This protocol is based upon the information contained in the Psychological Assessment, Referral & Treatment Services website generated by William Dubin. The material has been modified by the CCIU to adapt it to a skill training for practitioners and several techniques have been added. We take full responsibility for any differences that arise because of these modifications and recommend a visit to the website of those with particular interest in the original material. This document is published with the consent of ARTS.
The purpose of this protocol is to promote success by identifying and dealing with the biological, psychological and social factors that pertain to addiction and its resolution. The protocol is provided as a basis for addressing any addictive behavior and is not targeting a specific addiction. Addiction in this case is primarily concerned with the components of addictiveness such as immediate gratification, habituation, creative construction of reality, state learned bias, the ‘Imp of the Perverse’ and reactance, and the typical responses to these components. Addiction is such a potent and deceptive foe that intellectual appreciation is not sufficient. The procedural knowledge required to intentionally guide the client’s actions when face to face with potent stressors and temptations cannot be acquired by understanding alone. Each person must develop this competence through skill acquisition, personal experience and guided practice.
COMPONENTS OF THE SOLUTION
The skill that is most necessary for overcoming a self destructive path is for the client to learn to be an ‘impartial spectator’ of his/her own mental activities: trying to observe your own behavior as if you were observing the behavior of another. This was a concept that Adam Smith used as the central feature of his book, The Theory of Moral Sentiments. He defined the Impartial Spectator as the capacity to stand outside yourself and watch yourself in action, which is essentially the same mental action as the ancient Buddhist concept of mindful awareness. Smith understood that keeping the perspective of the Impartial Spectator under painful circumstances is hard work, requiring, in his words, the ‘utmost and most fatiguing exertions’. The cognitive path is not an easy one, however simple the skill might seem.
Part of becoming mindful is to understand how we think. We create mental maps of the outside world and represent these mental maps through our language, use of symbols and behaviors. The processes we use to create our mental maps and outputs are based on how we structure our thoughts.
You must believe in free will; there is no choice.
Isaac Bashevis Singer (1904-1991)
In addition to providing the tools for effective addiction management, this protocol has the ambitious goal of enhancing the client’s free-will!
Free will is a controversial topic, and in some ways the experience that we consciously control our current behavior is an illusion. Nevertheless, it is possible to willfully guide one’s own life’s course. Like the ability to drive, effective operation of the vehicle requires some knowledge about how things work, and then lots of practice in real settings. To operate the motor vehicle you must appreciate that pressing the accelerator pedal makes it go faster, turning the wheel steers it, etc. Once you learn how it works it becomes a matter of practice – with some guidance from a driving instructor – to achieve the desired competence. Those who live in the north are forced to develop additional skills to manage icy roads. While it seems unfair that life is harder and more dangerous for northerners than for southerners, fairness is irrelevant. Northerners and southerners must each cope with the reality they are presented. As partial compensation for the additional burden, northerners may get to be better drivers in wintry conditions than southerners.
The big advantage of skill acquisition over receiving treatment is that the former is irreversible. Once you have learned a skill and become habituated to that skill, it becomes difficult not to perform it, unless or until a replacement skill is learned.
There is a lot of pain in life. But the only pain that can be avoided is the pain that results from trying to avoid pain. – R. D. Laing
THE COMPONENTS OF THE PROBLEM
“Kids are told, ‘Don’t spend your
whole allowance for bubble gum
[immediate emotional impulse]
because you’re going to want to
spend it for something else later
It takes discipline, but the reward is freedom.
The problem of immediate gratification refers to the universal principle that a small immediate reward has a greater influence than a much larger, but delayed reward. Incentives that are especially good at producing immediate gratification are especially corrupting.
Every day we make hundreds, maybe thousands of decisions. Conscious, unconscious, right or wrong, these decisions make us who we are. They form the foundation of our past, our present and our future. They are the essence of who we are to ourselves and who we are to other people. A man decides to rob a bank and is labeled forever as a thief. A man decides to devote an above-average portion of his life to his children and he is labeled a good father.
Decisions themselves are a very human struggle associated with the ability to identify a future. The hunter-gatherer probably accepted the world as it came and lived out the role that was given. Modern humans, faced with a society based on individualism are forced to make decisions on how they are going to live. Such decisions are usually based on considerations of utility. The most basic definition of utility is the narrow one associated with the nineteenth-century utilitarian, Jeremy Bentham: that utility is the pursuit of pleasure or the avoidance of pain. Thus, most decisions have been made to maximize pleasure and minimize pain. This seems often to boil down to personal happiness and the happiness of those around us. Where this construct breaks down, of course, is when there is immediate pleasure or pain which is reversed over the long run.
In other words, at every turn, every fork in the road that is life, the individual looks to some internal indicator of happiness to decide the proper choice. Sort of an ‘if it feels good do it’ methodology. For example, a number of fathers (i.e. married, with children) are leaving their families to pursue relationships with women they have met. These men are acting on their ‘feelings’ to make their decision. Or, consider a woman who has cosmetic surgery purely to alter her body image in a manner that will make her ‘feel’ better about herself. Or, consider a man who devotes himself to his work so that he will receive the praise of society, which, in turn, makes him ‘feel’ like he has accomplished something.
It is not solely in these extreme cases where a person’s decision is based on happiness. It is every decision, the decision to drive fast, the decision of what to eat for breakfast, the decision of what color one’s hair should be. Some incentives such as physical health, career success, or loving relationships may have large magnitude, but are not produced immediately by a specific behavior and don’t produce any immediate ‘feel good’ states. In contrast, the gratification produced by incentives such as drugs, alcohol, or food is immediate, and for that reason exert an influence on behavior that is disproportional to their importance. Some people behave as if they valued such an incentives more than they value health, wealth, or family. . . causing great sorrow.
In all fairness, it looks different than it feels, and addictive disorders are experienced differently by the client than by the observer of the client. Observation of the many variations of the struggle, typically, indicates that the client genuinely wants to be successful, but repeatedly falls victim to pitfalls and traps that are only obvious in retrospect. The fact that these traps are invisible to us in real time illustrates an attribute of the human circumstance. We make decisions based on a perceptual system whose local biases are almost always invisible to us – although we can see them when we are distant enough to be objective. Some optical illusions seems to provide an experience of the difference between what the addicted person perceives and what s/he would ultimately consider to be true.
