When seeking help with substance use problems, people often cite the stigma associated with seeking help as a barrier. The common ways of describing individuals with such problems may perpetuate or diminish stigmatizing attitudes, yet little research exists to inform this debate.

John F. Kelly, Ph.D., associate director of the Massachusetts General Hospital’s (MGH) Center for addiction Medicine, notes that the World Health Organization declared the term “abuser” as stigmatizing three decades ago, but the term is still commonly used to describe people with addictions to illicit drugs.

Kelly recently took part in a scientific study to determine whether or not using different  labels evokes different judgments about behavioral self-regulation, social threat, and treatment vs. punishment. In the study, Kelly and colleagues surveyed more than 700 mental-health professionals attending a conference on addiction and mental illness. Half of the a survey referred to a hypothetical patient as a “substance abuser,” while the rest received a survey referring to the patient as having a “substance use disorder.” The surveys were otherwise identical.

The study found no differences between groups on the social threat or victim-treatment sub-scales. However, respondents who received the “substance abuser” version were more likely to say that the patient should be punished for failing to follow a treatment plan and to agree that the patient shouldered blame for having trouble complying with court-ordered treatment requirements.

The study concluded that even among highly trained mental health professionals, exposure to these two commonly used terms evokes systematically different judgments. The commonly used “substance abuser” term may indeed perpetuate stigmatizing attitudes. Whether individuals or mental-health professionals are conscious of it or not, this study suggests that this term perpetuates that kind of thinking.

According to Kelly, “From the perspective of the individual sufferers, who often feel intense self-loathing and self-blame, such terminology may add to the feelings that prevent them from seeking help.”

So, in our own recovery, how we identify ourselves may matter. If we choose, or have forced on us, terms like “alcoholic” or “drug abuser,” we may be buying into a negative stigma. If we choose to use a more technically accurate identifier, such as having a “substance use disorder,” we may be able to break free of old stigmas. We are then better able to focus on our own empowered recovery, without all that stigma.

The study was published in the International Journal of Drug Policy.

That voice we all hear in our head telling us to engage in destructive behaviors can be very convincing: it will try to rationalization, make up excuses, and lie relentlessly to get its way. So how do we fight giving in? Most people understand how to win an argument with a two-year old: don’t argue. Similarly, the way to fight an urge is to not argue with it. Put your foot down, and say NO to the urge. Instead of arguing with every well rehearsed reason the urge will throw at you, engage in a different conversation with yourself.

DISARM

Destructive Self-talk Awareness and Refusal Method (DISARM) is a tool which exposes the self-talk and images which tell us to use. It challenges those urge-producing thoughts at every opportunity, shooting them down and eventually reducing them to the point of absurdity. All humans, not just humans with substance abuse problems, have thoughts, urges, or other impulses, which, if followed, would harm their long-term interests. Realizing the power to control what we think and believe, especially about our strong urges to use, and understanding how to change the distorted thinking is crucial to success.

“It is a man’s own mind, not his enemy or foe, that lures him to evil ways.” ~Siddhārtha Gautama

We are wise to learn how to make ourselves aware of our destructive self-talk: the thinking that is contrary to our values and long-term interests. Once we recognize it, we can then adamantly refuse to go along with it.

When a strong urge is recognized, ask and answer the following questions:

1. Question: Do I have to give in to the urge because it is intense and hard to resist?
   Answer: No, I don’t have to give in. Because the urge is strong, it would be easy to give in, but I don’t HAVE TO. I have had urges that I did not give in to, therefore it must be possible to resist.
2. Question: Will it be awful to deny myself by not giving into the urge?
   Answer: No, it won’t be awful. It may be quite unpleasant, but unpleasant is not awful, it’s just unpleasant. If I don’t give in to the urge, it will get weaker and come less frequently. If I do give in, the urge will stay strong, be harder to resist next time and show up more frequently.
3. Question: Is it really unbearable not to give into this urge?
   Answer: I don’t like the way it feels to deny my urge, but since it doesn’t kill me not to give in, I can keep on resisting. (Remember, individuals drinking large amounts of alcohol may need to go to a detox center when they first stop because the sudden end of alcohol really could be injurious.)
4. Question: Am I somehow entitled to be able to give up using without strong urges to go back to using?
   Answer: No! I don’t have a note from God, my mother, or anyone else which entitles me not to have strong urges to use. It may be unpleasant to resist some of my urges, but no one gave me a ‘get out of unpleasantness free’ card.

