Author: Marc

Last week I was trying to think like a Buddhist, in preparation… I thought about the self-reinforcing nature of “attachment” (à la Buddhism) and the self-reinforcing nature of addiction (which we all know about from our, ahem, independent research). What Buddhists describe as the lynchpin of human suffering, the one thing that keeps us mired in our attachments, unable to free ourselves, is exactly the same thing that keeps us addicted. The culprit is craving and its relentless progression to grasping.

The cycle of human attachment is represented in Buddhism by a wheel that keeps on turning. First comes emptiness or loss, then we see something attractive outside ourselves that promises to fill that loss, then we crave — a state we all know and love. Craving seems to be a universal form of anxiety, focused on a goal rather than a threat. So we crave and crave, and here comes the clincher: the next thing we do is grasp — reach for it. That’s what keeps the whole wheel spinning, like a merry-go-round you can’t stop. Grasping of course leads to getting. Getting leads to more attachment. Attachment leads to more emptiness and loss, because the thing we’ve attached ourselves to is never enough to fill the void. And so we’re embarked on the next revolution of the wheel — searching for something outside ourselves.

The parallels with addiction are so obvious, I won’t bother to list them. I guess the only thing that’s special about addiction is that we keep grasping for the same thing again and again. There are good neural reasons for that — reasons the Buddhists may not have appreciated. Each cycle of craving, grasping, and loss leaves its trace on the synaptic architecture of our brain. The synapses that represent the addictive substance or behaviour, the getting or doing it, and the expected relief become increasingly reinforced each time they are activated. “What fires together wires together.”

As far as I know, Buddhist common sense recommends breaking the cycle between craving and grasping. Is it possible to remain in a state of craving without going after it — the thing you so badly want? Of course it’s possible, but it ain’t easy.

A paper published by Kuhn, Gevers, and Brass (2009, Journal of Neurophysiology) reports on a neat experiment. These guys measured electrical activity in the area of the dorsal anterior cingulate cortex (the dACC: the region responsible for effortful self-control), using brain wave signatures called event-related potentials. On most trials, the subjects were instructed to press one or two buttons in response to a pattern on the screen (called the “instructed Go” condition). But on some trials they were told not press the button (to withhold the action, called “instructed NoGo”). And on other trials, they were free to press or not press, according to their own whims (called “free Go” and “free NoGo”). Given this design, the researchers were able to compare the level of brain activity (in the region of the dACC) between instructed actions, free actions, instructed non-actions, and free non-actions.

The point is that instructed non-actions (“instructed NoGo’s”) are exactly what we face when we tell ourselves NOT to grasp, not to go for another drink, another bite, another pill or whatever. When you hold in mind the “instruction” not to do something, and you successfully obey your own instruction, then you’ve broken the cycle, at least for now. You’ve refrained from doing something you were just about to do: that’s craving without grasping.

The diagram showing the results of the experiment gives voltage values for different brain regions in each of the four conditions. In the second row, the “N2” tells the whole story. The N2 is considered a measure of self-control, and the N2 shows the maximum voltage (blue colour, because the voltage is negative rather than positive) in the “instructed NoGo” condition, not the “instructed Go” condition or either of the “free” conditions. So your brain, and specifically your dACC, is working hardest when it’s trying to refrain from doing something — harder than when it’s trying to do something. In Buddhist terms, it’s a lot easier to grasp than to refrain from grasping. And if you’ve been following my previous posts, you know where that self-restraint can lead: ego fatigue! Your dACC can’t take the strain and sooner or later gives up.

So here’s an instance where neuroscience and Buddhism tell us complementary aspects of the same story. Neuroscience tells us how hard it is to intentionally refrain from something you’re about to do. Buddhism tells us: Yes, it’s hard, but do it anyway! And you’ll be glad you did… That makes sense to me. If you can let yourself crave without grasping, even a few times, then you start to break down that automatic progression — that compelling momentum — that keeps the wheel going round and round. And after a while craving itself begins to diminish, because it’s got nowhere to go.

My family and I are going back to Toronto for two weeks to meet up with friends and family. So I may take a break from blogging — unless something really interesting comes along. Meanwhile, Happy Holidays to all of you! And thanks again for your warm good wishes last week — That’s the best present I could have wished for.