The Karma of Practice
People with addictive behaviors generally seek professional services because they have lapsed in their attempt to control their own behavior. They regained the weight they lost, gone back to drinking or drug using, etc. During the first session, the counselor usually asks the obvious questions: “What caused the first lapse?” and “What was the sequence of events that led up to it?” Oddly, the clients often don’t know. Why are they blind at the crucial moment?
Autonomous Behavior and Absence of Attention
Recall of a sequence of events requires that the sequence was originally coded into long term memory – a process that requires attention. At certain crucial moments, when attention is otherwise occupied, intention is not influencing performance – behavior is on ‘auto-pilot’ following the path of least resistance.
A behavioral sequence is said to be autonomous when it occurs by itself without intentional guidance. One way this comes about is through the development of habit. Performance becomes easier with practice, eventually becoming so effortless that conscious attention is not required for successful execution. Consider activities such as driving or using a word processor. When first attempted performance is slow, hesitant, and filled with error, but with practice speed increases, variability decreases, and execution becomes increasingly effortless. What once demanded considerable attention can now be performed rapidly and accurately with little or no awareness of the component actions.
Conscious attention is not required to initiate an autonomous sequence; mere exposure to the eliciting stimulus is sufficient. And, once initiated it has a ballistic quality: it tends to run on to a predetermined target without additional guidance.
When driving, a red light is sufficient to elicit a sequence of events that the driver controls, but the control is generally outside his/her awareness. Cognitive resources are not required to initiate and guide the complex sequence of behaviors that brings the vehicle safely to a smooth stop.
Rapid, accurate, effortless performance – that makes no demands on valuable conscious resources – has obvious advantages. The problem is changing a behavior after it has become autonomous. For example, an experienced driver would take longer to learn to reliably stop at a green light, than s/he originally took to learn to stop at a red light. Until the new habit is acquired, the driver must pay attention [be mindful] in order to over-ride the well practiced behavior of driving through a green light.
Autonomous behavior can be over-ridden, but it requires mindfulness or conscious attention to do so. The result of repeatedly following the path to immediate gratification is that this path becomes autonomous. As a result, whenever conscious resources are occupied by a demanding social situation, powerful emotional state, or diminished due to fatigue or intoxication, one tends to follow this default path.
An absent-minded relapse occurs when mindful processing, which is necessary to interrupt the autonomous sequence, is not invoked when needed. This may occur when a person was simply not conscious of the original commitment until the relapse sequence was already well under way. Less dramatic but more common, the person was more or less aware of the unfolding of the sequence of events leading to the lapse, and was also fully aware of the previous intention to remain abstinent, yet simply failed to dedicate the conscious effort required to interrupt the autonomous behavior chain.
Some high risk situations are characterized by a conflict between a previously made commitment and an autonomous habit. The conflict will resolve in either success or failure, and, needless to say, success is better.
When a tree falls in the forest, and no one is around to hear it, is there a sound?
This Rodney Dangerfield of philosophical questions gets no respect, because it seems to be one of those pointless questions that has no answer. But there is an answer – an answer with profound implications.
There is no sound!
When the tree falls it produces a series of pressure waves in the surrounding air. The ear drum converts these waves into a mechanical signal which is transmitted by 3 small bones to the fluid filled spiral bony canal of the inner ear. Hair cells of the canal are the actual receptors. Each is tuned to a particular frequency of the fluid waves. Hair cell vibrations are converted to electrical impulses, and transmitted along the auditory nerve to the auditory cortex where intensity and frequency of the vibrations are mapped. Neither pressure waves, physical movements of body parts [bones, hair], nor electrical signals are sound. What we call sound exists only in the mind of the perceiver.
Perception differs qualitatively from the physical properties of the stimulus. The nervous system extracts only certain information from the natural world. We perceive fluctuations of air pressure not as pressure waves but as sounds that we hear. We perceive electromagnetic waves of different frequency as colors that we see. We perceive chemical compounds dissolved in air or water as specific smells or tastes. In the words of neurologist Sir John Eccles:
“I want you to realize that there exists no color in the natural world, and no sound – nothing of this kind; no textures, no patterns, no beauty, no scent.” Sounds, colors, patterns, etc., appear to have an independent reality, yet are, in fact, constructed by the mind. All our experience of the natural world is our mind’s interpretation of the input it receives.
A first and seemingly immediate awareness, which more or less corresponds to the energy stimulation patterns, is referred to as ‘sensation’. ‘Perception’ can be distinguished from sensation in that it refers to a process which requires more organization than sensation, is more heavily dependent on learning than sensation, and requires more time for completion than sensation.
The differences between sensation and perception can also be experienced by viewing reversible figure, ambiguous figure or multi-stable perceptual illusions. Sensory patterns in the multi-stable figures do not change, but our organizational processing continues and we become aware of the shift in our perception.
In the classic text, Principles of Neural Science, Eric Kandel observes:
“The organizational mechanisms of vision are best demonstrated by illusions. Illusions illustrate that perception is a creative construction that the brain makes in interpreting visual data….Learning does not prevent us from being taken in by these illusions.”
Do you see the star or the boxes? Anything else?
An illusion is responsible for the voluntary selection of a path that predictably leads to sorrow. The lessons learned from a painful experience do not prevent us from being taken in again and again, unless we are able to hold the two sides of the illusion in mind at the time the decision is being made.
State Dependent Perception
The abuse of a loved one looks different after anger has given way to regret. In hindsight, the anger was temporary, and its cause looks trivial. Looking back through the filter of regret, the abuser may experience guilt, and vow never to repeat the destructive behavior. But the next time the abuser is in an angry state, the immediate provocation will not seem trivial, nor will the immediate perspective appear temporary.
Because perception is a construction of the mind, our biases are invisible to us and so we are taken in. When angry, the abuser is not usually aware that his/her perception is biased by his present emotional state. His/her subjective reality is state dependent, but s/he does not appreciate that. To the angry person comes a thought like: “S/he is always taking advantage of me!” Later when the person perceives the same situation in hindsight – when feeling contrite – s/he wonders, “Why do I always hurt the one I love?”
Objectively, we can see that both the emotion and contrition bias the immediate perception. But subjectively – in real time – this bias is invisible to us. The failure to appreciate that our subjective reality is state dependent causes great suffering.
