It’s amazing witnessing the lengths that addiction researchers and theorists will go to in order to avoid stating what’s so painfully obvious to any sane person. As an example, I present to you this passage from a popular manual on “relapse prevention”:
Substance cues include not only the drugs themselves, but also associated cues and situations. One such cue is money. When opioid-dependent clients start opioid replacement therapies such as methadone, the cost and time involved in obtaining illicit opioids is eliminated. This may free up money and energy, which may increase risk of abusing other substances, such as alcohol or cocaine.Receiving large amounts of money, such as lump-sum payments at onset of disability benefits, increases the risk of relapse among methadone maintenance clients (Herbst, Batki, Manfredi, & Jones, 1996).
Yes you read that correctly – money in the pocket of a substance user “increases the risk of relapse”! Well, of course it does. Thank god somebody actually got paid to study this wildly puzzling phenomenon.
I think this is a stunning example of how the real story is hidden underneath clinical language and jargon. Extra money in your pocket now becomes a powerful “cue”; and the choice to spend that money getting high is a “relapse”. It would be comical if so many people weren’t hurt by such thinking. If the term “cue” isn’t actually used with a patient, then its synonym, “trigger” is often used. Either way, and even in the absence of such terms, the point is clearly communicated: having money (or whatever your “cue” happens to be) will cause you to get high (“relapse”). And in fact, the counselor is so invested in seeing their client as powerless and “caused” as a billiard ball floating in space that they go on to teach them, in essence – “make sure you never have any money in your pocket, or you’ll use”. Is this healthy? Is this how people with substance use problems should conceive of themselves? Is it helpful? Does it address the real problem?
Exhibit 2 comes from a manual distributed by the NIDA, which outlines how a counselor might talk to their clients about how to deal with such “cues” as money:
“You’ve said that having money in your pocket is the toughest trigger for you right now. Let’s spend some time thinking through ways that you might not have to be exposed to money as much. What do you think would work? Is there an amount of money you can carry with you that feels safe? You talked about giving your check to your mother earlier; do you think this would work? You’ve said that she’s very angry about your cocaine use in the past; do you think she’d agree to do this? How would you negotiate her keeping your money for you? How could you arrange with her to get money you needed for living expenses? How long would this arrangement go on?”
Addiction counselors take it as a given fact of reality that their patients are fatally flawed with the disease of addiction which will leave them plagued with the burning desire to use drugs and alcohol for eternity. The addict is essentially a loaded gun, waiting to be triggered by some thing or other, such as a pocketful of money. Yes, people who desperately want to get high, will spend their money on drugs as soon as they’ve got enough to make it work. But is that a diseased person being cued (or triggered) into relapse of their disease? Or is it just a person freely choosing to fulfill a desire once they have the means to do it?
Your answer to that last question will set you on one of two divergent paths:
1. “Managing your disease” – forever trying to avoid cues and triggers such as money, stress, anxiety, any sight of alcohol or drugs, etc. – lest you be uncontrollably sent into “relapse”. or…
2. Owning your desires – and then proceeding to either fulfill them, or cultivate new desires.
Addiction counselors and other treatment providers clearly know which side they’re on – they are the experts at “managing the disease”. Do you think you’re stuck with a disease that needs to be managed? Or do you think that you could grow and change and find your way to being committed to new paths to happiness?
Many people get lost in the clinical language of the disease model, and end up living their lives in fear of unavoidable cues and triggers – forever searching for the perfect “coping skills” and “relapse prevention” techniques. But it doesn’t have to be that way, you can ditch that bleak philosophy with it’s counterproductive quick fixes – and you can focus yourself on more rewarding, delayed gratification happiness if you so choose. The Freedom Model philosophy along with Cognitive Behavioral Education (as offered by the Saint Jude Program) comprise one effective path to learning how to do this.
Isn’t it amazing – addiction is the only disease whose symptoms start when you have money in your pocket, and end when you’re broke!
G. Alan Marlatt PhD;Dennis M. Donovan PhD. Relapse Prevention, Second Edition: Maintenance Strategies in the Treatment of Addictive Behaviors (p. 158). Kindle Edition.
