“HERE’S HOW IT WORKS”

1. “HERE’S HOW IT WORKS” 12-Step Recovery Viewed through the Lens of Psychology Quinn T. Chipley, M.A., M.D. prepared for CAPTASA conference, January 23-24, 2009, Lexington, Kentucky

2. DISCLOSURES: This presenter has no funding from any institution, corporation, or agency regarding the content of this presentation. Although he loves his work at the University of Louisville as the Counseling Coordinator for the Health Sciences Center students, that institution should in no way be held responsible for the content of this presentation.

3. “PSYCHOLOGY 201: THE FOUNDATIONS IN NORMAL” Reinforcement Schedules from Behaviorism: variable rate, fixed rate, variable interval, fixed interval Cognitive-Behavioral Theory Triad of 1) Behavior, 2) Cognitions, and 3) Affect

4. Reinforcement Schedules from Behaviorism variable rate (slot machine), fixed rate (soda machine), variable interval (chaotic family), fixed interval (monthly paycheck)

5. Cognitive-Behavioral Theory Triad of 1) Behavior, 2) Cognitions, and 3) Affect Changing any one will change the other two, but it it easier to target Behavior and/ or Cognitions EXCEPT that pyscho-active drugs will target Affect directly behavior affect cognitions

6. Cognitive-Behavioral Theory (cont.) • Basic Facts • Behavior and/or Cognition are easier to target for conscious control than Affect • Behavior targets should be simple and clear • Cognitive interventions: must be short and sweet

7. “PSYCHOLOGY 301: SOCIAL PSYCHOLOGY” Social cues (e.g. – an audience or a group) amplify the responses of an important brain center (the medial pre-frontal cortex). Finger, et al. Neuroimaging 2006 Oct 15, 33 (1): 414-21 Guilt and embarrassment(a.k.a. – Shame) are “social emotions requiring the ability to represent the mental states of others” and “embarrassment might be a more complex process than that of guilt.” Takahashi H., et al. Neuroimage. 2004 Nov; 23(3): 967-74

8. “Psychology 541: Personality Theory” Regions of reward and salience: prefrontal cortex (PFC) and orbital frontal cortex (OFC) “REWARD” is strongly associated withthe ventral tegmental dopamine projections to the PFC. “SALIENCE” is a complex path that includes the striatum, the thalmus and the OFC. That pathway balances 1) novelty 2) pleasure and 3) irritation. It is the mechanism the personality uses to manage “shoulds” and “should-nots” of life. Normal ego is auto-reinforcing with “sustained recruitment of the reward system during self-relatedness” De Greck M. et al. Neuroimage. 2008 Feb 15; 39(4): 2066-75

9. “Psychology 345: Child Development” Normal Child Development Steps Sensory interaction (tries to eat the toy) Independent play (manipulates the toy) Parallel play (2 toddlers manipulate 2 toys, passively aware of each other) Interactive play (2 kids play with the same toy and are actively aware of each other) Social interaction (2 or more manipulate words and feelings; toy not required)

10. “Psychology 291: Neuropsychology” Neuroplasticity and Time Course: fast to slow Neurotransmitters GABA/glutamate (milliseconds) Neuromodulators such as dopamine, serotonin (seconds) Steroid Hormones (days, if signaling to the nucleus) Protein Receptor reduction/ multiplication (weeks) Axonal-Dendritic pruning/ proliferation (months to years) Take home lesson: lasting brain change takes ample time under sufficient pressure. This fact is why personality characteristics are basically stable across time and why Arnold Schwarzenegger’s character in “Total Recall” remains in the domain of science fiction.

11. “Psychology 541: Abnormal” The alcoholic/ addict brain is probably abnormally primed to respond to the substance. The active and early detoxified user has disturbed salience. Continued use of the substance displaces accurate sense-of-self. Displaced sense-of-self disrupts social interaction, interactive play, parallel play and will even degrade solitary play.

12. “Prediction of Reinforcing Responses to Psychostimulants in Humans by Brain Dopamine D2 Receptor Levels” • 23 healthy men (mean age=34 years, SD=7) • No drug abuse histories • Measured D2 receptor levels • Intravenous methylphenidate (0.5 mg/kg). 1999 Volkow and Wang

13. D2 Receptor Levels (Bmax/Kd) in 23 Healthy Male Subjects Who Reported the Effects of Methylphenidate as Pleasant, Unpleasant, or Neutrala The researchers postulate that while there are certainly many other factors which contribute to addiction, baseline levels of dopamine activity may create a window within which the effects of drugs of abuse become reinforcing. 1999 Volkow and Wang

14. Model proposing a network of four circuits involved with addiction: reward, motivation/drive, memory, and control. These circuits work together and change with experience. .. From: Volkow: J Gin Invest, volume 111(10).May 2003.1444-1451

