heard of the term, but I don’t know. What is it? I guess, it’s being committed to being straight”), and individuals who may have relapsed (e.g., “it used to feel free and happy without using”).

About one third of the answers from individuals not in recovery echo the public’s perception that recovery means people are ‘trying’ to remain abstinent: “Someone who is currently on guard about falling off the wagon at any moment.” The idea that for some, recovery suggests a struggle with drugs and/or alcohol is further supported by a number of respondents who indicated that they are not in recovery because they are not experiencing drugs and/or alcohol problems; for example: “Recovery… I don’t know, a glass of wine ain’t nothing to me” and “it’s not a battle for me- I don’t have to recover from anything.” The connotation of recovery as a struggle with substance abuse problems and statements from participants who felt they had overcome their problem suggest that recovery is understood by some as having had a severe problem. This is consistent with the image of AA being a place only for ‘skid row drunks.’

The majority of qualitative recovery definitions among participants who didnot consider themselves in recovery indicated that a specific action … was a necessary part of recovery.

The bulk of the answers implying a specific recovery requirement, however, concerned needing or seeking help – getting treatment and/or participating in 12-step recovery: “Being in treatment and not using drugs or alcohol,” “Abstaining and seeking outside help.” Several answers suggested that recovery implies needing to seek outside help because you cannot quit on your own: “Having trouble quitting, needing help,” “when you get some help, like detox, a program or something-not when you just stop on your own,”…

Benefits of recovery – While participants’ definitions of recovery may speak as much to semantics (i.e., the use of the term ‘recovery”) as to their experience, answers about what is or would be good about being in recovery illuminate the recovery experience itself. Regardless of the term used,significant behavior change takes time, it is challenging and stressful.

The most frequently cited benefit of recovery, mentioned by one third of participants, is that it is a new life, a second chance (“like being born again, not living a state of denial, enjoying life better, whole new wonderful feeling, health, financially”); one quarter (23%) cited being drug-free; other benefits cited in were: self-improvement (22.7%), having direction, achieving goals (17.5%), improved/more positive attitude (17.2%), improved finances/living conditions (16.2%), improved physical and/or mental health (16.1%), improved family life (13%) and having friends/a support network (11%).

Recovery: Process or endpoint? –

One of the more controversial issues when speaking of ‘recovery’ is whether it is process (with no specific endpoint) or a state (i.e., whether one is ever ‘recovered”). This question has potentially critical ramifications especially in terms how recovery is perceived by the public and indirectly, in terms of stigma and discrimination (e.g., prospective employers who view recovery as a lifelong process may be more likely to not hire a prospective worker in recovery for fear he/she will relapse or be unreliable). Findings were reviewed earlier suggesting that the public defines recovery as an attempt to stop using drugs and alcohol, suggesting that it may not be attainable.

Thus while maintaining recovery may be a lifelong process (e.g., maintaining certain practices), it is important to determine whether or not the process is lived as having an end (being recovered). In the US, the view of addiction as a chronic disorder, paired with the strong 12-step influence (“once an addict always an addict”) would suggest that recovery is a never-ending process.

Participants made qualitative statements that speak to whether one ever ‘gets there” – i.e., becomes recovered, suggesting that consistent with the disease model of addiction, recovery is a process with no fixed end point, and that it requires ongoing work

“Recovery is getting back some sort of order in your life, the disease is in remission- it’s not a cure- it has to be maintained daily.”

“Recovery is somewhere people think they’re going to get to and you’ll never get there.”

“I don’t think you ever recover from it, it’s learning how to manage it, stay abstinent & become a productive member of society.”

“you’re never recovered, I mean, it’s always ‘gonna be back there.”

“I think recovery’s a process. Um… for me, it’s just always trying to better myself. Um… and realizing that there may not be an end point, but just a… you know, they always say, like, sometimes it’s better to go through it than to get there.”

“I’m still on this journey because there is hope, you know. There is not a cure. But there is hope.”

“And I keep myself in the right, atmosphere or attitude or what not because there is a whole lot to recovery, you know. It ain’t just getting sober and staying clean. It is like you gotta do a lot of work.”

