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To know ourself fully, we must let the mind become conscious of itself (Cloninger, 2004).
Millions have utilized self-help groups and 12-step facilitated programming to attain lasting abstinence from their addictive disorders. Yet, most in the scientific community see such programming as being “non scientific” and lacking scientific explanation. By exploring such diverse fields as neuroscience, neuropsychology, developmental psychology (attachment theory) and interpersonal neurobiology, a science of recovery can be developed. This two-part series will explore some of the neurological evidence and, using a case study, explain how this evidence can assist patients on their recovery journey.
Incredible progress has been achieved in understanding the human brain and how such phenomenon as spirituality, therapeutic relationships and empathy take place. Science has produced greater understanding of the addicted brain and how this dynamic organ changes during the process called recovery. Unfortunately, most of this information never reaches those who can best utilize it. To that end, this writing endeavors to contribute to clinical understanding, with the goal of assisting those searching for personal recovery.
A place to start — we build each others brain
Neuropsychological rehabilitation involves two related variables. First, the patient must remain abstinent. Second, the brain must exercise using repetitive recovery-oriented behaviors and thoughts or, stated another way, “take the body and the mind shall follow.” Recovery can be considered as “one day at a time” within the context of a recovery environment (environmental enrichment) that allows the brain to “reform” as an organ programmed for recovery. These brain changes culminate in changes in personal behavior giving “stick with the winners” a new and powerful meaning. Since the mind is an interpersonal phenomenon — built in relationships with others — choices of whether to stay around the same people or to make dramatic changes, consistent with personal recovery, become critical.
Clinicians are trained in the language of pathology. The use of the term “personal recovery” demands an entirely different nomenclature. What words can be used to describe those that are able to find contentment in their lives after giving up the pleasure, relief or release caused by the infusion of a mood-altering substance into their brain?
Alcohol and drugs are environmental risk factors. For example, repeated administration of mood altering substances causes changes in neural functioning that are linked to anatomical changes in neurons in the dopaminergic and glutaminergic systems. In the nucleus accumbens, repeated exposure to cocaine, methamphetamine, and morphine causes increased branching of dendrites and increased receptor density. These changes in neuron structure lead to greater stimulation when dopamine or glutamates are released in the nucleus accumbens (Prevention Research Institute, 2005). This phenomenon is called sensitization and involves genetic alteration in the shape and function of nerve cells. Influenced by such variables as genetic susceptibility and stress (trauma), this sensitization can persist for years, or even a lifetime.
Hebb’s Rule (named after Donald Hebb) states that “cells that fire together, wire together.” When a synapse is frequently used, it will adapt its physical structure to make the connection stronger. This process occurs as the neuron receiving the repeated signals releases a substance called a neurotrophin. Neurotrophins cause the axon on the neighboring sending cell to branch and create new synaptic connections (Prevention Research Institute, 2005). This allows the brain to react and reshape itself (neural plasticity) to meet the demands of a changing life. In this case, the brain is going from being influenced by internal and environmental stimuli consistent with supporting addiction, to the changes consistent with recovery.
If the addictive substances and the negative environmental influences cause changes in the expression of genes, what occurs when the drugs are no longer present, and the recovering addict changes environmental influences? Novelty, environmental enrichment and physical activity can activate psychobiological arousal. This, in turn, can evoke gene expression and protein synthesis, leading to the formation of new nerve cells and other changes consistent with a recovering brain (Rossi, 2002). According to Rossi, “This process of neurogenesis and neural networks being “reformed in new configurations” appears to be the psychobiological foundation of the “reframing of psychological states” during psychotherapy and the healing arts ...” (Rossi, 2002).
Epigenesis is the process that mediates variations in gene expression, secondary to changes in the individual’s internal or external environment. “In epigenesis, methyl groups are added to specific sites on DNA, and acetyl groups are added to the histone proteins that form the chromosomal structure around DNA, thereby silencing (through methylation) or promoting (through acetylation) the expression of specific genes” (Fraga et al., 2005).
A subjective viewpoint on recovery
“You work with what is, rather than with what you wish were there” (Moore, 1992).
Stimulant addicts enter treatment with a high incidence (around 50 percent) of cognitive impairment. They also enter with little appreciation for a recovery-oriented lifestyle. To them, fun is using drugs. Misery is being without them.