15. overdrive Double pathology of the addict’s salience CUED Resting state hypofunctional

16. A NORMAL SOCIAL “DANCE” that involves taking turns for for attention

17. The Ego of the Dependent is replaced by substance; The Co-dependent shares the same gravitational center. Co-dependent Dependent XXX There is no dance: everyone avoids orbit interference

18. The “Game Plan” of addiction “Cocktail party conversation” : no toy but all interaction “It’s Miller Time” : interactive use is coupled sequentially to the toy (football, etc.) “Ping Pong Shots”: interactive drinking interlaced with the toy “Belly shots, Slammers; chugging”: the substance replaces the toy in interaction “Bar stool buddy”: parallel drinking Isolated drinking: solitary play with substance Finally, the child is consuming the toy substitute

19. The 12-Step Response To “The Problem”

20. What happens every time I say, “Hi, I’m Quinn and I’m an alcoholic”? EVERYONE: “Hi, Quinn!” The self is reinforced. The pathology is not reinforced. But the pathology is not denied. It is a Fixed Rate reinforcer of the essential identity: Not the Family name, but the person’s unique name

21. What happens if (in a 12-step meeting, I go on to say, “I think the sky is purple striped and really odd and that all the grass blades are too sharp on my feet this year and it makes me irritable with my kids. I just needed to say something. That’s all.” EVERYONE: “Thanks, Quinn!” i.e. - The behavior of participating in the social structure is reinforced, and no shaming statements about the near-psychotic content are made.

22. The 12 step approach distinguishes between “salience” and “behavior” and uses both. The only requirement for membership is… ”a desire to stop drinking. “ Note that “drinking” is a summation of many behaviors and “desire” is a product of “salience.” 12-step recovery recognizes salience as a necessary -- but not a sufficient --- condition for a solution.

23. Big Book of Alcoholics Anonymous, 3rd edition

24. The most frequent behavioral prohibition (usually phrased as a First person statement) is “do not pick up.” This a very specific, measurable unit of behavior so it becomes manageable. The most frequent behavioral prescription (Usually phrased as a warm imperative) is “keep coming back.” There are others… “take what you like and leave the rest.” Note how this recognizes that there is a “slot- machine” payoff regarding meetings and their content: The 12-step program has a variable rate reinforcer schedule in its structure.

25. 12-step meetings run on time. They have a predictable format. People have to take turns. They are readily available.

26. 12 step Folklore makes sense in the light of our review of Psychology “90 in 90” Why 90? Or why the old joke, “It takes 6 months to get some blood back into your alcohol system.” Answer: remember the time frame of neuroplasticity

27. 12-step Recovery and “Homespun” Cognitive-Behavioral Therapy CBT: Behave differently and you will eventually feel and think differently 12-Steps: “Fake it till you make it” CBT: Identify Dysfunctional Thoughts 12-Steps: “Stinking Thinking” CBT: Interrupt Dysfunctional Thoughts 12-Steps: “Don’t give them free-rent!”

28. 12-step meetings become the opportunity to find: “New playgrounds, Playmates, and playthings…”

29. References Finger, et al. “Caught in the act: the imp[act of audience on the neural response to morally and socially inappropriate behavior.” Neuroimaging 2006 Oct 15, 33 (1): 414-21 De Greck M. et al. “Is our self based on reward? Self-relatedness recruits neural activity in the reward system.” Neuroimage. 2008 Feb 15; 39(4): 2066-75 Takahashi H., et al.”Brain activation associated with evaluative processes of guilt and embarrassment.” Neuroimage. 2004 Nov; 23(3): 967-74 Volkow, Nora D. MD; Wang, et al, Prediction of Reinforcing Responses to Psychostimulants in Humans by Brain Dopamine D2 Receptor Levels, American Journal of Psychiatry, Volume 156(9), September 1999, pp 1440-1443 Volkow ND. Fowler JS. Wang GJ. The addicted human brain: insights from imaging studies. [Review] [62 refs] [Journal Article. Research Support, U.S. Gov't, Non-P.H.S.. Research Support, U.S. Gov't, P.H.S.. Review] Journal of Clinical Investigation. 111(10):1444-51, 2003 May. UI: 12750391

30. "Matching alcoholism treatments to client heterogeneity: Project MATCH three-year drinking outcomes." Alcoholism: clinical and experimental research 22.6 (1998):1300-11. Project MATCH secondary a priori hypotheses. By: Group, Project Match Research, Addiction, 09652140, Dec97, Vol. 92, Issue 12 Evidence-Based Addiction Treatment: How Research Supports the Use of the Twelve Steps Marvin D. Seppala M.D. Medical Director, CEO,Beyond Addictions, Slide presentation to 2008 CAPTASA conference Alcoholics Anonymous, The Story of How Many Thousands of Men and Women Have Recovered from Alcoholism, 3rd edition, AA World Services, Inc.