#12 Willpower

The role of willpower is probably the most controversial issue in discussions of addiction, its roots, and recovery. Initially some views seem contradictory. On one hand are those that see addiction as merely another disease and feel the individual is no more responsible than having  any other disease. On the other hand are those who talk about free will and choice, and that addiction is simply a choice.The discussion often polarizes into "either or" options. I would like to suggest that another option might follow a "both and" discussion as there are contradictions in both schools of thought.

Some diseases do involve choice. For example heart disease and cancer can be influenced by smoking or diet. On the other hand there is no choice involved in diseases like cystic fibrosis, muscular dystrophy or babies born addicted. Addiction is progressive and in its advanced stages it becomes impossible to recover by the unaided will. I meet folks who are so damaged by life and addiction that even after losing everything and almost dying a number of times from overdosing, they still continue to use.

I have also heard the discussion that addicts lack willpower or they would straighten up. The reality is that generally addicts have more than an abundance of willpower. In early addiction this can be evidenced by drinking all night and still showing up at work the next day. Addicts generally attempt to exercise control in all their relationships. However as the addiction progresses (part of the disease concept) the will becomes hijacked by what the chemicals are doing in the brain. (posts #10 and #11).

Post #3 discussed the "Spirituality of Addiction." Dallas Willard writing in the Journal of Spiritual Formation and Soul Care adds: The spirit is the will of the heart, which, lives mainly in our bodies. One of the ironies of spiritual formation is that every "spiritual" discipline involves bodily behavior. We have to involve the body  because that is where we live and what we live from. Spiritual formation is formation of the "inner" dimensions of the human being, resulting in transformation of the whole person, including the body in its social context.

Will operates in the physical body as well as the spirit in this sense of will being part of heart, spirit, character and choice. Addiction is a condition that originates initially in the pleasure / pain location of the primitive brain. Pleasure and avoidance of pain is experienced in the body leading eventually to craving. Progressively, individual will and choice are surrendered and overpowered by the addiction.

Dallas Willard discusses the issue of will in three categories: The impulsive, reflective and embodied.

·       Impulsive: This exercise of will generally originates in the instinctive part of the primitive brain and moves towards things that are attractive or trigger curiosity. It generates exploration but requires little forethought (which originates in the neo-cortex). For example we safe guard electric sockets knowing that small children impulsively stick a fork or their fingers in them. In adults it is simply choosing what is desired without using reason (eg. impulse buying).

·       Reflective: Experiencing either negative or positive experience from an impulsive act, we reflect on the consequences or rewards of an impulsive act and evaluate if the activity is in our best interests before acting on it.

·       Embodied: Desires have enslaved the will and

     bypass reflection or moments of clarity as now

     their body is running their life in terms of desire

     and the pursuit of pleasure.     

For some, impulsively experimenting with addictive substances leads to addiction characterized by the absence of reflection or moments of clarity about their use of addictive substances or behaviors.

I think another error in our thinking can be generalizing the role of will in addiction and not understanding that the role of will is distinctive in different stages of addiction. These stages will be discussed in the next blog.

#11 Neurotransmitters

A neuron (nerve cell) is an electrically excitable cell that processes and transmits information through electrical and chemical signals. Neurotransmitters are the brain chemicals that communicate information throughout our brain and body by relaying signals between neurons. The brain uses neurotransmitters to tell your heart to beat, your lungs to breathe and your stomach to digest.  Most importantly for our consideration, they affect mood. They are the parts of the central nervous system most affected by psychoactive drugs and other addictive behaviors like gambling, pornography, binge eating etc. Addiction triggers and magnifies the sensations or feelings that have a natural counterpart (neurotransmitters) in the body.

Dopamine is often known as the reward neurotransmitter as it triggers feelings of pleasure. If something feels good, dopamine is involved. All psychoactive drugs increase the levels of dopamine which is experienced initially as mood elevation and euphoria. Dopamine also helps regulate fine motor muscular activity and blocks pain. For example, it is exciting to win a race but with a stimulant drug like methamphetamine it would be ecstatic or 8 times as pleasurable.  In the early times of the Civil War, drinking alcohol was the only anesthetic for amputations and other painful surgeries. When someone ingests too much alcohol their muscular movements are affected by the flood of dopamine. The neo-cortex and sound judgement gets hijacked and numbed. (see Post #10, Addiction and the Brain)

Norepinephrine and Epinephrine (adrenaline) are strongly associated with bringing our nervous systems into "high alert." They increase our heart rate and our blood pressure. Our adrenal glands naturally release them into the blood stream. Stimulants like methamphetamine trigger these two neurotransmitters as well as dopamine. With large doses of meth, addicts can become so "over alert" they hallucinate visually and hear noises that don't exist. They can exhibit classic symptoms of paranoia. Rapid movements and nonsensical speech are also symptoms. All the basic instincts that reside in the primitive brain are exaggerated (particularly aggression and the sexual drive).