One way of viewing patients in early recovery is to study aspects of their character that might be important in improving response to treatment. “The hope of therapy is that treatment leads to fundamental improvement in personality, particularly in character. Empirically, what is often found in therapeutic interventions is that the level of self-directedness at the beginning of therapy predicts the degree of improvement” (Cloninger, 2004). Persons with high levels of “self-directedness” are responsible, purposeful, resourceful, self-accepting and hopeful, whereas those with low levels are blaming, aimless, inept, vain and deliberating (Cloninger, 2004).
Looking at patients in a rehabilitation center milieu, the perspective is certainly not as clean and clear as it is in a research lab. Not only are there clients with multiple disorders, but many with associated histories of early life developmental trauma. The majority of chronic recidivists come from environments where abuse and neglect were associated with alcoholism, drug addiction and other DSM-IV pathology. The scope of this series does not entertain the treatment of co-occurring disorders but does address some the problems with lack of neural integration secondary to trauma.
Considerable time and research have been devoted to the understanding of what it takes to recover. However, available data that discusses contentment in recovery is very limited. Only in recent years was a study of happiness, well-being and positive emotions seriously undertaken. Positive emotions activate the brain and widen one’s view of the world and enhance imaginative thought. For the addict in early recovery, being able to have a positive picture of recovery could contribute to his or her success. Based on a study at the University of Iowa, unpleasant pictures provoke activation of the primitive, subcortical parts of the brain associated with danger. A pleasant picture activates the prefrontal cortex. This area of the brain is crucial to problem solving, reducing impulses, abstract and conceptual thinking and the development of conscience (Jamieson, 2004).
It should be taken seriously when an addict says in early recovery asks, “What’s in it for me?” Since reward and reinforcement are principle driving forces of addiction, how does the addict subjectively and objectively replace the drug? If recovery is neither fun nor meaningful, why would an alcoholic or addict go through the process? Clinical staff doesn’t ask much from patients — “Just change all of your friends and places you go while changing just about everything you do!” From their sponsors they hear, “Don’t drink and go to meetings.”
A state of serenity, a meditative state or “flow” provides an example of how positive emotion is critical to recovery. “It is the only truly scientific level of consciousness and the only level of self-awareness in which well-being can be attained by the full understanding of emotional conflicts and intellectual contradictions” (Cloninger, 2004).
From a subjective perspective, there are people at self-help meetings who those in early recovery tend to gravitate toward. For some reason, they seem to have something that others want. The same phenomenon can be observed in a treatment setting. Patients tend to want to be around certain clinicians. They too seem to have something desirable. What is it about these types of people? How can we understand them? How do you get there? Observation reveals that these individuals seem content, positive and serene. Some might say “they really have it together.” Probably, they have achieved some measure of competence in the following areas: integration of self; connection to others; and connection to a higher power of one’s choice.
Integration of self
The following case illustrates how integration relates to well being:
Marcus grew up in a home with an abusive alcoholic father who beat Marcus with a leather belt when he was drunk. At age 12 Marcus decided that he would never let anyone hurt him again and from that point declared, “If anyone gets in my face I will kick their ass.” Although he had many drinking buddies, Marcus continually had problems with male authority figures such as supervisors, teachers, policemen and male therapists. As his alcoholism progressed, he became less able to control his rage. When asked he said, “It’s like there is another person inside of me that takes over — I have no control.” While in treatment, Marcus had a hard time getting in touch with his feelings and could not seem to find words to express his feelings. He described his rage as “All or nothing — I either don’t feel anything or feel too much.”
Research on relapse indicates that anger/rage is just below people, places, and things when investigating factors associated with return to use. In Marcus’s case he seemed to have little or no control of this emotion when around male authority figures. One perspective of his problem is to view it as a lack of vertical integration in his brain. His frontal cortex doesn’t appear to be able to override his brain stem leading to impulsive acting out. As Marcus says, “It’s like another person inside of me that takes over — I have no control.”
In treatment Marcus could not get in touch with his feelings and lacked words to describe his feelings. The language of the brain is feelings mediated by the monoamines (Norepinephrine, Dopamine, and Serotonin). This difficulty can be perceived as a problem of horizontal
integration. In other words, the left hemisphere of his brain is not well integrated with the right hemisphere.