So I’m having this relatively uneventful week, doing a bit of homework for my Dutch lessons, preparing for a class I’ll be teaching next term, defrosting the freezer, debating with a publisher as to why she should accept my next book, driving the kids to soccer and always arriving late, though no one seems to care, and wondering during my few un-busy moments what I’m actually doing with my life. Do I seriously think there’s more I can contribute to the addiction literature – besides blogging, which I love? Or should I hang up my spurs and take up growing tulips?

When all of a sudden I spy an email from the Mind and Life Institute, a group started by the Dalai Lama and a few other notables, whose mission is to identify links between the contemplative arts (e.g., Buddhist meditation) and neuroscience. I figured it was a generic invitation to their yearly conference. I went a few years ago, and it was actually great. Each day I woke up early, did a lot of yoga, ate a lot of vegetables, and spent many hours with my eyes closed, making infinitesimal progress toward enlightenment but getting pretty relaxed.

No, it wasn’t that. It was a letter, addressed to me. I had to read it twice to believe it. It was an invitation to spend five days with the Dalai Lama at his residence in Dharamsala, all expenses paid. I would be one of fewer than ten scientists or scholars or addiction specialists, and we would be meeting with him throughout the five days to discuss craving and addiction. The Dalai Lama remains deeply interested in societal problems, especially those that might be addressed from both Buddhist and scientific perspectives. According to the letter, he sees addiction as a major source of suffering in today’s world. I have to agree with him there.

So…yeah…I’m blinking rapidly and checking the address to make sure it’s not a hoax. They “very much hope you are able to join us for this special conference …” and would I please let them know as soon as possible. So I thought about it – for approximately 2 ½ seconds. I would give my left arm, maybe my right arm, to meet this man and talk about addiction with him and a few other folks. I’d go just for the ride. Just to be in his presence. Besides, Dharamsala isn’t Rotterdam. It’s halfway up the Himalayas. It’s a beautiful place according to the pictures.  Just to be there would be an amazing trip, but to talk with this precious man about, let’s face it, my favourite subject. Yes, I accept!!!

I don’t know why I’m telling you all this. I guess just to share the most exciting moment in my life for the last couple of years. But this opportunity also brings to mind something I’ve thought about for awhile. When I argue my usual position, that addiction is not a disease, I often get a lot of flack. In particular, the disease advocates often argue that addiction must be a disease because it changes the brain, often irrevocably. And I argue back that I think addiction is an extreme form of normality, because normal learning also changes the brain, often irrevocably, especially when the learning concerns goals or intentions that are highly emotionally charged, such as falling in love, having a child, religious conversion, and, well, developing a serious fondness for coke, smack or booze. I haven’t yet been able to make my argument as articulate and convincing as I’d like to. In a recent post on a science blog, I tried to put it as succinctly as possible. And dozens of comments came back – most of which were not in agreement. So I’d counter that, if drug addiction was a disease, then so would gambling and other serious behavioural addictions be diseases, not to mention a passionate affair with the man or woman next door, and so on and so forth.

But how’s this for cutting to the chase: Just about everyone describes addiction as a continuous state of craving that can only be relieved by acquiring/doing the thing you crave. Whatever is going on in the brain, the psychology of it is pretty straightforward. So if I were a Buddhist, I’d probably say: hey, that’s human existence for you. Human existence is characterized by longing, by craving…and then being propelled by the craving into grasping – which means going after the thing you crave and getting it. Which always lets you down, since material things never satisfy the emptiness that’s at the core of craving. Which is why Buddhists recommend that you do some serious meditating and thereby give up your attachments. When that starts to happen, then you can watch yourself being in a state of craving without going to the next step, grasping. You can just watch it, see it for what it is, and let it go.

(Which may be why a lot of people find meditation extremely helpful for recovery.)

I wonder if the Dalai Lama will see addiction in a similar way. I suspect that he, of all people, will see it as an extreme form of attachment, which of course generates craving, which is why addicts suffer so much – until we’re able to watch the cravings come and go. I doubt I’d have to convince him than addiction is not a disease; it’s a highly focused state of longing – for something that glitters but isn’t even close to gold.

(Another reminder: Check out the Guest Memoir page, linked above. We’ve gotten a couple of new ones, and they’re really gripping. Please comment if you’ve got anything at all to add, or send us your own memoir.)

In the last two posts – one by Persephone and one by me – we talked about the possibility that 12-step treatment offers a “static” rather than “developmental” approach to recovery. Persephone argued that certain features of 12-step practice kept the addict or alcoholic in a frozen state of heightened anxiety, much like PTSD. My last post was an attempt to extend and articulate some of Persephone’s points. I was really taken with the similarities between her idea of “static recovery” and PTSD, and I provided information about traumatic memory maintenance in support.