State Dependent Learning and Memory
Local emotional states influence behavior selection. State Dependent Learning is shown in the laboratory by the following observation: Rats who learn to run a maze when drunk perform better when tested drunk than when tested sober. Rats who learn when sober perform better when tested sober.
Learning is state-bound. That is, what is learned in one state may not generalize well and so may not be available when in a different state. Likewise, memory is state dependent – previous failures are more easily recalled at times when one feels like a failure. Because feeling like a failure begets future failure, clichés such as: “Nothing succeeds like success” have some validity.
The story of Omar
During the first session, Omar told of repeated self-destructive relapses. After each one he swore: “I’ve learned my lesson this time, and I will never make that mistake again!” Each time he really meant it, and yet each vow was eventually followed by a lapse, and each lapse by regret. Now, in the counselor’s office, he is about to do it again. Omar is not stupid, and is aware of his history. Yet he makes the same mistake again and again. Why?
From his history we can conclude that:
- His vow is worthless – although he is genuinely committed to it when he makes it.
- His appraisal of the costs and benefits of the lapse is different afterwards than it was just before the lapse.
High risk states for Omar include stress [particularly anger and frustration], and temptation [immediate access to the incentive]. A lapse produces immediate gratification, and Omar learns that the outcome of lapsing is reward. This learning is bound to the state in which the lapse occurred.
Later there will be a price to pay, but Omar will be in a different state when he pays it. The lesson that the lapse is ultimately punishing is bound to the remorseful state, and so will not available to Omar during future high risk states – although, each painful lesson will be frustratingly familiar. While experiencing the punishment he will not understand why he keeps making the same mistake, because now the powerful biases of the high risk state are unavailable to him. Unaware of the illusion of state dependency, Omar torments himself by attributing his long and frustrating history of failure to personal inadequacy.
Escape from this demoralizing pattern is so difficult, not because behaving successfully requires more strength than he has, but because his appraisal of success changes with local conditions, and he is blind to his changing bias.
Attachment is the great fabricator of illusions; reality can be attained only by someone who is detached. – Simone Weil
The Imp of the Perverse
People often find themselves doing exactly what they told themselves not to do. The very intention to suppress a response has the paradoxical effect of producing it. In the “Tell-Tale Heart”, Edgar Allan Poe described this phenomenon poetically, and labeled it: the Imp of the Perverse. Consider this challenge:
Try not to scratch your nose. Continue reading, but be aware that even letting your nose itch would indicate a lack of personal control. So try not to even think about your nose, and see if you can read to the end of this protocol without once scratching your nose or the area near it.
The intention to not let your nose itch – especially if you take it seriously – often has the perverse consequence of producing nose itching. There are two interesting and interrelated cognitive operations of this phenomenon:
- Negative Suggestion: Negative representations are defined in terms of positive representations [their opposite], but positive representations are defined directly. For example, the statement: “It is not raining” requires a representation of: “It is raining”. Likewise, the statement: “Chester is not a pedophile” requires the audience to comprehend the assertion: “Chester is a pedophile”, and then reject it. But the association between Chester and child molestation now has a representation in the audience’s mind. To understand the instruction: “Don’t let your nose itch!” the reader must refer to an internal representation of an itchy nose – which causes the nose to itch.
- Ironic process: To determine if you are successful in having a nose that is not itching, you must compare the current sensations with what they would be if your nose was itching. According to this interpretation, it is checking to make sure you are successful that causes the nose to itch. Ironic, isn’t it?
Always frame intentions in terms of what you want – not what you don’t want!
Humans hate restrictions – especially of those freedoms they already have. Reactance refers to the motivation to react or rebel against restriction. In one study, two-year old boys accompanied their mothers into a room containing equally attractive toys. The toys were arranged so that one stood in front of a transparent Plexiglas barrier, and the other stood out of reach behind the barrier. The boys showed a strong preference for the toy they couldn’t have. Their inability to get the toy behind the barrier caused many boys to tantrum, which was not relieved by giving the child the equally attractive toy.
Once an object [such as chocolate] is forbidden, there is an emotional reaction to the restriction, which, perversely, enhances the desire for the forbidden object. This version of counter-regulatory motivation is called: reactance effect.
The motivation to stay with the plan is state-dependent, and so rises and falls according to immediate conditions. However, reactance is intrinsic to the task, and so is always present. Whenever immediate conditions are insufficient to support the motivation to stay with the plan, even for a moment, reactance is there to motivate a first lapse.
The mistake was not forbidding the serpent; then Adam would have eaten the serpent – G. B. Shaw
Restrained Eaters Research
Studying counter-regulatory motivation is difficult, because people hide their perverse nature when they think they are being observed. Consequently, a deceptive methodology has been developed to study it. Dieters [restrained eaters] and non-dieters are told that they are participating in a taste preference study. After sampling a variety of foods [the pre-load] and offering their critique, they are ‘thanked’ for their participation with a free lunch. The lunch is offered buffet style, and each participant can consume as much as desired. Unbeknownst to the participants, behind one-way mirrors are research staff observing them and calculating how many calories each subject consumes. The effect of low calorie and high calorie pre-loads on subsequent eating are compared.
When the pre-load was low calorie, dieters consumed fewer calories during the buffet than did non-dieters – after all, they were on a diet. However, when the pre-load was high calorie, dieters consumed significantly more calories during the buffet than those who were not dieting!
Interpretation of these results: After consuming the high calorie pre-load, the restriction was temporarily removed, for example: “I have already broken my diet – I’ll start back tomorrow”. The idea that there will be a restriction in the future paradoxically enhances the motivation to act counter to the restriction – “to get it while I can”. The urgency to take advantage of the apparently limited opportunity often produces extreme and bizarre behavior once a lapse has occurred.
The Insult Is the Injury
Addicted individuals interpret their repeated relapses as proof of personal weakness. The belief that the cause of the failure is within is an internal attribution for failure – for example “I do not have what it takes to be successful.” The lapser may also believe “The fact that I failed in the past means that I will fail in the future.” This is a stable attribution for failure, for example, “I am weak, and the same weaknesses that caused me to fail in the past, will cause me to fail in the future.”
