Take the 12 Steps... and Sit Down!

Sunday, December 13, 2009

In my previous work as a clinical director of a drug and alcohol treatment program in a county jail and in my current outpatient work with substance use clients I continuously come across a certain iatrogenic (treatment-related) legacy of powerlessness which stems directly from the 1st of the 12 Steps of the AA/NA philosophy ("We admitted we were powerless over our addiction - that our lives had become unmanageable").

I get it: admitting that you have a problem is a psychologically healthy thing. But admitting that you are powerless to solve it?! What a self-deflating stumble of a step to start a journey of recovery... What were Bill W. and Dr. Bob thinking?!

Perhaps, Bill W. and Dr. Bob were trying to pull off a bit of East-West synthesis? Perhaps, the thinking was that surrender or letting go of one's attachment to the idea of being in control is power? That passively accepting and witnessing the urge to drink (or use drugs) rather than directly fighting the urge head-on would be akin to psychological judo or jujutsu, the "soft method" martial arts that harnesses the opponent's strength and adapts to changing circumstance?

Perhaps, perhaps, perhaps...

Or, perhaps, this confession of powerlessness over addiction is nothing more than a failure to appreciate the psychology of a craving.

Let's take a look!

Just the other day, a guy I've been working with, who's been through the revolving door of the 12 step programs and who had decided to seek psychotherapy in addition to "working the program," triumphantly announces that he "did" the first step. Again!

Now, he's known about my approach to substance use treatment and he has showed himself to be an open mind capable of critical thinking. So he seemed entirely non-defensive when I asked him about what he meant when he "admitted to being powerless over the Disease."

Keep in mind that by now he and I have spent many a session working exclusively on craving control skills.He paused... and, with a sheepish smile, dared: "I am powerful over the Disease, Doc?"

You have to appreciate the weight of 12 Step dogma that he was trying to raise from! Had he leaked this hypothesis at a meeting or in a session with a 12 Step "recovery zealot" he would have likely been accused of being in denial, "slipping," or "lapsing." So, for him to even dare to think that he might be, in fact, powerful over the Disease took guts...

It's basic and axiomatic: if you've been drinking and/or using for any length of time, you'll have craving thoughts. Nothing you can do about that. They'll pop into your mind, uninvited, particularly, when you are around certain "people, places, and things" or when you are in a certain state of mind.

This is plain ol' Classical Conditioning stimulus-response. And indeed, a person who has been using and/or drinking develops numerous conditioned associations between various stimuli and his/her drug of choice.

Naturally, until such person gets used to ("habituates to") these stimuli (in his/her post-cessation, post-drug-use life), he or she will experience conditioned cravings. So, in this sense, up to a point, you are powerless to entirely prevent and/or eliminate craving thoughts from their initial occurrence (after having been exposed to drinking/using stimuli).

But...

But just because you are powerless to prevent the craving thought from occurring in the first place, it doesn't mean that you are powerless to manage or control this thought.

Bottom-line: you are not powerless over how to respond to these cravings, over whether to act them out or to manage them. In fact, the Buddhist mindfulness meditation has been researched, clinically piloted and increasingly mainstreamed into the craving control repertoire of the contemporary drug and alcohol rehabilitation programs.

So, how about this for a first practical step: step aside (from the craving thought) and sit down (in mindfulness meditation) to restore your mind to its non-craving baseline.

Let's review what we got here...

Addiction is a habit. Habits are stimulus-response patterns. If you have had any given habit for some time, when you decide to stop, your mind will keep reminding you to engage in a certain conditioned response whenever you are triggered or exposed to certain stimuli. But just because, your mind reminds you that you used to do this or that in this or that situation, it doesn't necessarily mean that you are powerless to avoid doing this or that, once triggered. So, while you are powerless to completely avoid these mental reminders, these craving thoughts, you do have power to manage these thoughts (through good ol' self-talk or by merely witnessing these thoughts and controlling your experience through mindfulness and/or relaxation).

Now, take a look at the following equation (1).

Using/Drinking Episode = Access to the Drug + Desire to Use/Drink/Consume the Drug

In order for you to use/drink, two things have to be absolutely present: you have to actually have the boose or drugs in your immediate possession and you have to have an active, immediate desire to consume the substance.

For example, if I got some drugs on me but I've been pulled over for speeding, my desire to use is on hold. Right now, all I care about is to get back on my way preferably without a speeding ticket, let alone without a possession charge. So, even though I have immediate and direct access to the drug, I have lost my immediate craving to use. As such, there is no using episode.

Similarly, if I actually got busted for possession and now I am sitting in the county jail, and I got a "whopper" of a craving but no immediate access to drugs, there's not going to be a using episode as I have no direct, immediate means to satisfy my craving.

Or, say, I am sitting at home getting ready to shoot up. But then I think: I gotta see my PO (probation officer) tomorrow and pee in the cup. If my urine's dirty, the PO is gonna "violate" me and send me back to jail. So, here I am: I got access to the drug and I sure have a craving for it. But - based on my pragmatic calculations - I gotta wait till after I see my PO. So, I have the tactical motivation to control my cravings (even if I have no strategic, long-term commitment to recovery) and, if I have the skill-power to control the craving, the basic know-how of how to manage this moment of desire, I might just avoid a using episode (if only for a day).