But today I want to take a different approach – and I think it provides a real reconciliation between the pro and con positions on 12-step recovery. The point I want to make is that any and all recovery has to be developmental in nature. Pure stasis simply cannot correspond with recovery.

The term neuroplasticity has been bandied around a lot. Norman Doidge seems to think he invented the concept, or at least brought it into the limelight, but it’s been around for ages. Dr. Eric Kandel of Columbia shared a Nobel Prize in 2000, reflecting decades of research on how the brain changes when learning occurs. In a nutshell, Kandel showed that the connections among neurons – synapses – must change physically if memories are to be formed. He showed this at a molecular level, validating Hebb’s famous insight from the 40s: What fires together wires together. Well all the neural change that takes place when we learn and remember things is really just neuroplasticity.

Neuroplasticity is strongly amplified when people are highly motivated to change, probably because of the strong emotions that come into play and focus one’s attention. In her wonderful book, Barbara Arrowsmith-Young describes the many cognitive exercises she devised for herself, in order to overcome her very severe learning disabilities. They worked. She went from a high-school student who could not comprehend history, who even had a hard time understanding simple sentences, to a writer and teacher who has set up roughly 70 schools for learning-disabled children in North America. Barbara, whom I met in Australia last year, has a delightful phrase for neuroplasticity dedicated to replacing bad habits with good ones.

What fires together wires together, and what fires apart wires apart!

(I don’t actually know the origin of this phrase, but I like it.)

In 1993, Mogliner and colleagues looked at the brains of people who had been plagued with webbed fingers. That means that some of their fingers could not operate separately – they functioned in total unison. After surgery was performed to allow the fingers to move independently, these authors looked at changes in the (somatosensory) cortex. What they found was that the synaptic wiring of neurons in the corresponding brain regions had changed substantially, just weeks after people started to control their fingers independently.

The parallel with addiction seems striking. You “learned” your addiction through neuroplasticity, which is how you learn everything. You maintained your addiction because you lost some of that plasticity. As if your fingers had become attached together, you could no longer separate your desire for wellbeing from your desire for drugs, booze, or whatever. Then, if you did indeed recover, whether in AA, NA, or standing naked on the 33^rd floor balcony of the Chicago Sheraton in February, that means you got your neuroplasticity back. Your brain started changing again – perhaps radically. You started to separate one set of desires from another and to act on them independently. And just as in Mogliner’s study, your brain began to regrow its synaptic patterns – to allow the change to take place, to hold onto the change, and thereby to permit a new degree of personal freedom.

The take-home message is simple: All recovery is developmental. Without developmental change in mind and brain, you would stay exactly the way you are.

Hi all—

Here’s an announcement before the main act: Please look at the Guest Memoirs page if you haven’t already. The first four memoirs are terrific, and hugely different. I hope that we’ll soon get more, and I hope people will leave comments on those already posted. It may seem hard to “comment” on something autobiographical….but just saying “I get how you must have felt,” one way or another, can mean a lot to someone who has just exposed themselves so openly.

The main act:

I haven’t published a post in a few weeks. I’ve had one part-written since the day after Persephone’s amazing post (see previous), but it remained in note form while I was busy with other things. Those things included my twin 6-year olds. Mama (my wife, Isabel) was in the States for 10 days, doing research (and staying in fancy hotels) while I slaved away here. It was more work than I’d expected, because the boys now go to an after-school daycare, where I need to pick them up, but I never seem to get there without getting lost and ending up in farm country.  So that’s an hour out of my day, getting them to school in traffic is another 45 minutes, Dutch lessons plus practice – 4-6 hours per week, showing up for work at the university once in a while, cleaning up an amazing amount of trash left over from the intense Halloween party we had a couple of weeks ago (fabulous costumes, lots of food and wine, even a fire juggler) but did we have to buy 30 rolls of toilet paper so the kids could have a dress-the-mummy contest? Yet the main time drain was none of the above: it was keeping a lid on the kids. With Mama gone that long, they were bouncing off walls, ignoring my commands, arguing more, breaking rules. So I spent a lot of time disciplining these adorable little buggers…not my favorite parental duty.