It is important to understand how the term integration relates to well-being. Utilizing complexity theory from quantum physics might be most helpful. “Systems that are able to move toward maximal complexity are healthy systems. They are the most stable, adaptive, and flexible — a wonderfully concise definition of well-being. Mental health can thus be defined as a self-organizational process that enables the system-be it a person, relationship,
family, school, community, or society-to continually move toward maximal complexity” (Siegel, 2003). In other words, the more integrated the brain, the more complex it is. The more complex the brain, the more mentally healthy it is.
There are a number of techniques that can be utilized to assist Marcus. One technique involves the creation of contingent communication within his own skull. Contingent communication involves a perception, making sense of the perception and responding in a timely and effective fashion. Secondly, mindfulness meditation can help change brain function. “Mindfulness promotes the integrative function of the prefrontal cortex,” Siegel says. “It allows brain circuits to fire that have perhaps never fired before, giving people a sensation of inner awareness that they may never have had before” (Siegel, 2003). Dr Siegel is describing what was earlier defined as integration.
Achieving vertical integration
Vertical integration involves contingent communication from the cerebral cortex through the limbic system, brain stem and down to the body. When the brain is vertically integrated, the frontal cortex has inhibitory control over lower brain functions, giving it the ability to process, inhibit and organize reflexes, impulses and emotions generated by the brain stem and limbic system. The prefrontal cortex allows us to learn from our mistakes and correct behavior that is self-detrimental (Amen, 2002).
A child — like Marcus — growing up in a traumatic environment, will develop an exceedingly active brain stem. The majority of stress response systems reside in this area, and increased excitation in the lower brain can lead to anxiety, anger, rage and impulsivity. Forms of trauma can lead to an underdevelopment of the frontal cortical area. This can lead to problems with empathy, problem solving, impulsivity and the ability to abstract and conceptualize. Furthermore, patients like Marcus can overestimate the degree of threat or misread visual cues such as facial expressions. The outcome is an inability to modulate. The Excitatory lower portion of his brain overrides the Inhibitory frontal cortex.
Marcus may have learned a number of coping strategies while in treatment. Imagine what will happen when he experiences a situation in early recovery that reminds him of the old trauma (for example, his supervisor at work gets angry with him). His brain has learned to go into an excitation mode and a “hyperarousal” pattern. His brain stem overrides the frontal cortex. In the aftermath of another angry failure, he experiences what Alcoholics Anonymous calls an option reduction, where he feels like he is going to “use, die or go crazy.”
While in treatment, Marcus said to his therapist, “If I wanted to I could kick your ass.” The following dialogue took place between Marcus and his therapist:
Therapist: “Whatever you do, don’t stop behaving the way you are right now because you know and I know that it saved your life, didn’t it?
Therapist: “I’d like to talk to that part of you (remember the 12 year-old) that made a conscious decision to never let anyone hurt you again.”
Marcus: Nonverbal aggressive cues diminish and he starts to cry.
The therapist has established congruent communication with Marcus and he has responded by deescalating. In the past, male authority figures have told him they would kick him out of treatment, fire him, put him in jail or punish him in other fashions. These responses only reinforced Marcus’s perception that when he allowed these types of people to get close, they hurt him. Marcus’s therapist has broken this old non-productive pattern of failure.
The therapist now can use psychoeducation to help Marcus understand the history and pattern of his problem with anger. A good place to start is to teach him about a neural circuit called the “checker system.”
Therapist: “Do you know that your brain has a circuit that helps protect you and that it is called the “checker system.”
Marcus: “I have never heard of that.”
Therapist: “The “checker system’s” job is to keep you safe. (Looking at a picture of the brain) It involves areas in your brain — the amygdale, basal ganglia, and in Marcus’s case, the brain stem. The job of the checker system is to keep you out of harm’s way and it is doing the best that it can. This is how it works:
• It SCANS (vigilance)
• It Alerts (fear when danger is perceived)
• It Motivates (causes practical behavior)
Your “checker system” is doing the best it can, but when you get in situations that remind you of your father, it gets very hyper and your brain stem and other areas of the lower brain interpret the situation as a “fight or flight” survival dilemma. This is a hardwired, somewhat out-of-date survival system that was very effective when the caveman had to decide whether to run or fight the saber-toothed tiger. It may have helped you when you were young but now there are different demands. Your anger is interfering with your relationships, hindering your promotability, and disturbing your attachment to your children.
