Below is a link to a lecture given by Dr. Gabor Maté to a Canadian First Nation group. He gives a great overview of some of the science behind substance addiction. He also gets to the root of passing the behavior to our children. This lecture is very educational and explains some of the “causes and conditions” that lead from substance use, to abuse, to addiction.

http://www.youtube.com/watch?v=BpHiFqXCYKc

This is a great example of a professional in the drug treatment industry with an enlightened view: examining not only the symptoms, but also the “causes and conditions” that lead to substance abuse. By understanding why we behave as we do, we can learn new skills and retrain how we think. Through this understanding and acceptance we can overcome self destructive behavior.

Thank you to Darren Littlejohn, The 12-Step Buddhist, for passing this video on to me.

About Dr. Maté: Vancouver, Canada-based physician and author. He is staff physician at the Portland Hotel Society, which runs a residence and harm reduction facility as well as Insite, North America’s only supervised safe-injection site. His four books, all bestsellers in Canada, include Scattered: How Attention Deficit Disorder Originates and What You Can Do About It, When the Body Says No, and his latest, In the Realm of Hungry Ghosts: Close Encounters with Addiction.

Before you begin to make changes in your life, it might be useful to understand the process. The theory called the Stages of Change Model (SCM) describes the mind/body stages we go through when we do change.

James Prochaska, Ph.D and Carlo Diclemente, Ph.D (1982) developed SCM  in the late 1970’s and early 1980’s while at the University of Rhode Island. They were studying how smokers were able to give up their habits. The model has been applied to a broad range of behaviors including weight loss, injury prevention, overcoming alcohol, and drug problems among others.

This a model of change which is unique in many ways. First, it is empirically driven: it is based on the researchers’ scientific investigation of change in humans. Second, the model conceptualizes change as entailing a number of stages which all require alterations in attitude in order to progress. Third, the model depicts change as a cycle, rather than an all or nothing step or series of steps. The authors contend that it is quite normal for people to require several trips through the stages to make lasting change. Additionally, each of us progresses through the stages at our own rate.

One of the reason the SCM is attractive, is that it recognizes change as flexible to individual needs. Some people make lasting change quite rapidly, others require a few times through the stages to acquire more knowledge and build skills. Just as some can master skiing on the first try, others require a couple of seasons to get to the intermediate level.

In this sense relapse can be viewed as a normal part of the change process, as opposed to a complete failure. This does not mean that relapse is desirable or even invariably expected. It simply means that change is difficult, and it is unreasonable to expect everyone to be able to modify a habit perfectly with out any slips. Relapses can vary in severity, as can our reactions to them. Some relapses can be so discouraging that people return to a precontemplative stage for a long time before contemplating change again. Others get right back on track, considering the antecedents to relapse, where they need to put more effort, and swiftly move back into action again.

We enter the stages of change from a state of precontemplation– during which the idea of change is not seriously considered. The cycle begins when we start to contemplate the need for change. Hopefully we will tip the scales in favor of change and become determined to take action. Then specific alterations in thinking and behaving will be initiated. It is hoped that the alterations become accepted and eventually ingrained or automatic. If we are able to maintain our accomplishments, we can exit the cycle entirely.

The Stages of Change

In brief, the stages of change are:

• Precontemplation – Not acknowledging that there is a problem behavior that needs to be changed.
• Contemplation – Acknowledging that there is a problem but not yet wanting to make a change.
• Preparation - Planning to make the changes.
• Action - Actively changing behavior and thoughts.
• Maintenance – Maintaining the behavior change.
• Lapses - Returning to old behaviors and abandoning the new changes. This can happen at any point in the stages.

Stage One: Precontemplation

In the precontemplation stage, people are not thinking seriously about changing and are not interested in any kind of help. People in this stage tend to defend their current bad habit(s) and do not feel it is a problem. They may be defensive in the face of other people’s efforts to pressure them to quit. They do not focus their attention on quitting and tend not to discuss their bad habit with others. It would be easy to call this “denial,” but a much more accurate view would be to describe Precontemplation as a state when a person is “uninformed” in the sense that no personally convincing reason for change has been presented as of yet. In this stage people simply do not yet see themselves as having a problem.

Stage Two: Contemplation

In the contemplation stage, people are more aware of the personal consequences of their habit. They start to think about their problem. Although they are able to consider the possibility of changing, they tend to be ambivalent about it. In this stage, people are weighing the pros and cons of quitting or modifying their behavior. Although they think about the negative aspects of their bad habit and the positives associated with giving it up (or reducing), they may doubt that the long-term benefits associated with quitting will outweigh the short-term costs. It might take as little as a couple weeks or as long as a lifetime to get through the contemplation stage. On the plus side, people are more open to receiving information about their bad habit. They become more likely to use educational interventions and reflect on their own feelings and thoughts concerning their bad habit.

Stage Three: Preparation

People in the preparation/determination are planning to take action and are making the final adjustments before they begin to change their behavior. Their motivation for this change may be reflected by statements such as: “I’ve got to do something about this. What can I do?”