Which brings me back to Persephone’s post. The main problem with the 12-step approach, she says, is the freeze on emotional development they seem to demand, intentionally or not. So recovery becomes a way of not moving – it’s static. According to Persephone, the epitome of successful recovery in NA/AA is to sit around with the same people, year after year, sharing stories about how shitty it was being an addict, so that you can REMAIN clean or sober. It’s all about remaining a certain way rather than growing. As Persephone saw it, they tell you that your addiction is doing push-ups in the parking lot, or waiting to leap on you, so the only safe course is to stay here with us – stay being the operative word. And the result is that you continue to define yourself as an addict. In other words, not only the way you govern your life but your whole self-image is frozen in place. This is what you are, and if any change occurs, be warned: it’s going to be a change backward – back to being an addict who’s no longer in control.

Persephone proposed the following: With your behavior, your choices, your capacity to explore, and your self-image all frozen in this way, and with the horror stories of your addiction constantly resurfacing, you are in the same condition as someone with PTSD – post-traumatic stress disorder. What a concept! People with PTSD live with continuous anxiety, denial and avoidance mechanisms, intrusive thoughts, and more, about what happened to them, whether it was a serious accident, a mugging, physical or sexual abuse, rape, getting wounded in a war… And the therapeutic principle for recovery is pretty simple: you have to free yourself from those fears, from the anxiety that it’s still happening or will happen again, by reprocessing the event, with some sense of acceptance. Yes, it happened, but it’s over now. You have to do that before you can move on. Then you shift from a static state to a fluid state, let down your defenses, allow for the unexpected, and find the confidence that you can handle whatever comes.

So here are my kids in a state of anxiety. They’re not old enough to conceptualize how long 10 days will last. As far as they’re concerned, Mama is just plain gone. They love me a lot, and we sure got closer during this period. But their anxiety changed everything! They regressed, they became more moody, aggressive, shut-down, or simply unregulated. And to continue the analogy with NA/AA, I became like their sponsor. Come to Papa when you start to lose it, and then do exactly as I say. Because the thing/person you really want is missing from your life, and you’re in danger of going from bad to worse. My style of parenting changed. Everything became more rule-bound, there were a lot more time-outs, consequences dished out, time deducted from weekend TV… In brief, living with anxiety takes its toll. I knew this as a psychologist anyway – I just got reminded: anxiety diminishes cognitive flexibility and creativity, and it draws attention to the negatives – whether you’re a motherless 6-year old or a boozeless 60-year old.

My kids became dry drunks for over a week.

One of the coolest (but still experimental) treatments for PTSD is to relive the traumatic event while you’re taking beta blockers, drugs that reduce sympathetic arousal. This article describes the approach. So why should that work? Are you just relieving anxiety over time? No, the theory says you are interfering with the maintenance of traumatic memories. Memory strength and endurance depend on a kind of rehearsal process. You have to keep on reliving the memory (at least some version of it) while feeling the emotions that came with it – e.g., the fear unleashed when a trauma occurs, or maybe that stew of shame, anger, and horror that comes with addiction. (I still vividly remember the time I shot the heroin left in “the cotton” from a junkie with yellow eyeballs, broadcasting hepatitis – and I get a jolt of disgust and shame each and every time.) Without that emotional charge, the memory fades…just like other memories.

Memories are encoded in the connections (synapses) between brain cells. You have to reinforce those connections (keep strengthening those synapses) to keep vivid memories vivid. Strong emotions like anxiety activate or facilitate synaptic cascades (e.g., in the amygdala). Anxiety also does the job of connecting novel events to that ball of fear at the core of the trauma, thus extending the synaptic network still further. With beta blockers in your blood, you can relive the memories without the anxiety, allowing the memories to become diluted or dissipated. They start to dissolve and lose their hold on you. Then you can spread your wings and fly, rather than remain frozen with your wings permanently clipped (Persephone’s words, with a nod to Lennon & McCartney). That’s when your emotional world starts to grow again.

According to Persephone, many/most 12-step groups intentionally reinforce a PTSD-like state: Be afraid…be very afraid… Sort of like the opposite of trauma treatment using beta blockers, many 12-step groups seem to kindle the very emotions that cement your already vivid memories of when you were seriously fucked up. Almost like telling scary stories to keep little kids in line.

But sometimes it works: because living with PTSD is one way to keep away from danger. After getting mugged or raped, you won’t go strolling through city parks at night, you’ll stay inside when the parade comes by, you’ll avoid people of a certain type, you might avoid eye-contact with strangers altogether, and you’ll continue to see yourself as a victim or a loser. Not only is that a static state; it’s also an unhealthy state. It maintains anxiety rather than relieving it. You stay clean because you stay scared.