Where's the unmanageable disease here? Which part exactly am I so fundamentally unable to control? So, even though I have direct access to the drug, by controlling my craving - albeit for an arguably myopic reason - I am able to avoid a using episode. No disease here: just applied, situational morality of avoiding adverse circumstances. Mere interplay of tactical motivation and craving control skill-power.

But what a laudable, promising self-regulatory precedent to build on! What a clinical treasure trove of the distinction between "can't control the craving" and "won't control the craving" to process and analyze!

What all this means is that in order to avoid a using/drinking episode, you have to either eliminate the access to the drug and/or to control the craving to use.

The former - elimination of the access to the drug - is a Stimulus Avoidance strategy best accomplished through a tried-and-true AA dictum of staying away from "people, places, and things."

The latter - elimination of the immediate desire to use the substance in question - is the Response Control strategy best accomplished through craving control.

It goes without saying that if you've been using for long, let alone drinking, avoidance of internal and external stimuli that may trigger a craving is simply impractical.

After all, even if you don't go to the block corner any more, you still got your cell phone. And even if erase your contacts on the phone, you still hear all about it wherever you go - at a meeting, in the movies, you name it... And even if you were to go on a 7-years-in-Tibet retreat, you still have your mind to remind you of the good ol' times, right?

So, the Stimulus Avoidance strategy, the strategy of avoiding access to the drug - let's face it - is limited. What's left - and that should be plenty enough - is craving control. If you work on cultivating a solid, no-nonsense craving control skill-power, you need no will-power or God-power, and you definitely have no need for this dubious relapse prevention scare-tactic of "powerlessness."

"What kinds of craving control methods are out there?" you might ask.

I am glad you finally asked: psychological and chemical.

Psychological craving control methods, in the descending order of my clinical preference, are Mindfulness (best, in my opinion), Relaxation (good), Self-Talk (satisfactory), Distraction (so-so).

Chemical craving control methods: you name it - from methadone to Cyboxin...

I can almost hear it: "Busted! Gotcha, sucka! You said "methodone," you said Cyboxin... See! See! It's a disease. A Disease!!! Not a habit! How can you be in control of a disease?!!! It's physical, not mental, don't you see?!!!"

I see, I see... I'll take an unpopular stab at this mind-body Cartesian non-sense in a minute... But for now, let me just reminisce a bit...

Back when I was running a non-12-step drug and alcohol program in a county jail, I'd get challenged on my assumptions (like above) all the time. In adrenaline overdrive for two years, at least, I had to fend off these Disease Model counterarguments from my inmate clients. There's nothing, nothing like Antisocials' thirst for justice... The energy, the righteousness, the hunger to stump the expert! I enjoyed that work greatly: it paid off: while imprisoned, many of these minds were admirably free...

So, back to this notion of disease... It's just, frankly, silly Cartesian mind-body dualism. Thoughts and feelings are real, they exist - therefore, they have a chemical (physiological) signature in this three-dimensional reality. Of course! No one's arguing with this - it is banally self-evident. So, just because somebody can show you what your "addicted" brain looks like on drugs, it doesn't mean that your habit is a disease.

I might be in a habit of tearing up every time I see a picture of that couple - holding hands - leaping out of the Twin Towers on 9/11. Think about it: I see the image and have a sad thought, and my eyes make water! A thought in my mind results in water pouring out of my eyes! Some fleeting event in my consciousness and look at this mess: I need a tissue, my eyes are red. A change in the state of mind led to a change in the state of body. Mind and Body are the Twin Towers: they stand together and they collapse together.

Need another example? Okay, here's one. I took a leak but forgot to zip up my fly. Now, when a client (God forbid!) points this out to me, I have a thought: "Oh, man! How could I?!" A fleeting event in my consciousness - and my face, my face (!) reddens as I blush. A thought of embarrassment - and blood, blood (!) re-distributes its flow and floods my face... What the hell... Must be a case of... "emotional-vascular" disease...

This mind-body connection is so tight that it's time we took the hyphen from this "mind-body" dualism...

So, what am I getting at? What I am saying is that addiction is a habit, and as any habit, it is a stimulus-response pattern, and as any human habit, addiction involves both mind and body (or better yet, the un-hyphenated bodymind), and that there is no difference between mind and body, they are a one indivisible whole, so when you control one part of this whole, you control the other part of this whole. That's how the whole thing works - as a whole! That's why craving control can be achieved either through psychological or chemical pathways. All roads lead to Rome, don't they?

You might say: "but what about the withdrawal effects, what about tolerance?" Again, everything you feel or think or do, has a physical/physiological manifestation.

If you want to have a sip of coffee, the thought "I want some coffee" translates into a complicated physiological cascade until this thought of yours eventuated in a motor behavior of your hand picking up a cup of coffee from a table and bringing it to your lips. If you drink coffee a lot, then eventually your bodymind adjusts to this ongoing and habitual intake of caffeine.