This is sort of a research phase as they start taking steps toward cessation of their behavior. They attempt to gather information about what they will need to do to change their behavior, or seek help to understand how to successfully change. At this stage it is important to gather resources and knowledge that will help with success.

It is also important to establish a goal which works with you. A goal which is reasonable for one person, may be unreasonable or inadequate for another. Our goals must be consistent with our capabilities, our values, and our needs. Sometimes, especially by experts in the field of addiction treatment, a successful outcome is mandated as the only realistic goal.

Too often, people skip this stage: they try to move directly from contemplation into action and fail because they haven’t adequately researched or accepted what it is going to take to make this major lifestyle change. For example, many people with intentions for change believe that they must undergo a drastic lifestyle and identity change in order to alter a habit. For example, many recovering substance abusers believe that they must abstain not only from the substance they have abused, but also from all past behaviors, deny all pleasure, and assume a stoic lifestyle. Rarely is this drastic a lifestyle change necessary, or even ideal for lasting change. Often with this “all-or-nothing” approach to change, is that people find that it is virtually impossible to bare, or that they just hate it. They eventually become discouraged and stop the whole change process.

So, at this stage, it is important to examine what specifically you want to modify in your life, and what about your lifestyle is better left unchanged. Understand what you want to change, the motivation for the change, and most importantly, have a destination or way-point defined so that you can recognize the change.

Stage Four: Action

This is the stage where people not only have a desire to change, but also believe they have the ability to change their behavior and are actively involved in taking steps to change their behavior.

The amount of time people spend in action varies: but, in general it lasts about 6 months. This step requires the greatest commitment of time and energy. Mentally, they review their commitment to themselves, practice new skills, and develop plans to deal with both personal and external pressures that may lead to slips. They may use short-term rewards to sustain their motivation, and analyze their behavior change efforts in a way that enhances their self-confidence. People at this stage also tend to be open to receiving help and are also likely to seek support from others: this can be a very important element.

As people make conscience efforts to quit or change the behavior, they are at greatest risk for relapsing to old behaviors. Being mindful of triggers, and the reactions to them, is important. This is where actively building skills, changing thoughts toward the old behavior, and developing alternative coping behaviors comes in to play.

Stage Five: Maintenance

Maintenance involves being able to successfully practicing new skills and avoiding the temptations to return to the old habit. The goal of the maintenance stage is to maintain the new status quo. People in this stage tend to remind themselves of how much progress they have made, while still being cognizant of what it took to make the change.

People in maintenance constantly reformulate the rules of their lives and are acquiring even more skills to deal with life and avoid relapse. They are able to anticipate the situations in which a relapse could occur and prepare coping strategies in advance. They remain aware that what they are striving for is worthwhile and personally meaningful. They are accepting of themselves and recognize that it takes time to let go of old behavior patterns and to become proficient at new ones: realizing that ultimately the new behavior will become as comfortable to live with as the old. Even though they may have thoughts of returning to their old bad habits, they resist the temptation and stay on track.

As you progress through your own stages of change, it can be helpful to re-evaluate your progress in moving through these stages.

Lapses

Along the way to permanent cessation of a habit, many people experience a lapse. These are often accompanied by feelings of discouragement and seeing oneself as a failure.

There is a real risk that people who lapse will experience an immediate sense of failure that can seriously undermine their self-confidence. One of the most significant problems with the 12-step model is the all-or-none manner in which lapses are construed. Regardless of the intensity, slips and lapses have been viewed as failure, time to “start over.”

It is important to remember that experiencing a lapse is common.  In fact, most successful self-changers go through the stages three or four times before they make it through successfully without a lapse. Many will return to the contemplation stage of change; others return to the planning stage to implement what they have learned from the lapse. Consequently, the Stages of Change Model considers a lapse to be normal.

Rather than seeing a failure, analyze how the slip happened and use it as an opportunity to learn how to cope differently. People who lapse may need to learn a more effective ways anticipate high-risk situations, control environmental cues that tempt them to engage in their bad habits,  learn how to handle unexpected episodes of stress, or redefine their personal boundaries. Analyzing what happened gives a stronger sense of self control and the ability to get back on track. In fact, relapses can be important opportunities for learning and becoming stronger.

Transcendence

In addition, there is one more stage that Marc Kern Ph.D., CAS added which is not part of Prochaska-DiClemente original Stages of Change model: Transcendence.

Eventually, if you “maintain maintenance” long enough, you will reach a point where you will be able to work with your emotions and understand your own behavior and view it in a new light. This is the stage of “transcendence.” In this stage, not only is your old habit no longer an integral part of your life but to return to it would seem atypical, abnormal, even weird to you. When you reach this point in your process of change, you will know that you have transcended the old habits and that you are truly becoming a new “you”, who no longer needs the old behaviors to sustain yourself.

References

DiClemente, C. C. & Prochaska, J. O. (1982). Self-change and therapy change of smoking behavior: A comparison of processes of change in cessation and maintenance. Addictive Behaviors, 7, 133-142.

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.”