 

Discussion

Prior exposure to treatment and to 12-step fellowships, both of which encourage embracing abstinence as recovery goal, was significantly associated with defining recovery as total abstinence. Interestingly, both individuals who do and do not consider themselves in recovery embraced abstinence as their definition of recovery. While substance users are often ambivalent about quitting drugs, individuals with a long and severe history of substance use who seek remission may come to the conclusion that total abstinence is required from personal experience with relapses and attempts at controlled use. Most failed remission attempts are based on moderation and abstinence proves more successful (e.g., Burman, 1997; Maisto, et al., 2002). Greater lifetime addiction severity was associated with endorsing abstinence, and some participants who did not consider themselves in recovery indicated that recovery implies struggling and/or needing outside help.

BACK TO ME: DISCOVERY AND RECOVERY

With respect to scope, recovery goes beyond substance use for most. This is consistent with 12-step tenets (e.g., “but sobriety is not enough,” Alcoholic Anonymous, 1939/2001, p. 83). Frequently used expressions to define recovery were ‘a new life,’ ‘a second chance,’ or, life itself. The verb “to recover” is defined as (1) to get back : REGAIN; (2) to bring back to normal position or condition; (3) to make up for; (4) to find or identify again; and (5) to save from loss and restore to usefulness: RECLAIM (Merriam Webster).

Several participants framed this notion as regaining something that was lost – the opportunity of becoming what they were meant to be before they started using drugs and alcohol (section 3.4.2). The Big Book expressed this as “We were reborn” (AA, 1939/2001, p. 63).

NO SUCH THING AS GRADUATING: RECOVERY IS A PROCESS RATHER THAN AN ENDPOINT

Reclaiming oneself is a process of growth and a process of change in attitudes, thinking and behaviors consistent with the rich descriptions and experiences documented by Stephanie Brown (1985).

Recovery as a process should not be interpreted as inconsistent with recovery as abstinence; rather abstinence (a state) is viewed as a requirement of the ongoing process of recovery.

The work of change is what distinguishes recovery from mere abstinence (“You could stop doing anything that you want. It’s about the change that comes in—into it, that’s the recovery part.”). The process aspect of recovery has been reported previously in studies conducted among alcohol- and drug-dependent samples both in the US and abroad (e.g., Blomqvist, 2002; Flynn et al., 2003).

A small-scale study of drug-dependent persons abstinent for an average of 9 years sheds light on the stages of the process(Margolis et al., 2000). Participants reported first passing through a phase almost solely focused on staying abstinent, particularly the first year. Only once this foundation (abstinence) was established could they concentrate on “living a normal life,” where abstinence was no longer the main focus.

Finally, following that transitional period, the individual enters late recovery, a time of individual growth and search for meaning. Our findings on the focus of recovery definitions are consistent with these stages: individuals in remission 18 to 36 months (the transition phase) were more likely to define recovery as a process whereas those in remission three years or longer were more likely to focus on the ‘new life’ aspect of recovery and less likely to define recovery in terms of substance use.

Recovered?

Conceptualizing recovery as a process leads to the question of whether one ever ‘gets there” – whether one is ever “recovered.” This is rarely discussed in scientific literature. Most participants regard recovery as “an ongoing process. There’s no such thing as graduating.” This is consistent with the disease model and with prevalent view of addiction as a ‘chronic’ condition (McLellan, Lewis, O’Brien, and Kleber, 2000; White, Boyle and Loveland, 2002); it is also consistent with reports that resolving addiction often takes multiple attempt and treatment episodes (e.g., Dennis et al, 2005; Laudet & White, 2004).

Other biomedical fields have reached consensus about what clinical ‘remission’ means (e.g., five years disease free in oncology). Whether and when SUD remission ever becomes ‘stable’ in terms of substance use (i.e., when the risk of return to drug use is minimized) remains somewhat unsettled.

Three to five years is the timeframe most commonly used (Finney and Moos, 1991; Flynn et al, 2003; Longabaugh & Lewis, 1988; Timko et al., 2000; Vaillant, 1983/1995) and it corresponds to the experiences of persons in long-term recovery (Margolis et al., 2000). While the risk of relapse does not completely disappear after three or even five years of continuous abstinence (e.g., Hser et al., 2001), it appears to be minimal (e.g., Vaillant, 1983/1995).

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Addiction is a chronic condition; there may not be a complete or permanent solution (i.e., the risk of relapse may remain for multiple years) but it can be treated and managed. There are many paths to recovery (e.g., Moos & Moos, 2005) but treatment is most often needed when dependence is chronic and severe.