We cannot simply will ourselves to not have certain thoughts and feelings. However, we can learn how to recognize the thoughts driving urges and how to refuse to go along with them: we can learn to DISARM them. We can then walk away from the situation, or get our mind involved with something else, rather than dwelling on the urge to use. DISARM allows the individual experiencing the craving and to carefully and rationally answer a few key questions. The results of using DISARM will help an individual to understand that urges can truly be overcome. As success is experienced, the urges will eventually become less strong and will occur less frequently.

DISARMING the ‘ENEMY’

Some people find it helpful to use a technique to dissociate themselves from the voice inside each of us which says, ‘It’s a good idea to do something self- destructive.’ It is a game you can play with yourself, which might help you to:

1. Identify the specific thoughts which, if followed, would lead to using when you have already decided that, in the long term, this choice is not for you, and
2. Steadfastly refuse to go along with this thinking no matter how attractive it might seem.

Instead of talking yourself into lapsing you can develop powerful countering and coping statements. To do this, it may help to invent and personify an ‘enemy’ who lives in your mind, and whose only purpose is to get you to use. The Enemy (your alter ego) knows you well, and can change form to take advantage of your weakest moments. Name your enemy (i.e., salesman, gangster, diplomat, bad cop). When urges come, ask yourself, ‘What is she/he telling me now? How is she/he trying to trick me?

When thoughts are identified:

1. Without debate, ATTACK the enemy with powerful counter statements: ‘Nice try, jerk. You can’t fool me!’ You can be as aggressive or profane as your nature allows with the Enemy – after all, it’s trying to screw up your life.
2. Then quickly FOCUS on some other thoughts, images, or activities which are consistent with what you want in the long run and inconsistent with what the Enemy is saying. The Enemy then looses its perceived power and fades away.

Once the urge has passed, you can submit the Enemy’s tricks to an ABC analysis in order to rationally dispute them. You usually discover irrational themes and patterns to the thoughts and arguments the Enemy throws at you. While the coping statements used in DISARM alone will often work, it is important not to omit disputing. If your coping statements aren’t working, it is because you don’t believe them as strongly as you believe the Enemy. Through disputing we can develop powerful coping statements you fully believe for use in the future. Through actually resisting the Enemy’s suggestions, you become increasingly more skilled at doing it.

By Tim Townsend
Originally published by ST. LOUIS POST-DISPATCH January 30th, 2010

By the end of January, plenty of New Year’s resolutions have been broken.

For those who have ignored pledges to hit the gym every day, or stay away from “American Idol,” a broken resolution is little more than an annual defeat of the will. But for people trying to get their alcohol problem under control, a broken resolution can have devastating consequences.

Alcoholics Anonymous, with 2 million members worldwide, is the largest organization people turn to when they recognize they have a drinking problem. But the religious overtones in AA’s famous “12 Steps” — with their focus on God and the powerlessness of the individual — can be jarring to those whose vision of faith differs from AA’s.

“I knew there was no way in hell this was going to work for me,” said Donna Dierker, a Creve Coeur neuroscientist who considers herself agnostic and who tried AA when she wanted to moderate her drinking in 2002. “I was just ideologically opposed to the 12 Steps.”

Some who struggle with alcohol also struggle with the notion of surrendering to a supernatural force in order to solve their problems — a key component of AA’s 12-step program.

They cringe at the idea that they are powerless to help themselves, and that they must rely on something they don’t believe in to gain control over their lives. Those two ideas are contained in AA’s first two steps:

“Step 1: We admitted we were powerless over our addiction — that our lives had become unmanageable. Step 2: (We came) to believe that a power greater than ourselves could restore us to sanity.”

Dierker — and many others turned off by the religious content of AA — have turned to other programs. Dierker opted for Moderation Management (MM), which calls itself a “behavioral change program.” In language starkly different from AA’s, MM says it “empowers individuals to accept personal responsibility for choosing and maintaining their own path, whether moderation or abstinence.”

AA, which was founded 75 years ago, has roots in a Christian movement called the Oxford Group. It describes the 12 steps — seven of which mention God or spirituality — as the “heart” of the organization’s recovery program. But it also makes it clear that “newcomers are not required to accept or follow” them.

AA also has 12 traditions, or principles — first adopted in 1950 — one of which says: “For our group there is but one ultimate authority — a loving God as He may express Himself in our group conscience.”
MM comes at the problem from a different angle. It relies on research from organizations such as the National Institute on Alcoholism and Alcohol Abuse, and spirituality doesn’t enter the picture. Nearly all of MM’s advisers and directors are doctors.