Kathleen M Carroll Ph.D., A Cognitive-Behavioral Approach: Treating Cocaine Addiction, National Institute on Drug Abuse, NIH Publication Number 98-4308, Printed April 1998
This is good. Freeway off ramps near former stomping grounds, and parking next to a bar are actually considered triggers to some. I decided to learn from that, because I didn’t want to be at the mercy of my environment. I saw something on TV about a researcher in Europe who helps former crack addicts change their memories/assocations/triggers. I think she made them watch crack paraphernalia on a screen while handling some worms in a box, or something like that. I got the idea to reshape my own associations and memories. I made myself think of my drug and crawly worms at the same time. When I was younger, I associated cocaine with the devil because I really thought it was an evil drug by the time I was done with it. These negative associations really worked for me.
Now I’m thoroughly confused. I thought Cognitive Behavioral Education was derived from Cognitive Behavioral Therapy which was derived from Relapse Prevention. So I ask, just what is Cognitive Behavioral Education?
Hi Joe,
You might go to my page on it for a brief explanation: http://www.thecleanslate.org/landing/cbe/
CBE is not based on CBT – but they share a common principle: that emotions and behaviors come from thoughts and beliefs.
CBE is also definitely not based on Relapse Prevention – my belief is that relapse prevention, by virtue of building up relapses and cravings and urges as inevitable events that must be battled, has the danger of reinforcing (or outright creating) an unnecessary negative connection between substance usage and so-called “triggers”/”cues” “underlying causes” etc. Plus, relapse as we know it (loss of control and recurrence of “symptoms” of the disease of addiction) is not a reality – substance use is a reality – calling it relapse takes it out of the realm of choice, and reinforces the self-defeating disease/loss-of-control theories.
CBE is an educational program, it has a curriculum, people learn to expand their range of cognitive and behavioral options; and evaluate their substance use options clearly without guilt or judgment; so that they can pursue whichever path they end up believing will bring them the greatest amount of happiness. There is no therapy involved; there are no “coping skills” taught; and there is no management of a non-existent disease in CBE. There are only people discussing principles of human behavior and personal change, judging their own situations for themselves, and then carrying out whatever changes they see fit. It is BRI’s own proprietary method, developed along the course of over 20 years of direct research and work helping people with substance use problems.
-Steven Slate
Wish I had found this site five years ago before I decided to quit drinking, struggled and sought help through the mainstream recovery system. We find ourselves on the horns of a dilema. We like the effects but know we’re heading toward disaster. The recovery system offers faith healing. We know we’re out of control but the system confirms our fears telling us we are powerless. You’re saying CBE can teach us how to control our drinking/drugging by expanding our range of cognitive and behavioral options. What are the theories behind CBE?
Isn’t it just will power with a fancy name? I found will power totally ineffective and from my studies many addicts have gone on the wagon time after time to no avail. It is thought will power fails because our desire to use is based on neurological signals in the reactive part of our brain which can supersede rational thought. Does CBE teach us how to make rational thought supersede our reactions? Am I over complicating the issue?
I have resolved my drinking problem (much too late) but I used the principles of habit replacement. I still smoke maybe CBE can help me with that.
Joe,
On the question of how to control your drinking – my position is (and that of CBE) is that whether you’re using heavily, moderately, or abstaining – you’re already controlling your drinking. So we don’t teach people how to do any of these things (I said as much, in different words, in my last reply to you).
I think willpower is a tricky concept (perhaps an anti-concept), because when you do anything (include spending one’s entire paycheck on crack) you are exercising the power to carry out your will. What we do is not about teaching willpower, or building willpower, etc.
CBE teaches principles of human behavior/ what goes into choices. Very briefly, people are always pursuing self-interest, i.e. voluntarily choosing their behaviors in an effort to acquire personal happiness. People use drugs and alcohol because it brings them some level of happiness, and they believe that the benefits essentially outweigh the costs of the behavior, contextually (in their life, compared to the other options they believe they have available to them). That is, at the moment that you’re getting high or drunk, you believe it’s your best option for happiness. Side note – I know there are people who say they don’t like getting high or drunk, and thus they don’t know why they do it – but strangely enough, they only say this after being coerced into 12-step programs.
The CBE approach essentially teaches people these facts about human behavior, so they can escape the confusing cultural beliefs about addiction, and then evaluate whether they think they have better options for happiness (by exploring other principles of human behavior, and asking them to evaluate their options). In a roundabout way, we’re saying to our students “you’ve been doing what you want, but what do you think you might want moving forward?”
So it’s not about willpower, you already have tons of willpower. It’s about changing your will (and not by taking on god’s will – unless that’s what you think will make you happy).