The therapist is helping Marcus to have a different type of relationship with his brain. With this understanding — presented in a nonpathological fashion — he can start to learn to self-regulate. Self-regulation takes place secondary to neural integration. As disparate parts of his brain become integrated, complexity increases. With increases in complexity comes an increase in personal stability and adaptation.
Therapist: “For the next week I want you to observe what is happening in your brain.” This is called discernment. Marcus is also taught self-regulation strategies such as breathing meditation.
Therapist: (second session) “Marcus, I want you to start to have contingent communication within your own brain. Your frontal cortex can have a dialogue with the lower parts of your brain. Thank your “checker system” for keeping you safe and let it know that it is your friend. Also, let it know that you need to speak with the lower parts of your brain about being safe. Let your lower brain and your frontal cortex become a team instead of adversaries.”
This type of dialogue promotes neural integration. It allows the past events in Marcus’s life to stay in the past. He can now distinguish something that happened in the past from something that is happening in the present. When he is around male authority figures he can look at the situation through the eyes of an adult rather than the eyes of a child. This has been called “moving from there to here” or “going from subjectivity to objectivity.” Mary Sykes Wylie describes this increase in neural integration as “the consolidation of memory via the hippocampus into the neocortex, and the synthesis of left-brain logic and right-brain emotion, so that the past event becomes no more and no less than an aspect of your conscious autobiographical story” (Wylie, 2004). As the old self-destructive patterns are brought into consciousness and understood by the logical cause-effect left hemisphere, Marcus begins the process of change. He is prepared to learn behavioral coping strategies to augment the meditation techniques.
Achieving horizontal integration
According to Louis Cozolino, “the primary focus of psychotherapy appears to be the integration of affect and cognition. Intellectual understanding of a psychological problem in the absence of increased integration with emotion, sensation, and behavior does not result in change. All forms of treatment recognize the need for stress, from the subtle disruption of defenses created by the compassion of Carl Rogers, to the exposure to feared stimuli in cognitive therapies. There is a recognition that the evocation of emotion coupled with conscious awareness is most likely to result in symptom reduction and personal growth” (Cozolino, 2002).
Marcus had difficulty getting in touch with his feelings and also could not find words to express his feelings. Horizontal left- to right-brain integration can help him in multiple ways. Left-right integration allows for feelings to be brought into conscious awareness where they can be understood. The goal is to balance the left and right hemispheres. The left hemisphere is more closely identified with cortical (intellectual functioning) while the right hemisphere is more closely connected to the body via the brainstem and limbic system. The question becomes, what type of approach might best be used to promote integration?
For more than 40,000 years stories have been the favored format for passing on multi-level information. A story has the elements of the intellect, as well as emotions and body sensations. Neural growth and integration is enhanced by the integration of conceptual knowledge with emotional and body experiences using a narrative format that is co-created with a therapist. If Marcus can tell a congruent story about his life, not only will he break through old defense systems installed as protection against the early life abuse that disallowed integration, but he can improve as a parent. For example, such coherent narratives can break multigenerational patterns of disorganized attachment. “The process of listening to and telling stories brings together behavior, affect, sensation, and conscious awareness in a way that maximizes the integration of a wide variety of neural networks. Through stories we connect with others, share the words, thoughts, and feelings of the characters, and provide the opportunity for moral lesions, catharsis and self-reflection” (Cozolino, 2002).
One way of approaching the story is through the development of what is called a spiritual autobiography. “The pilgrimage to look for the source of one’s faith and see one’s experience in relation to that search is not limited to artists and writers, but is shared by a growing number of people of many different backgrounds, interests and ages” (Wakefield, 1990).
Integration brings new insight. Neurons that have never connected are now working together. You may have experienced this phenomenon many times in your life. Remember a time when you could not quite come up with the answer and as hard as you tried nothing happened. After time and contemplation, it suddenly came to you — an “ah ha” experience — sometimes, as a little voice in your head. You suddenly gained new insight. Your brain integrated in a new way. New neural connections were established.