On a recent Sunday, about 20 people sat in a dark room at the Ethical Society of St. Louis in Ladue watching Dierker work her way through a PowerPoint presentation about moderating problem drinking. Afterward, the discussion continued at a nonalcoholic beer-tasting in the next room.

MM is largely an online network, and therefore its popularity is difficult to measure, but there are face-to-face MM meetings around the country, too. Dierker started one in St. Louis about a year ago; in August, the meeting moved to the Ethical Society every Wednesday evening. Not everyone who attends MM meetings is a secularist, and some who attend also go to AA meetings.

AA says it “is not allied with any sect, denomination, politics, organization or institution,” but court opinions have been mixed on the issue.

In March, a Pennsylvania appellate court ruled that AA was not protected by religious land use laws because it could not be considered a religious organization.

“The fact that the 12-step program is used and it contains references to ‘God’ and a ‘Higher Power’ does not mean that all members believe that they are partaking in a religious experience when they are attending an AA … meeting,” according to the ruling.

But in 2007, the 9th U.S. Circuit Court of Appeals in San Francisco said that, because of AA’s religious content, prison inmates could not be coerced to take part in AA meetings as a condition of their release.

Many AA meetings are held in church and synagogue basements around the country. Rabbi James Goodman runs a hybrid meeting called Shalvah (“serenity” in Hebrew) at Neve Shalom, a Jewish Renewal Community temple in unincorporated St. Louis County.

“The purpose is to create a bridge between the 12-step model and the traditional spiritual resources of Judaism,” Goodman said.

The meeting, held on Thursday evenings, attracts from 20 to 40 people, about half of whom are Jewish, according to Goodman.

Moderation Management is not the only group that has taken God completely out of the recovery process.

James Christopher is the founder of S.O.S. — Secular Organizations for Sobriety. Christopher said S.O.S. will celebrate its 25th anniversary this year, and he calls the group the “largest and oldest secular alternative to Alcoholics Anonymous.”

“We have a self-empowerment approach, rather than faith-based approach,” Christopher said. “But we’re not anti-religious.”

Ginger Frank, an addiction therapist at Jefferson Barracks, runs a meeting for veterans called SMART Recovery. On its website, SMART Recovery says it has “a scientific foundation, not a spiritual one,” and “teaches increasing self-reliance, rather than powerlessness.”

Unlike MM, SMART Recovery — which has about 300 meetings worldwide compared with about 90,000 AA meetings — is an abstinence program. Frank said there are several people in training to be SMART Recovery coordinators in the St. Louis area, and there are likely to be other meetings outside Jefferson Barracks soon.

“We don’t encourage the concept of powerlessness at all,” Frank said. “We can prove to people that they do, in fact, have power over their addiction. If they’re in jail, they’re not using. If they’re in the hospital, they’re not using. They do have a choice.”

Why do we harm our selves by choosing destructive habits? Is it because things like alcohol and drugs have some mysterious power to control us? No. We choose our actions based on our experiences, our habits, and the way we think. If we want to change our destructive behavior we must change; we must learn to choose different solutions to our problems.

“Our liquor was but a symptom. So we had to get down to causes and conditions.” ~William G. Wilson, The Big Book, page 64.

We can simply choose to avoid the substances and experiences that are destructive. I have heard the term “white knuckling it” to describe this solution: it is uncomfortable, difficult, and usually leads back to our destructive behavior as a way to relieve the pain. We must understand that we choose those behaviors because on some level, they work. When we simply stop the behavior without finding a more beneficial alternative, we suffer. Avoidance does not eliminate the underlying thoughts, beliefs, and lack of knowing of alternatives behaviors that drew us to the destructive behavior in the first place.

In this video Sogyal Rinpoche discusses how the mind works to perceive the world around us. As he explains, we must look inward to get to the root of suffering rather than focusing on the external symptoms. We can change to address the causes of our condition, and we can address the real problem we were trying to fix with our destructive behavior.

“All men’s miseries derive from not being able to sit in a quiet room alone.” ~Blaise Pascal

To explain some of the terms used in this video for the non-Buddhists: “Samsara” refers to a general state of overt or subtle sufferings that occur in day to day life. “Nirvana” is the state of being free from that suffering.

Thank you to Darren Littlejohn, The 12-Step Buddhist, for acquainting me with Sogyal Rinpoche’s videos.

I am often asked if Buddhists pray, and if so, to whom. In this short video Sogyal Rinpoche explains the role of prayer in Tibetan Buddhism, and how it relates to, and differs from, the western religious understanding of prayer.