As seen in the restrained eaters research, the very intention to restrict eating produces counter-regulatory motivation. Once the first lapse occurs other lawful processes are triggered, which produce a full blown relapse. People relapse because the deck is stacked against them. Escaping an addictive disorder is much more difficult than most people realize. This formidable task is complicated by factors such as perceptual illusions and counter-regulatory motivation. A task such as this is worthy of respect. Accepting the internal, stable attribution [the problem is within me and it is not going to change] is not only wrong headed, but sets one up for failure.
Consider the following study which demonstrates how internal attribution and counter-regulatory motivation can work together to affect one’s self-perception. Teen-aged boys were told that a book was too sexually explicit to be read by those under 21. This restriction had the effect of dramatically increasing their desire to read the book. The experimenters knew that the attractiveness of the book was enhanced because the book was forbidden. But the boys had a different perspective; they attributed their motivation to read the book to a personal weakness – to be attracted to lewd content. Forbidding the book had the perverse consequence of causing the subjects to believe that they were perverse.
Jill: You think I am stupid.
Jack: I don’t think you are stupid.
Jill: I must be stupid to think you think I am stupid when you don’t.
– R. D. Laing
THE COMPONENTS OF THE COGNITIVE PATH
Perversely, some people follow a path that they know will produce more costs than benefits, because following the path of greatest advantage sets up a conflict. On one side there is the autonomous behavior that leads to immediate gratification. Against this is pitted the person’s decision to move in the direction of greatest advantage. The conflict plays out in real time: choices are made, outcomes are experienced, and so the course of one’s life is defined.
Following the path of greatest advantage is not a trivial task; one must over-ride two attributes of the psyche that favor relapse despite good intentions:
- The Problem of Immediate Gratification: Motivation to approach or avoid is much more sensitive to the immediacy than to the magnitude of the payoff. This problem causes people to choose a small reward now at the expense of a much larger but delayed reward. Another version is to avoid a small punishment now and get the punishment later.
- The Karma of Practice [habituation]: The more well worn a path, the easier it is to follow – habit strengthens with exercise. The stronger the habit the easier it becomes to perform, and the more conscious effort is required to interrupt. With sufficient practice a behavioral sequence becomes autonomous, in that it is not intentionally chosen, but plays out all by itself. The consequence of repeatedly performing a behavior sequence is that it becomes autonomous.
The path of greatest advantage begins with the decision to over-ride the problem of immediate gratification and the karma of bad habits. Note that the word: ‘decide’ is derived from the root ‘cide’ as in sui-cide, homi-cide, insecti-cide and means: to kill. When, for example, an alcoholic makes the decision to quit drinking it is understood that s/he means to kill, for once and for all, the option to drink alcohol, and thereby lock out drinking in the future.
Nearby stimuli influence motivation much more than distant stimuli: bad mood or luck now can have a greater influence on behavior than a commitment made last month. In some situations the alcoholic wants to drink, in others s/he wants to quit drinking forever. Commitment is required precisely because motivation is fluid, and changes with immediate conditions.
The decision to act marks the transition from fluid motivation to frozen commitment. Incentive use will no longer be controlled by immediate conditions, but by the commitment one makes at this moment of decision.
A commitment is a promise to perform in a specified way at a future time. The ability to deliver on this promise – despite the pull of local conditions – can be strengthened or weakened. Making a commitment is like making a wager – a bet that you will do what you committed to do. Winning the bet increases will power – the power to adhere to future commitments. Failing to adhere to the commitment loses the bet, and with it some amount of future will-power. Addiction is the consequence of losing this bet too many times.
Don’t Be Reasonable!
When you make a commitment you are giving odds – one loss overcomes many victories. You must do exactly what you committed to do. A well formed commitment is developed with the no-exceptions requirement in mind, and so requires a clear specification. It may be stated as an “I will” intention, e.g., “I will remain clean and sober in all circumstances – no exceptions.” Remember coding the intention as a negative, e.g., “I will not drink alcohol” is poor form and often results in poor outcomes.
Motivation changes with local conditions. In the beginning, addicted individuals are highly motivated to adhere to their decision to change. Naturally, they expect to always feel this way, but they will not.
As the crisis that motivated the commitment recedes into the past and one becomes involved in the continuous stream of events that play out in real time, the commitment decays. Immediate motivation becomes more a function of local circumstances than the distant commitment. The problem of immediate gratification which at first supported the commitment – when the addict wanted immediate gratification of the desire to be free of the addition – must be over-ridden when the addict is faced with immediate temptation. The motivation to maintain abstinence is greater during the contrite state following an unfortunate drinking episode, than during a high-risk situation some months later.
Motivation is an abstract construct, but action changes the world. Will s/he lapse or adhere to the commitment during that high-risk situation? Whatever happens at the moment becomes part of the performer’s biography. What had been merely a possibility is promoted to a reality; the alternative options vanish into oblivion. Once performed, overt action becomes part of world history, and can not be undone.
And so the decision to kill off a rewarding incentive sets up a conflict that plays out over time. On one side there is the autonomous behavior that leads to immediate gratification. Against this is pitted the rational decision to move in the direction of greatest advantage. The ability to follow the path of greatest advantage despite habit and immediate gratification is itself the result of following the cognitive path of self discovery.
Selecting a Path
Good outcome requires that the rules committed to now – when you are in your rational state of mind – will influence behavior in the future despite the influence of local stressors and temptations. Most people with addictive disorders repeatedly fail to adhere to their voluntary commitments despite their intentions to avoid the errors that led to lapses in the past.
The critical question is: Do you have the power to make a decision now that will remain effective to guide your actions in the future?
Relapse prevention is the consequence of following the cognitive path and being mindful for a long time. With this in mind, an important early task is to select a path that is well matched to your personal attributes and environmental realties.
At first, people consume substances such as alcohol, nicotine, unhealthy foods; or engage in activities such as gambling or pornography to make themselves feel good. With repeated practice the behavior becomes habituated, and the person becomes dependent on the external source of control. Once this happens, it is difficult to reverse the process. None of the many different approaches to addressing addictive disorders produce satisfactory long-term outcome.
Treatment programs for addictive disorders have unacceptably high relapse rates, and many approaches have iatrogenic consequences . For this reason, good long-term outcome requires not just immediate behavior change, but relapse prevention. Unfortunately, the behavior change that results from complying with a treatment program tends to be temporary.