Endorphin is short for endogenous morphine. It is structurally very similar to the opioids (opium, morphine, heroin, oxycontin, codeine, percodan etc.) and works by attaching to the endorphin receptor sites. It creates pain reduction as well as pleasure. Endorphins are produced by the pituitary gland and the hypothalamus which are part of the neo-cortex as opposed to the other potential addictive neurotransmitters being part of the primitive brain. (see Post #10, Addiction and the Brain). This is one reason why it is so difficult to diagnose opiate addiction, as there is little loss of motor control as there is with dopamine (staggering, slurred speech and impaired vision etc.) An exception would be an overdose of opiates characterized by nodding off. Dilation of the pupils is about the only visible symptom, and often opiate abusers wear sun glasses as their visual perceptions appear so bright. 

Serotonin is an inhibitory neurotransmitter that is intimately involved with emotion and mood. Depletion of serotonin is related to depression, problems with anger control, and obsessive-compulsive disorders. Hallucinogens such as LSD, mescaline, psilocybin and ecstasy attach to serotonin receptor sites and block transmissions in perceptual pathways distorting perception of reality. 

Anandamide is has an affinity for receptor sites that accommodate THC (Tetrahydrocannabinol) the main ingredient in marijuana. It is found in the limbic system of the primitive brain and the areas responsible for integration of sensory experiences with emotions.  Long term studies continue to show that marijuana can become addictive and long term use affects learning, motor coordination, and memory.

In summary, drugs and other addictive behaviors imitate the brain's natural chemical messengers and over stimulate the reward circuit of the brain. With our understandable concerns about addiction the rates of addiction must be put in perspective. Addiction takes considerable time to develop. 1% of first-time users of inhalants and tranquilizers were addicted a year later. For hallucinogens and sedatives the figure was 2%, pain relievers and alcohol 3%, powder cocaine 4%, uppers 5%, marijuana 6%, crack cocaine 9%  and the most addictive was heroin at 13%. The greatest predictor of addiction is the age of first use.

Addicts are searching for a means of dealing with psychosocial stress associated with developmental psychological stress and social dislocation. (See blog # 7, Dislocation) The addict is drawn to a culture which promises to complete these unfinished tasks and this influences their drug of choice. Opiate users are drawn to themes of nurturing and support. Stimulant users are drawn to themes of autonomy. Hallucinogen users are drawn to themes of inclusion and belonging. Alcohol users are drawn to themes of will and power. The cultures of technology are sufficiently broad as to offer the psychological rewards of all the cultures of substance abuse combined. Ross Laird.com

My next post will explore the role of willpower in addiction.

#10 Addiction & the Brain

The brain is a 3 pound mass of interwoven nerve cells and one of the most magnificent and mysterious wonders of creation. It is the supervisory center of the nervous system serving as the site of thought, emotions, memory, and self-awareness. By means of electrochemical impulses, the brain controls our conscious, voluntary behavior and the autonomic nervous system through its feedback circuitry regulating the physiological functions of the body. The blood-brain barrier provides protection against toxins, bacteria, and other pathogens, but all psychoactive drugs are able to pass through.

The advent of eleven different brain measuring scans allow neuroscientists to explore the structure and workings of the living brain. There are a variety of ways to describe the different parts and functions of the brain. In the interests of simplicity in understanding addiction, we will use the terms "primitive" and "neo-cortex." The primitive brain controls the autonomic system but also equips the experiencing of our basic instinctive emotions such as fear, hunger, anger, pleasure and lust. The neo-cortex processes information from the primitive brain as well as conscious voluntary behavior, cognition, and memory. It tries to make sense of the feelings and instinctive drives coming from the primitive brain. Imagine someone craving a drink of water which originates in the primitive brain. In response, the neo-cortex will organize a way to get it. 