If that’s the solution offered by many 12-step programs – to plug yourself into a static state of PTSD in order to avoid the dangers of relapse – then I can sure see why a lot of people don’t sign on, or stay for a while and then get out. I can see why the notion of a lifetime addict can be a self-fulfilling prophecy. And I can see how people get hurt, sometimes badly hurt, when they try to break free: because they may actually get chastised for wanting to leave their PTSD behind — and that hurts.

For the most serious, interminable addictions, this might well be worth the price. We’ve heard a number of claims to that effect. But for those who do have the capacity to continue growing, leaving their addictions behind and moving on, it doesn’t sound like an ideal solution.

Please note! I’m not trying to rekindle the debate as to the pro’s and cons of AA/NA. Been there, done that. I’m just trying to build a clinical and neural extension onto the perspective of one person – who seemingly reflects the experiences of many others (judging from comments received!) – people who didn’t find what they needed.

Next post, coming in a few days, I’m going to zoom in on the relation between anxiety, memory, and habit formation – both in the development of addiction and in recovery seen as a developmental process — by looking more closely at what’s happening in the brain.

By Persephone…..

(This piece was sent to me by a member of this blog community, and I think it’s incredibly astute and revealing. As a developmental psychologist, I strongly agree that the recovery process should be viewed as developmental, not static. P.S. It’s apparently no longer be-nice-to-12-step week.)

After I had been clean for what one member counted as 17 months, I finally went back to an NA meeting, only to discover that there is such a thing as being held in stasis in recovery — and that I had, myself, been there. I was acutely aware before, but even more by that point, that for many of my 12 step instructors (for lack of a better word) we were supposed to freeze ourselves in that very moment in which we finally realized that we were “diseased” and had decided to devote ourselves to recovery. We were to cling to that moment in time, reaching backwards instead of forward, into the depths of our misery lest we forget it, developing emotionally only artificially via these 12 steps but otherwise staying rather static in some very crucial ways. So, I watched as roughly 30 people recounted, and with the same stories I had observed over 17 months prior, the worst moments of their addiction. Having not been in a 12 step program since getting clean, but rather in trauma therapy (when I had any therapy at all) as well as restructuring my life on my own based around my new-found loves of self-restraint and goal oriented thinking (not to mention just plain having fun), I could only see in these shares shadows of my past. My very sick past, and one in which I was unable to achieve any kind of “recovery”. I could also see exactly what my therapist always warned as dangerous in terms of staying in the moment and forcing oneself to relive past traumas, though my new and healthy brain had already directed me against this sort of thinking. Very far away from this kind of thinking, so why was this not the case in the most well-known substance abuse venue in the western world?

I realized while listening to these shares (over 30) that none of this emotional development had taken place with the members of this particular group. Hopelessness, anxiety, and the common thread that the “disease” was still very present (and quite personified, doing push-ups in the parking lot and lurking around every corner just waiting to flare back into active addiction), even in the relatively normal actions and thoughts these people had experienced that day. They were still experiencing the anxieties and fears I by then had come to associate only with active addiction and very, very early sobriety. Not being trained in psychology but having had my fair share of trauma counseling and the usual smattering of readings about trauma and abuse, I also associated these problems as being almost akin to PTSD, which is almost by definition a state of stasis in which one cannot process or heal from a traumatic experience.

Yet even in my tattered memory, I was acutely aware of what I was taught during my short tenure in NA and the inevitable stint in a 12 step rehab that followed (I say this not to offend adherents to the 12 step method, but to stress that the effect this static-not-developmental treatment had on me was to, well, keep me in my addiction — which for me was synonymous with hopelessness and trauma.). I, and the others, were told that we must essentially live with clipped wings. If we were allowed to ever truly fly, we’d surely be conquered by our own “self-will” and excesses of ego. Anger and hatred (“resentments”, in 12 step parlance) were to be eradicated. How we were supposed to do this without extreme amounts of repression (or a particularly intense spiritual experience) was rather beyond me, and frankly it was my anger that was keeping me going. I consider anger now a useful stage of sorts in my development as a now-recovered person, much like the anger in the often quoted stages of grieving. But no, never in “recovery”. “Resentments” lead to relapse, we were taught. We were to progress only through the steps, despite our various ideological differences with them, but never through normal human emotions. We were all taught that we were faulty, that our brains were faulty from birth, that we were born addicts and must consider our brains to be diseased until the day we died.