The influence of external control weakens when the external factors are removed. Drivers slow down when they see a police car, but will speed up a few miles later; decongestant nasal spray is effective for a few hours, but eventually wears off.
Externally directed treatment is often comfortable for dependent individuals. They want something external to the self to take responsibility for achieving success, because they have lost faith in their own ability to manage themselves. Intrusive treatment does produce short term behavior change, but does not generally lead to freedom from dependence.
One way to achieve good long-term outcome is to develop internal control of behavior: independence. While this takes energy, there is a valuable payoff: once you develop the capability to influence your own behavior, the change is irreversible! Rather than wear off, self determination becomes more robust with time and experience.
Escape From Freedom
Because we are free, we are constantly making decisions, and every decision affects our lives. In some way, we are responsible for nearly everything that happens to us. We get what is coming to us in the form of the natural consequences of our behavior.
The alternative to accepting responsibility for how we live our lives is the belief in external responsibility: we can only have influence over outcomes to the extent we know the secret protocols, or the magical words. The Buddha meditated for many years in a search for the secret to understanding the human condition. His insight is simple, and once you appreciate it you can be free of this illusion, and instead follow the path of greatest advantage – the Cognitive Path.
The secret is … there is no secret!
The discovery that Santa Claus is fiction is one of several developmental milestones on the path to adulthood. Development continues through adulthood, and there are other discoveries to be made on the passage to independence. One is the appreciation that there are no easy short cuts or hidden secrets to freedom from addictive disorders.
The irony of seeking treatment for a dependence on an external source of control has probably not escaped the astute reader. The expectation of being freed from dependence by an external force is an illusion – kill it! Your client can achieve independence only when s/he has the procedural skills to manage whatever situations arise. Like the procedural skill of driving a vehicle, once acquired the change tends to be irreversible
The next level of maturity is a major life transition – one which some never make. This understanding is the beginning of the passage from dependence to independence. No one else can do this for you! The path ahead is for your steps alone.
Accessing Free Will
Turkeys make excellent mothers; they spend much time warming and cleaning their young. But this complex behavior is triggered by one thing – the ‘cheep cheep’ sound of her chicks. If the chick makes that sound the mother will care for it, otherwise she will ignore it. Cialdini describes a study in which a polecat, the turkey’s natural enemy, was stuffed with a tape recording of the ‘cheep cheep’ sound. When the stuffed pole cat was pulled by string to approach the turkey she attacked it viciously. But when the taped sound was turned on, the turkey not only did not attack it, but gathered it under her to comfort it. When the sound was turned off she again attacked it.
We are different than turkeys, and can choose how to behave. In fact, some people select long range goals, develop plans, and make adjustments along the way until they achieve their goal. Their biographical course appears to be self-determined. Turkeys cannot consciously guide their future course, and as far as we know, nothing else can either.
Perhaps a new phenomenon – free will – emerged with human cognition. However, some cognitive scientists argue that free will is an illusion . It is only because we are so much more complex than turkeys that we appear to possess something the turkeys do not. We can’t resolve the free will debate by asking people whether they intended to do something or not, because the experience of intention may be an attribution that follows behavior rather than the actual cause of the behavior. The subjective experience of free will is not evidence for its existence.
We can never be sure that A causes B, as there could always be a third variable C that causes both of them. While it seems that our intentions cause our actions, there may be causes, of which we are unaware, that produce both of them. In fact, there is evidence that even before we are aware of the intention to perform an action, the neural precursors of the action have already occurred . For example, subjects were told to note the time on a clock when they made the decision to press a button, and then to press the button. They took 0.2 seconds on average to press the button, after they decided to do so. But an EEG monitoring their brain waves revealed a spike 0.3 seconds before they decided to press the button. Based on this and other evidence it is likely that ongoing behavior is determined by factors that are already in place at the moment of action.
Is it possible, then, to intentionally alter the course of events? Can an individual use his or her own cognitive resources to figure out that it is time to change course, and then make it happen? Can I influence my own biography, and intentionally create one that I judge to be better than the path of least resistance.
At least two factors are required to control the future of one’s own life. First, the client must understand the workings of his/her mind [psychoeducation] and second, the client must have a strategic and tactical plan of action to be carried out in times of high stress [skill acquisition]. This plan of action is an individual plan, but has components of anticipatory planning [future pacing] and coping tactics. The more the client is able to build a repertoire of appropriate thoughts and behaviors that can be applied to the high stress situation, the more likely that s/he will be able to avoid relapse and continued addiction. The final step, of course, is the ability to keep these understandings and plans in mind when the difficult times occur.
Volition, or will, refers to the ability to over-ride the local distractions and follow the intended path. The challenge of the Psyche is to choose the path of greatest advantage – the one I judge to be in my own best interests, rather than yield in the direction of least resistance – the one formed by local conditions.
Seymour Epstein proposed an alternative to Unconscious vs. Conscious Model of the Psyche:
Experiential Processing Rational Processing
Hedonically oriented: What feels good Rationally oriented: What is sensible
Connections determined by the principals of classical conditioning Connections determined by the principals of logic
Has a long evolutionary history and operates in animals as well as humans Has a brief evolutionary history – only available to humans
Encodes reality in concrete images, metaphors and narratives Encodes reality in abstract symbols, words and numbers
Does not require formal language. Behavior is mediated by “vibes” or feelings from past experience Requires language. Behavior is mediated by conscious, rational appraisal of events
Rapid processing: Oriented toward immediate action Slower processing: Oriented toward future action
Slow to change: Change requires repetitive or intense experience Rapid to change: Changes with the speed of thought
Context-specific processing – experience is state dependent Cross-context processing – logic is independent of local state
Experienced passively – unconsciously – one is overtaken by one’s emotions Experienced actively – consciously. One can intentionally override urges
Certainty is self-evident – seeing [experiencing] is believing Certainty requires justification via logic and evidence, so that one is not taken in by illusions
Using this vocabulary, intentional influence over your own biography requires a two part strategy: first your Rational Processing System must figure out what you want and how to get it. The second, and critical part of the strategy is to train the Experiential Processing System to perform as intended in real-time.