The primitive brain is located at the base of the skull including the brain stem and is much smaller than the neo-cortex. One might reason because of the major difference in size, the neo-cortex would be in control. This is not the case. During stress we try to resist impulses to resort to instinctive or primitive behavior often characterized by the flight/fight syndrome. A balanced life requires healthy interaction  between these two parts of the brain. 

The role of the nucleus accumbens, generally described as the pleasure / reward center, is our last consideration of the primitive brain and is key to understanding the impact of alcohol and other drugs on the whole brain. Although it has traditionally been studied for its role in drug addiction, it plays an equal role in processing many other rewards such as food, sex, gambling, and other compulsive behaviors which are now recognized as  addictions. (See current definition of addiction in Post #1)

Neurotransmitters are chemicals in the central nervous system that transmit messages between nerve cells. Over a hundred of them help regulate the body’s natural stimulants, painkillers, mood stabilizers, muscle relaxants, arousal, sleep, aggression, and all other functions of the central nervous system. Drugs increase or block the release of these naturally occurring neurotransmitters. 

Alcohol and other drugs create sensations or effects that have a natural counterpart in the nervous system. They trick and over stimulate the release of the body’s natural chemicals, which then “flood” and "hijack" the central nervous system. Drugs don’t get one intoxicated; they trigger the release of a surplus of the body’s own chemicals at levels which are intoxicating. 

With this background, in my next post we will begin to explore drugs of choice and what part of the brain they take hostage.  

#9 The RSAT Program

I moved to Roseburg OR. in 2002 to become the lead counselor for a program funded by the Federal Gov't called RSAT (Residential Substance Abuse Treatment). It was conducted in the Douglas County Jail and those referred were facing prison terms for drug related crimes. It was a co-ed program with the clients living in dormitories. These were was connected to a classroom where we conducted the program keeping the number of clients to 15. If the clients completed the program, and committed no further crimes or major probation violations after treatment, they could avoid a prison term. Duration of treatment varied from a 6 month minimum to 9 month maximum depending on our evaluation of their progress. Intensive aftercare for at least a year followed treatment. The program was based on the data that with long term treatment there is no difference in the rates of recovery between those who volunteer or are forced by the courts.

In our best year, 61% of those completing inpatient treatment were still clean and sober after a year. One client was arrested for a DUI right after release from jail and was sent to prison but this was the only criminal violation that year. The Federal Supervisors did not trust our figures, as that rate is unheard of. Any program that has 20% - 30% of clients still clean and sober after a year is considered successful, and the criminal recidivism that low was also unheard of. They sent a small team to investigate for a week, sitting in our process, and ended up taking our treatment model back to Washington DC as a model for future grantees. 

The program was solid, using a model of individual therapy in group dealing with developmental trauma, a strong emphasis on the 12 steps of A.A., accountability personally and to the group, an educational emphasis with treatment plans on addiction, and a strong emphasis on family involvement. Some new clients chose going to prison and rolled themselves out of the program as it was not a softer, easier way. But, that wasn't what made the program so successful. 

In retrospect, the success was because of a "perfect storm" of cultural / social support discussed previously in my posts on "Proximity" (#5 and #6). Roseburg is a small town with about 21,000 which meant there was little funding competition for social services that unfortunately often occurs in larger cities.  My female co-therapist and I had an incredible professional relationship balancing each other's strengths. The Lieutenant of the Jail was pro-treatment and he appointed a deputy as a liaison between the other deputies, the clients and our staff which smoothed the issues with many deputies who didn't understand treatment and felt we were giving privileges to criminals. She also directly dealt with our clients breaking rules. In extreme cases she put them in isolation which was dead time towards graduation. The  liaison deputy arranged for the local community college to grant 9 hours college credit for the morning addiction education. Also graduates were offered a free semester upon graduation from the program. GED was already offered in the jail and many were able to complete this while in treatment.

There was one probation officer for the whole program and he had a background in counseling and would sit in group from time to time. The Mental Health associate who came in once a week was an old friend I had known twenty years before in Dallas TX. Medical was totally cooperative with occasionally needed psychotropics as we began to notice a high correlation between ADD-ADHD and meth addiction as well as health concerns. The Oxford House movement expanded to Roseburg which provided safe and sober living. A local civic group built 8 apartments for men and a house for 5 women for safe living. A former colleague was there during the daytime providing supervision. A local restaurant was willing to provide employment, and the graduates working there were highly thought of. Other local businesses followed suit and employment became possible for graduates.