I have an old computer in my apt that I never use. I have no problem not using it, because I now have a macbook air, and it’s so fast and easy to use and wonderful that I’m not even gonna attempt to use my old computer. Not even when something goes wrong with this one – I’ll just get this one fixed. I don’t believe the old computer is a good option anymore. I widened my range of computer options by seeing what was available on the market, and making a plan to get something new and better that serves my purposes better. This is, in a sense, option expansion. My will to use that old piece of crap computer is gone, because I expanded my range of options, and found that using the old computer isn’t worth it anymore.
That is what we teach people to do in regard to substance use problems – re-evaluate and/or expand their range of options for personal happiness, so that they can change their will.
-Steven
Well thanks for the details. I understand the merit of your approach but I’m sceptical of it’s practical benefit. I’m sure it is effective with some people. It seems circular. You seem to say we always do what we want to do but how, then, do you explain the addict who knows he wants to quit but can’t. Is that due to the recovery culture? This is confusing.
I love your site because you link everything to actual research and because of your position concerning the disease “concept”. My belief in the disease concept of alcoholism certainly retarded my recovery. I had to work out a solution on my own terms but I was discouraged by everyone who ‘just wanted to help”.
One interesting point: I’ve been to AA meetings where the question of the disease concept was discussed and I think about half of the attendees did not believe in it. Maybe these were the ones who soon would drop out.
That person can stop. We have no evidence that they can’t. We know that sometimes they want to stop, and sometimes, particularly when they do it – they want to get high or drunk. They’re either in that contemplation type of stage where they’re teetering on the edge of no longer wanting it, or they’re completely bogged down in recovery culture garbage which has taught them to deny the simplest explanation for their behavior: they enjoy the high!
Have you read Jeffrey Schaler’s book Addiction Is A Choice? Besides taking the view that AA is innocuous, it’s probably the best book on the choice model perspective of addiction. He has a great chapter on “loss of control”, here’s an excerpt:
When you say you used principles of habit replacement, what did you do, more specifically?
Well, I substituted food for beer. I found when I was full I wasn’t interested in drinking. Then I decided to keep a gallon of milk available and I drank a big glass of milk whenever I wanted a beer. Then I would put the $20.00 I saved away every day I didn’t drink and use it to buy a nice dinner. I also started keeping track of my drinking. It decreased from daily to once every 10 days or so gradually over four months. Then I decided to quit completely because while I was drinking only every ten days or so I seemed to drink at least 12 beers when I drank.
This all started when I read Vaillant’s “Natural History of Alcoholism”. His thesis was that alcoholism was both an ingrained habit and a disease. Vallaint found that many of his sample used a substitute dependency when they stopped drinking. Vaillant’s case for a disease model is rather thin. It is based on the genetics and the pracicality of medical detox treatment. His case for a habit or learned behavior model is solidly based on volumns of research like that which you have cited above.
My research showed that alcohol stimulated blood sugar endorphins, GABA, grelin and dopamine. Food has similar effects so it all made sense. I remember fondly the revelation that alcoholism was learned behavior because that meant all I had to do was unlearn the habit. It is well known that one good way to change a habit is to replace it with another more benign habit.
I would also like to comment on Merry’s study. Of course, it had to be conducted in a laboratory setting so while it is an important demonstration it doesn’t ‘prove’ the point. It proves that drinking behavior is subject to setting. It is well known in behavioral psychology that setting is an important factor in behavior. In Cohen’s experiment, again we have a lab setting but here the variable is the reward for controlled drinking introduced to the alcoholic. Behavior is certainly a product of rewards and punishments. My question then becomes how do we apply the lessons learned from these experiments to life as lived? Take another famous example: the Vietnam veteran study frequently cited by Heyman and I assume by Schaler. Again, change the setting, change the rewards and the potential punishments and the subject changes his (or her) behavior. The subjects in these studies did not decide to change, their enviroments changed around them which steered them toward change. These distinctions are important. Strictly speaking, yes, everything we do is a choice but some choices are subconscious and reactive not active and conscious choices. We see this problem in addiction constantly. There is sometimes a conflict between what we need, want or choose. To say addiction is just a choice only describes it and does not show the way out. To say it is a disease doesn’t accurately describe addiction but, like a placebo, it may provide a way out for some especially those who know the addiction is ruining their lives but can’t understand why they keep drinking and drugging. I say addiction is a habit and addicts are not diseased but they are very ‘sick’. Addicts ‘choose’ to use out of habit. The choice is subconscious. One way out is then to change the enviroment, the rewards and the punishments. Can this be taught? I don’t know, but it becomes very personnal. Each must work it out for themselves until someone much smarter than me comes along and puts it into perspective.