Sculpting the Experiential Processing System
Performing a complex action becomes easier with practice. With sufficient practice it become so easy that it requires no conscious effort at all. At this point, the habituated reaction has become the default path, and now requires conscious effort to inhibit or interrupt. When a self-injurious reaction has received sufficient practice it becomes autonomous, and changing it requires that you remain mindful enough to over-ride the automatic reaction – difficult when your cognitive resources are depleted or otherwise occupied.
When face to face with an emotionally provocative situation your client will not be the same person s/he is now. Events that may seem trivial from his/her current rational perspective will be viewed differently when s/he is upset. When encountering a high-risk situation in real time, s/he will most likely experience it the same way, and exhibit the same reactions s/he did when last s/he encountered such a situation. Because this sequence of events produced outcomes that were counter to your client’s interests, you were motivated to read this protocol. Perversely, the text concludes that understanding the text is not sufficient. The Experiential Processing System must be molded according to your client’s taste. The automatic system must be habituated to act in accordance with the Rational Processing System’s goals and intentions.
Metaphors for Sculpting Experiential Processing System
- Habit strength, like muscular strength changes gradually. It grows stronger with exercise, and atrophies with disuse. It takes about the same length of time to sculpt your body through weight training as it does to sculpt your Experiential Processing System.
- A boxer does not have the luxury of deciding how to react to a right cross. The reaction must be so well practiced that it has become autonomous. To perform successfully the boxer will hire sparring partners so s/he can practice reacting well to real time challenges. With sufficient practice, the intended reactions become ‘spinal’ – automatic, requiring no conscious guidance.
- In the metaphor of an athlete or a dancer, the counselor is the trainer or coach who will observe the client’s reactions and provide technical feedback, along with suggested exercises in preparation for the challenges that lie ahead. Each high-risk situation encountered can be viewed as a gift, an opportunity to perform the way the Rational Processing System judges to be the path of greatest advantage.
The basic building blocks of our thoughts are from our senses. (Representational systems). Using the senses (seeing/visual, hearing/ auditory, feeling/kinesthetic, smelling/olfactory and tasting/gustatory and interpreting internally [appraising, attributing, generalizing, making analogies, categorizing, etc.] is what is commonly known as thinking. Your subjective experience (mental map of the world), is created from combinations of the five senses and these combinations have meaning based on qualities with which they are coded (submodalities/qualia). How you code (use submodalities/qualia) an experience (combination of representational systems) will affect how you feel about that experience. Actually, the way you interpret and label the experience at the time has a lot to do with how you code it. Thus, the recall of that experience is in the coded representation.
If you have an internal picture (visualization) of a ‘happy’ experience, and an internal picture of an ‘unhappy’ experience, the difference that makes the difference is not what the pictures are of, but the qualities (submodalities) of the pictures.
For example, the ‘happy’ memory’s picture might look ‘bright’ (contrast submodality), and the ‘unhappy’ picture might look ‘dark’ (contrast submodality). The ‘happy’ picture might be ‘closer’ (location submodality) while the ‘unhappy’ picture might be ‘farther away’ (location submodality). You might see the ‘happy’ memory as if you are looking through your own eyes (Associated submodality), and in the ‘unhappy’ memory, you might see yourself in the picture, (Dissociated submodality) as if you are watching a video of yourself.
If you took the visual qualities of how you remember the ‘happy’ experience and applied these qualities to the ‘unhappy’ experience, (shifting submodalities/submodality shift) you’d begin to feel different, and probably better, about the ‘unhappy’ experience. The difference in how you feel about your experiences is not based on what you see, hear, feel internally (representation), but on the qualities or details of the pictures, sounds, and feelings (submodalities).
Part of mindfulness is to prepare your mind in what to think in stressful situations before the stressful situation occurs. This time of anticipatory planning is often referred to as ‘future pacing’ and concerns both the development of coping strategies and the ‘anchoring’ of emotional states. [See CBT#30]
If you want to feel different in a future situation, for example, if you want to have more self-confidence when in a high risk situation, you can future pace, i.e. link this feeling [confidence] to the situation. To do this, first set up an anchor for the desired mental state. It can be any kind of state, like confidence, happiness, etc. Then, you have to choose an anchor. This can be any touch, word, sound or movement. If you anchor yourself, you normally use a touch as an anchor. It could be something like touching your ear, scratching your nose, giving your wrist a squeeze or touching your thumb and first two fingers together. Now, go into the state you want to anchor. This can be done by:
- recalling a time in your past when you felt the way you want to feel every time you fire off the anchor. Close your eyes and see yourself from a dissociated point of view. Then step into the picture and look at this scene as if you were looking through your eyes (associated point of view). See, hear and feel everything as if you were actually there.
- imagining a time where you could have felt this way. Step into this picture, be associated into this scene.
- associating into somebody else who you know feels this way. First, see him/her from a dissociated point of view. Then, move into the image of him/her, associate into him/her. You will begin to feel the same things you think s/he feels.
- doing something in which you feel this way. If you know that there is an activity in which you are in the state you want to anchor, why not try doing this activity to anchor your state. For example, if you want to anchor happiness, do everything that will make you happy. Read some jokes, play games, have fun…
You can make your mental state stronger by changing the submodalities.
And now, anchor this state. Simply do the thing you have chosen as your anchor.
See a picture of yourself in this high risk situation and be associated into this picture and fire off your anchor. Now, you will automatically have the anchored feeling when you are in such a situation.
You can test your anchor by going into a normal mental state and then firing off your anchor. If your mental state doesn’t change the way you want it to, go back and make your state stronger and better.
To use the gift of rational processing, it is important to appreciate when it is available and what it can and cannot do.
- Rational processing is too slow to influence behavior in real time. Performance, to be smooth and responsive to a changing world, requires a rapid, holistic processing . When we try to consciously control ongoing behavior, we disrupt it.
- Rational processing is only possible when there is a surplus of cognitive resources. It is not available when cognitive resources are depleted or otherwise occupied – e.g., by complex cognitive demands, or by strong emotional states.
- Rational processing is free of state dependent biases: 2+2=4 is true regardless of one’s state of mind.
- Rational processing can produce rapid change – e.g., “I used to believe in the tooth fairy, but one day I realized that it had been my mother all along”. Once I appreciate this, my trajectory changed forever. This is contrasted with the need for many repetitions to change a habit.
- Rational processing can influence future behavior through a variety of means including: pre-commitment, rehearsal of desired performance, environmental engineering.