Adding mindfulness meditation
There are seven attitudinal factors that make-up the foundation of mindfulness, according to John Kabat-Zinn, PhD. These factors are interrelated and are to be cultivated with practice over time (Kabat-Zinn, 2005). A brief summary of these factors are as follows:
• Non-judging — becoming an impartial witness to your own experience
• Patience — learning to accept the fact that life’s events will unfold in their own time
• Beginner’s Mind — looking at events in life as if it was the first time they are experienced
• Trust — learning to trust your intuition and developing a basic trust in yourself
• Non-striving — paying attention to what is happening around you and instead of a goal, strive to “not-do”
• Acceptance — living in the present and seeing things as they really are, not as we would like for them to be
• Letting Go — instead of letting your mind hold on to thoughts and feelings, let them go
Utilizing the above attitudinal factors as a philosophy of life, the following protocol can be used to teach patients practical procedures that can be used on a regular basis while also teaching “on the fly” strategies:
Establish a routine that includes regular times and places. Also, choose techniques, including:
• Repeating a prayer or special saying
• Focus on a word or phrase, “One”
• Directed Breathing
• Progressive Muscle Relaxation
• Warming of the hands
• Warming of another part of body, such as the chest or feet
• Focus on a spot on the wall
As a part of the meditation close with “What am I grateful for today?”
Allow the patient to experience a number of the techniques listed above, and ask him or her to choose several that they believe will work best. Have the patient practice on a daily basis using regular times and places, if possible. When assisting the patient in working through or problem solving a stressful situation, he or she can practice while in group or individual therapy. This will give the patient confidence that the strategies will work when they are needed “on the fly” at the job, in school, or at home.
When teaching breathing technique, a picture of flowers and a candle can be used with the description: SMELL THE FLOWERS, BLOW OUT THE CANDLE. This insures that the patient will use the right breathing procedure taking air in thru the nose and exhaling through the mouth.
At this point Marcus has learned to not identify with his childhood coping and survival response-anger-that has caused him so many problems. The left hemisphere of his brain has helped him make logical sense of an unconscious and self-defeating process. Since the brain is an associative organ, Marcus had learned to associate male authority figures with hurt and to respond with angry acting-out. As a 12 year-old, this was the best coping and survival strategy his brain could manufacture. However, with the introduction of self-regulation strategies such as mindfulness and breathing meditation, his brain can start to associate relaxation in situations that produced anger and rage. Now he can remember the helpful techniques he has learned from his therapist, in group, or from his sponsor when he is confronted.
Cardwell C. Nuckols, MA, PhD (
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
) is President of Cardwell C. Nuckols and Associates, LLC, a national and international training and consulting Organization.
References
Amen, Daniel G. Healing the Hardware of the Soul. The Free Press. New York, 2002.
Cloninger, Robert C. (2004). Feeling Good: The Science of Well-Being. Oxford. New York.
Cozolino, Louis. (2002). The Neuroscience of Psychotherapy. WW Norton, New York.
Fraga, MF et al. (2005). Epigenetic Differences Arise During the Lifetime of Monozygotic Twins. Proc Natl Acad Sci USA.102:10413-4.
Jamieson, Kay R. (2004). Exuberance: The Passion For Life. Alfred A. Knopf. New York.
Kabat-Zinn, Jon. (2005). Full Catastrophe Living. Delta. New York.
Moore, Thomas. (1992). Care of the Soul. Harper Collins. New York.
Prevention Research Institute (2005). The Brain and Addiction: A Research Review. Lexington, KY.
Rossi, Ernest L. (2002). The Psychobiology of Gene Expression. WW Norton & Co. New York.
Siegel, Daniel J. (2003). An Interpersonal Neurobiology of Psychotherapy: The Developing Mind and Resolution of Trauma (In: Healing Trauma, Edited by Solomon, Marion F. and Siegel, Daniel J.). WW Norton. New York.
Wakefield, Dan. (1990). The Story of Your Life. Beacon Press, Boston.
Wylie, Mary S. Mindsight. Psychotherapy Networker. September/October, 2004, 37.
This article is published in Counselor,The Magazine for Addiction Professionals, December 2005, v.6, n.6, pp.24-31.
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