Roseburg has strong recovery self help groups, and so graduates were able to find strong sponsorship and had many options for the regular attendance required. Two after care groups were led by my therapy colleague and myself for a minimum of six months, and then once a week minimum for the second six months. An outpatient family group was also available once a week to help the recovery for families damaged by addiction. 

One interesting aspect of the program was that on Friday afternoons I would hold a session where clients could ask questions about the Bible. It was a voluntary process to respect their civil rights, but all members of the groups chose to attend. In one graduating class we had four clients, two men and two women, return to the churches of their childhood and be baptized signifying their re-commitment. 

Tragically, for circumstances beyond our control, the "perfect storm" of cultural / social / support was not to last. Initially, because of competition for funds with economic cutbacks, we lost the cooperation of Mental Health. Then the leadership of the jail changed and the new lieutenant did not have the openness and cooperation we had enjoyed.  Medical no longer cooperated as it was now run by a individual contractor seeking to cut expenses. The liaison deputy facing relocation to save funds, resigned and went into social work at the local hospital. My personality was too confrontive of the changes, and I was removed from the program to work back in outpatient corrections. 

Sadly, the program regressed back to the recovery rates expected from such a program and then funding ran out shortly after. When I do workshops with churches, I use this as an example of how a church could provide a refuge of recovery for addiction. I attempt to organize committees to assist pastors in coordinating the necessary ingredients for a cultural / social/ spiritual involvement by the church. 

In my next blog we will begin to explore neuroscience and how drugs affect the brain. 

#8 Rat Park

The traditional and long standing theory of addiction maintains that most people who use drugs beyond a certain amount become addicted (alcohol is a drug).  No matter what proportion of drug users become addicted, this is caused by exposure to the drug. The solution then is to eliminate drugs, but the War on Drugs has been shown to escalate the illegal drug industry as the rates of addiction continue to rise. Has nothing has been learned from the Prohibition Era (1920-1933)?

Data supporting this prevalent theory of addiction came from numerous laboratory trials with rats and monkeys and observing how frequently caged animals would push levers to obtain drugs. Predictably, the caged animals would avoid normal eating and drinking leading to death without intervention. 

Dr. Bruce Alexander, author of The Globalization of Addiction: A Study in Poverty of the Spirit challenged this belief in the late 70's with his experiments known as Rat Park.  He professed that the laboratory rats kept in cramped metal cages were distressed (dislocated) and like distressed people would relieve their distress pharmacologically. 

To test his hypothesis, he designed an alternative laboratory environment based on the needs of the rats rather than the researchers. Rat Park was 95 sq ft or 200 times larger than a standard laboratory cage. There were 20 rats of both sexes, an abundance of food, wheels for play, aromatic cedar shavings, woodland vistas painted on surrounding walls and enough space to socialize as well as for mating and raising litters. Given a choice of plain water or water laced with morphine they chose the plain water. Then rats that had been forced to consume morphine for 57 straight days were introduced to the colony and chose the tap water and went through withdrawal. This validated his theory that addiction is not directly caused by access to drugs but is a symptom of dislocation. (refer to blog post #7)

Major science journals at the time rejected his paper mainly because it challenged the current theories. Dr Alexander feels we over-individualize addiction, rather than look at the cultural / social / spiritual roots of his theory of dislocation. Although these experiments have been replicated they still have not influenced the mainstream of addiction theory. Rat Park measured not the addictiveness of opiates, but the cruelty of the stresses inflicted on rats in solitary confinement and dislocation from their natural environment. 

It is estimated that at least 80% of those incarcerated in North America are there for a drug related crime and very few jails and prisons offer treatment. It seems there is money to build prisons which have become a major industry often run by contractors.  I believe those who manufacture or sell drugs should be incarcerated, but we need to re-evaluate the process of incarcerating users of drugs when no other crime was committed. The answer is not legalizing drugs but discussing decriminalizing the possession of small amounts and providing treatment. Sadly, with budget cuts the former availability of treatment even 5 years ago is not available in the USA.

My next post will discuss the success of a long term treatment program in the Douglas County Jail in Roseburg OR. that integrated the theories of Proxemics and Dislocation.