What this means is that all of the concepts that are included here hold the possibility of immediate change of attitude and trajectory of one’s life, but may not. The psychoeducational training of the protocol includes the opportunity for spontaneous change which can then be supported by procedural habit.
Do we have free will? At lower levels probably not, even though our experience of cause and effect makes the existence of free will seem self evident. On the other hand if we define free will as the possibility of self-determination – the ability to have a premeditated influence on the unfolding of our biography – then free will is possible. The Rational Processing system can influence how things unfold for you, but this is not a trivial task. Your clients have one precious life to live, and hopefully the information on these pages will assist you in helping them follow the path of greatest advantage as they perceive it.
When we analyze ‘will’ we shall find ourselves pushed back to the level of attention as the seat of will. The effort which goes into the exercise of the will is really effort of attention; the strain in willing is the effort to keep the consciousness clear, i.e., the strain of keeping the attention focused. – Rollo May
“. . . to choose the path of greatest advantage, rather than yield in the direction of least resistance.” – G. B. Shaw
I will act AS IF what I do makes a difference. – William James
In discussing evil, the Zohar [an ancient book of Jewish mysticism] tells the story about a king who wanted to test his son, to see if he would be virtuous. So he hired a woman to entice the son, instructing her to use all her wiles with him. The Zohar asks, “Is the woman not also a loyal servant of the king?” In this parable, as soon as the prince realizes that the woman is in the hire of his father, she is no longer a threat. The same is true of evil.
Show me a thoroughly satisfied man – and I will show you a failure. – Thomas Edison
In most cases relapses occur not because the person was overpowered by unbearable forces, but because the first lapse did not seem like a really bad idea at the time.
Escaping addiction appears straightforward enough. At first, the addicted person clearly understands that the addiction is a bad deal and has vowed to change, and fully expects to energetically resist lapsing at future high risk times. Sadly, by the time s/he encounters the high-risk situation everything has changed.
Motivation is not fixed. What was strongly abhorrent at one moment may be strongly attractive at another. Changes in appraisal may occur so fast and so subtly that traps which are obvious to you now, will be invisible at the critical moment. To guide your own path, you must recognize diverting influences before it is too late!
Since hindsight is better than foresight, study the client’s history – look for warning signals – events that have preceded previous relapses such as certain cognitive events. Listed below are some of the classic warning signals.
- Goal Oriented – Permitting a lapse will help achieve some goal.
Example: “The addictive behavior will help me relax and perform well in this social situation.”
- Anticipatory – Attention to the immediate pleasurable aspects of the lapse, while ignoring its delayed painful consequences [often accompanied by minimization].
Example: “It would feel so good.”
- Minimization – Underrating the negative consequences of a lapse; ignoring the painful lessons of past lapses.
Example: “I’ll just have a little, it won’t cause a problem.”
- Why questions – Posing a ‘why’ or ‘why not’ question with the tacit understanding that if you can’t answer it at the moment you have license to lapse.
Example: “Life sucks anyway, so why not?”
- Reactance – Counter-regulatory motivation in reaction to restriction of a freedom.
Example: “Other people enjoy this incentive, why can’t I? I’ll do what I want!”
Denial is the stealthiest of them all. The chain of events that leads to relapse often begins and unfolds all by itself – autonomously – without rationalization or justification.
Your client will be in greatest danger of falling into denial whenever his/her cognitive resources are unavailable. The mnemonic HALT refers to some situations which tax cognitive resources and thereby make one vulnerable: Hungry, Angry, Lonely, or Tired. If the client fails to recognize these first tier warning signals, s/he will be approaching the final links of the relapse chain.
Last Lines of Defense
“Look at me!” – If the incentive captures the client’s attention, s/he must recapture it without delay. Any thought or image of the incentive – or people, places and things associated with it – reduces the psychological distance between the client and the first lapse. Attending to the incentive is always a warning signal – consider:
- Apparently Irrelevant Decisions – Attraction to activities that are seemingly unrelated to the addictive behavior, but decrease the distance between you and the incentive.
- Thinking about circumstances in which it might be OK to use the incentive.
- Debating with yourself about lapsing.
- Imagining how it would feel to re-experience the addictive incentive. [Note: Dreams about the incentive are not warning signals, and may in fact promote long-term recovery].
The door is open – At first there was no question about adhering to the commitment. But at some point the door to the first lapse has become open. While there has been no conscious decision to renege on the ‘no exceptions’ commitment, something has changed. If your client allows the door to remain open, s/he will surely lapse. S/he must close the door immediately and firmly. This is the last chance to rescue victory from the jaws of defeat.
Redirecting attention to the original commitment may not seem heroic at the time, which is why mindful behavior is so exceptional. Engaging in an effortful coping tactic during the ordinary experience of real time may seem forced, weird, or unspontaneous. Of course it is. The default path – the one that seems natural – is lapsing. To escape addiction your client must over-ride these autonomous tendencies and habituate a path that produces more pleasure and less pain.
It is the enemy whom you do not recognize who is the most dangerous – Fernando Rojas
If you want the future to be different from the past, study the past – Spinoza
Hell is discovering the truth – too late – John Locke
That which deceives us and does us harm also undeceives us and does us good. – J. Roux
Even thinking about wickedness is already the beginning of wickedness. – Confucius
The safest road to hell is the gradual one – The gentle slope, soft under foot, without sudden turnings, without milestones, without sign posts. – C. S. Lewis
Crib Sheet: Coping Tactics
The DEAD Tactics
These four basic tactics put distance between the client and the incentive
- Delay – Put temporal distance [time] between you and the incentive. This is a positive way of phrasing the commitment: “I will not use at this moment!”
Example – “Whenever I notice a warning signal, I will commit to remaining clean for the next hour.” This does not mean that you will lapse at the end of hour. If you still experience desire, commit to another hour.
- Escape – Leave the scene – put geographical distance between you and the incentive.
- Avoid – Prevent problems by avoiding people, places, and thinking patterns associated with the addictive activity.
- Distract – Aim your attention mindfully, and do not entertain thoughts or images associated with the incentive.
Example: Any thought or image associated with the incentive triggers the Self-Determination question: “What is the best use of my attention right now?” Continually move your attention to whatever is the answer, until it stays where you want it for a while.
- Distraction/redirection – e.g., calling someone, reading, engaging in a favorite hobby, etc.