Our findings suggest that for severely dependent individuals, recovery is a process of change and growth for which abstinence from alcohol and others drugs is a prerequisite.

McLellan and colleagues (2005) have made the argument that “Typically, the immediate goal of reducing alcohol and drug use is necessary but rarely sufficient for the achievement of the longer-term goals of improved personal health and social function and reduced threats to public health and safety—i.e. recovery” (p. 448). This conceptualization of clinical outcome is consistent with the World Health Organization’s conceptualization of health as “a state of complete physical, mental, and social well-being, not merely the absence of disease” (1985, p.34).

The question remains : whether we are willing to pay for positive health (wellness) oriented services for substance dependent populations is unclear.

Present findings suggest that the benefits of recovery are many (improved health, life conditions, social life etc.) and they are highly valued. Quality of life (QOL) among active users is poor and abstinence, especially sustained abstinence, is associated with QOL improvements (e.g.,Donovan et al., 2005; Foster et al., 1999; Laudet et al., 2006; Morgan et al., 2003).

Higher life satisfaction prospectively predicts sustained remission (Laudet, Becker & White, in press; also see Rudolf & Priebe, 2002) and low QOL may heighten relapse risk (Claus, Mannen & Schicht, 1999; Hoffmann & Miller, 1993). Thus the clinical goal of addiction treatment must go beyond fostering reduction in substance use to improving personal and social health.

The addiction field can seek guidance from the mental health field where…in a working definition set forth in the New Freedom Commission on Mental Health: “Recovery refers to the process in which people are able to live, work, learn, and participate fully in their communities” (2003, p.5).

How do clinicians foster recovery? Vaillant (1983/1995) described the conditions necessary to the recovery process as abstinence, substitute dependencies, behavioral and medical consequences, enhanced hope and self-esteem and social support in the form of unambivalent relationships. Persons in recovery consistently cite the support of family and peers (and the need to seek and accept support), spirituality, inner strength and the desire to get better as critical sources of strength (e.g., Blomqvist, 2002;Flynn et al., 2003;Laudet et al., 2002,).

Many clients initiate treatment due to external pressures (family, legal, employment) and may not be initially motivated for change; however, once in the therapeutic environment, even externally motivated clients (e.g., legally mandated) may reflect on their situation and accept the need for treatment (Kelly, Finnney & Moos, 2005). The cessation of substance use is often preceded by a period of cognitive preparation (akin to the contemplation stage Prochaska & DiClemente, 1992 – e.g., Burman, 1997and2003; Sobell et al., 2001); participating in treatment during this period may significantly enhances motivation for change by introducing the notion that behaviors and activities that are not drug-related could have healthier consequences and provide more satisfying reward possibilities (Burman, 2003), thus ‘raising the price’ of subsequent substance use and enhancing the likelihood of abstinence.”

 

There are also the financial implications of spending money on effective treatment for those who wish to recover rather than counting the cost of increased crime, prison sentences, extensive medical care,  etc etc. It makes economic sense to spend money in a preventative sense in addiction, as well as being simply a moral decision  to medically treat those who are chronically ill. First do no harm is part of the Hippocratic Oath. Can we say that spending huge amounts of money on harm reduction, controlled use programs, methadone scripts etc etc is actually “treating” alcoholics and addicts?

To quote Russell Brand, that is “like putting a sticking plaster on a broken soul” – it only sustains the problem not alleviating or treating the underlying conditions.

We can help society and families recover also from the effects of alcoholic and addict behaviour. Recovery involves improved well being for family and society members too.

We have to offer a chance to start over, to have access to a new life much better than we could ever have imagined.

Recovery cannot really be about giving you reduced amounts of whatever is poisoning you, ailing you. It cannot be about substituting one drug for another. Substituting one addictive behaviour for another. It cannot be about yet another chemical straight-jacket or prison.

Recovery has to be about getting better. Improving well being. This is what increased in health when a treatment is successful so why should it be different for addicts and alcoholics.

Many millions of people recover from their addictive behaviours, that is fact! We need to start getting this message out,  “We do recover!”

Recovery is much much better than drinking and drugging ever where. This is what we need to get across.

To be in a fairly constant state of contentment is priceless and something no drug could ever achieve!  

References

1. Laudet, A. B. (2007). What does recovery mean to you? Lessons from the recovery experience for research and practice. Journal of Substance Abuse Treatment, 33(3), 243–256. doi:10.1016/j.jsat.2007.04.014