Namely (you are better off skipping this psychophysiological mumbo-jumbo straight from Wikipedia unless you've already had a cup of coffee yourself this morning): "Because caffeine is primarily an antagonist of the central nervous system's receptors for the neurotransmitter adenosine, the bodies of individuals who regularly consume caffeine adapt to the continual presence of the drug by substantially increasing the number of adenosine receptors in the central nervous system. This increase in the number of the adenosine receptors makes the body much more sensitive to adenosine, with two primary consequences. First, the stimulatory effects of caffeine are substantially reduced, a phenomenon known as a tolerance adaptation. Second, because these adaptive responses to caffeine make individuals much more sensitive to adenosine, a reduction in caffeine intake will effectively increase the normal physiological effects of adenosine, resulting in unwelcome withdrawal symptoms in tolerant users" (Wikipedia).

My point?

Just because we are not consciously supervising all this psycho-physiological re-calibration, it doesn't mean that it is a disease. When I cry, I do not consciously direct my tear glands to produce water. Nor do I instruct my circulatory system to divert a pint of blood to my face when I feel embarrassed. That's just what happens. The Cartesian mind-body paradigm of modern medicine, particularly, addiction medicine, latches on to the fact that what we do has a physiological signature and imbues it with the significance of the disease.

Just because my body reflects the workings of my mind in the mirror of flesh it doesn't mean that these workings are independent and uncontrollable. To think of addiction as a disease (rather than a habit with a physiological signature) is to presuppose a ghost in the (human) machine.

You might object: "But don't you see, drug use changes the bodily chemistry... Haven't you read the very passage you posted from Wikipedia... See, here they say, the increase in the number of adenosine receptors... These are actual structural changes!"

Yes, they are, indeed, structural changes. Real as they can be. Some structural changes are reversible as the postural crossing of the legs as I adjust my posture in the chair. And some, not so much: as you alter the pigmentation of your skin with the tat of your girl-friend's name on your shoulder.

The body documents what the mind does and the fact of this physiological signature is not a disease but a reality of our corporeal psychosomatic organization.

But let us get back to the point of this blog (and, by the way, if you want a more definitive de-construction of the Disease Model, read Stanton Peele's "Diseasing of America" and Jeffrey Schaler's "Addiction is a Choice;" while at it, you might also check out Santoro's "Kill the Craving" exposure-response prevention protocol).

So, the "steps." I am not opposed to them. In fact, I clinically treasure the vast networking and support resources the 12 Step paradigm has on tap for the folks embarking on recovery. But three of these steps, in my opinion, could stand a bit of revision.

With the above considerations in mind, the 1st, 2nd, and 11th Steps of the 12 Step approach could be reformulated as follows:

Step 1: "We admitted that while our minds become unmanageable when we are intoxicated, and while we are powerless over having an occasional conditioned craving for drugs and/or alcohol, we do have the power to control our cravings and thus to prevent drinking/using episodes in the future."

*It is, of course, true that once intoxicated, a person's capacity to render effective, strategically-savvy decisions is debilitated to the extent proportionate to the degree and type of intoxication as well as to the degree of one's metabolic processes and tolerance. Consequently, a person is powerless over drugs and/or alcohol when he or she, in fact, ceases to exist as an intact psycho-physiological entity that he or she is at a non-intoxicated baseline. That, however, does not mean that once the person sobers up he or she is powerless to prevent future substance use. The extent of your intoxication yesterday has nothing to do with whether you will or not control your craving to use again tomorrow. Sure, it's harder to control your cravings when you are "jonesing" than when you are not: but harder doesn't mean impossible...

Step 2: "We came to know that we, ourselves, could restore us to our functional baseline**"

**Note that in paraphrasing step 2, I have replaced the phrase "restores to sanity" with "restore to functional baseline." The term "sanity" implies that substance use is madness and therefore retrospectively invalidates substance use as a legitimate, albeit imperfect, form of coping. After all, in order to change, clients need a belief in their sanity; any implication of prior insanity only contributes to unnecessary sense of hopelessness. After all, if past predicts the future, then past insanity predicts future insanity. Clients should not be robbed of their phenomenology as being rational.

Step 11: "Sought through mindfulness meditation (or other craving control) to improve our conscious contact with ourselves and to control our cravings"

Re-processing of the Powerlessness legacy in such a way may allow the client with strong prior allegiance to the 12 Step philosophy to retain a modified version of the steps. Most of the 12 Steps, in my opinion, definitely take a person in recovery in the right direction. But, as the evidence on the use of mindfulness in craving control suggests, perhaps, it's a good idea to take a few mindful steps and then to sit down in Zazen (Buddhist "sitting meditation") once in a while.

So, to all of you, well-intentioned and hard-working steppers: march on! Just don't goose-step past the obvious. You have the power to control your cravings. Craving is but another train of thought: step aside and sit down....

The journey of recovery, a millions steps no less!, perhaps, begins with, first, sitting still - transfixed in meditation...

I wish you well in your struggle for self-empowerment.