- Utilize rational processing during high risk situations, example: “This is the High Risk Situation I have been preparing for; it is important to set good precedent now”.
- Coping statements -“These cravings won’t last forever,” “The more I experience the cravings without giving in, the closer I am to completing this passage,” “The craving will go away whether I give in to it or not. ” Some people find it useful to transcribe the coping statement on a Reminder Card and carry them with them.
- Rate stress/desire on the 10 point SUDS [Subjective Units of Desire Scale]: “I understand this experience will change over time, and I am detaching from the experience to observe it.”
- Cognitive Distraction – Do a thought record, or otherwise journal your observations; describe your surroundings in as much detail as possible. Observe from outside yourself.
- Scrooge’s Technique: Remind yourself in vivid imagery of the benefits of success, or the penalties of failure.
- Thought stopping – Yell: “Stop!” to yourself, followed either by a review of predefined coping statements or by focus on the answer to the question: “What is the best use of my attention right now?”
- Use Cognitive methods to examine thoughts and beliefs about cravings. For example, many individuals have thoughts like “I can’t stand urges” “Urges last forever” “I’m powerless over my urges” etc. Are these beliefs really true? – see Urge Surfing below.
Flow with the experience and detach from outcomes.
Urge Surfing – The father of ‘Relapse Prevention’, G. Alan Marlatt touted this method of viewing the urge as a wave that may be strong at first, but eventually diminishes in a relatively short period of time. One can imagine oneself as a surfer on that wave, and if you can hang on long enough you will have successfully ridden it out. Most people who are trying to eliminate an addictive behavior don’t realize that the cravings are short because they always give in before it subsides on its own. For all such folks know, the craving would continue to increase until they exploded or went crazy. In fact that never happens. What always happens is if you adhere to the commitment the craving always dissipates all by itself. Some people like to remind themselves “I’m only minutes away from success!” whenever they have a craving.
- Turn it over to a higher power.
- Cued Relaxation – elicit a relaxation response by intentionally following a memorized protocol
- Elicit a different internal state by Aiming Attention
- Other Self-hypnosis techniques.
- Pull up into adult – Change posture and mind set during a single breath cycle.
- Use Reminder Card to “think through” the lapse or remind yourself of your beliefs and commitments.
- Take a Breather – Slow belly breathing as you focus on a mantra – e.g., “breathe in…. and relax.”
This cheat sheet contains abbreviated versions of tactics to facilitate self-determination.
The Reminder Card
When you encounter a high risk situation, you will be in a different state of mind than the one you are experiencing now, and everything will be different. Below is a card about the size of a dollar bill, so you can carry it with you in your wallet. The Decision Matrix side is to remind you why it is so important to do the right thing when in a high risk situation. The other side is designed to remind you of the beliefs and intentions that made sense when you were in your right mind.
Side 1: Decision Matrix:
In the first empty box, under the word ‘Positive’, write the immediate positive consequences of giving in – e.g., it would taste good, give me pleasure, relax me. In the next box, under the word ‘Negative’, write how you would feel later – e.g., guilty, disappointed in my self, weak. In the third box, Long-Term Positive, write the long-term benefits of lapsing – for most people this will be an empty box, although some individuals are motivated to be overweight – e.g., to protect myself from the sexual impulses of others. The last box is the most important – the long-term penalties of obesity. Many people want to fill this space with abstractions – e.g., death, loss of active life. While these may be true, they are cheap. You have lapsed and have not died, and so the word is not as motivating as you may think. We need something that will elicit a strong emotional reaction. It is recommended that you use a small screenplay of what is waiting for you if you continue down the path you have been on. Details including people’s facial expressions are particularly good. For example, your loved ones visiting you at the hospital, and you are looking up at them from your bed and see their expressions of sadness that you are ill, but also anger: “You knew this could happen if you continued to eat this way, and now look at you, and we have to use our savings to keep you alive.”
Consequences of Lapsing Positive Negative
Side 2: Beliefs and Intentions
Write what you need to read when you will be in a high risk situation.
These are my beliefs:
When I Encounter Cravings or High Risk Situations I Will:
If I lapse I will:
If you have lapsed in the past you may be able to learn some lessons about cause and effect. Please consider the sequence of events that led from an intention to control this behavior to the subsequent lapse of control. How did the sequence of internal and external events progress for you? You may describe a specific episode or a make up a representative example. Please describe the sequence of events as if you were developing a screenplay for a movie, also include internal events such as thoughts, images, and emotions.
From your current perspective, can you identify moments within this sequence when you had an opportunity to change the course of events? If so, please choose one and consider what you actually could do that would be effective – see for ideas. Please use the space for notes, and a conclusion.
The Cognitive Path of Greatest Advantage
Goal Statement: The conditions that will exist when you achieve the goal. Examples: I am fit and healthy; I am clean, sober, and clear thinking
Motivation: List the benefits of success and the penalties of failure: Sample Benefits: Health, self-confidence
Penalties: low quality life, self-loathing
Behavioral Commitment: Describe how you intend to achieve the Goal
Example: Complete abstinence from drugs, following a specific eating plan.
Executive Commitment: How you will guarantee that you execute the Behavioral Commitment when you encounter high risk situations in real time. For example: When I encounter [High Risk Situation. . . ] I will [Intended Coping Response. . . ]
Example: Whenever I think about drinking I will immediate visualize the Relapse Screenplay.
[Use the back of this sheet to specify [sculpt] how you intend to react when you encounter predictable high risk situations].
The no exceptions clause: I agree to permit no exceptions to the contingencies stated here – regardless of how reasonable a momentary lapse may seem at the time.
Stay the Path to Prevent Relapse: After high risk situations you will have the benefit of hindsight. Nature will tell you the truth about how your psyche works in real time. The nature of the Relapse Prevention challenge changes, and requires continued adjustment.
If I successfully cope with high risk situations I will: [what you will do to keep moving forward].
Examples: I’ll keep a journal, I commit to sobriety for 12 months and then formally re-evaluate then.
If I lapse I will: [plan for preventing demoralization, and getting back on track].
Example: As soon as a lapse has begun I will email the counselor and begin the process of looking at things from a detached perspective so I can write about or discuss how it came about. I commit to developing a new plan based on what I learn from this lesson in cause and effect.
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