Understanding the formation of all habits helps clients grasp the automatic nature of their addictive actions, and knowing about how craving is created by the intensity of the reward-pathway stimulation shows clients how potent this brain change is. It helps them understand the irrationality of addiction. They see how they can wake up intending not to use and then, by the end of the day and without any clear decision involved, they’ve stopped in the bar, had a few hits off a joint, or bought a pint of ice cream. Neuroscience tells us that prefrontal functions—such as judgment, analysis, and self-control—are damaged by large quantities of alcohol used consistently. Thus, even when not intoxicated, the thinking brain isn’t functioning in an optimal way. For example, when Jolie judged herself as bad and wondered if she was “really an alcoholic,” there was another part of her that wanted to defend her use of alcohol.
The good news is that the brain quickly bounces back from much of the damage caused by alcohol, often within weeks, and while substances like ecstasy can be permanently damaging, many behavioral addictions and drugs of abuse don’t leave permanent brain scars. But during initial recovery, especially from alcohol, the brain needs a sort of external prefrontal cortex for a few weeks while healing begins. It needs help assessing situations, making plans, and exerting impulse control while trying to reestablish good function. The good judgment of a healthy brain takes a while to return. The best place to get that external prefrontal cortex is through therapy and 12-step meetings like Alcoholics Anonymous (AA).
Jolie didn’t consider herself an addict, but she did have a strong habit of drinking after her work day. Therefore, I discussed with her that once a person develops an addiction, they’ll probably need to avoid that substance or behavior. It was critical for her to see her drinking as serious and progressive—from habit to addiction. As long as she thought it was a “just a bad habit,” she wouldn’t consider drinking itself to be a problem. The power of the word alcoholic implied something more significant, and her fear of that word was going to help her be willing to talk honestly in therapy.
Although I suspected that Jolie was probably an alcoholic and that I hadn’t heard all the ways in which her drinking had presented problems in her life, we hadn’t yet come to an agreement about calling her use of alcohol an addiction. We did, however, agree that, to start, an important goal of hers would be to weaken the habit, the chunk of behavior that was pouring a glass of wine as soon as she got home from work. Weakening this habit would take time and require substituting drinking with a different behavior that would give her the same reward: relaxation of mind and body. Talking it over with me, Jolie thought that taking a hot bath seemed like a good way to release tension after work, but then she realized she’d probably just take the wine glass into the tub. To prevent that from happening, she decided to get some exercise every day immediately after work. However, since the cue of coming home, even if just to change clothes, would trigger the desire to drink, she’d take her exercise clothes to work with her so she could stop at the gym on her way home.
The release of physical tension at the gym helped Jolie quite a bit and gave her mental relief. Often when she’d get home from swimming or a spin class, she wouldn’t feel the tension that had driven her to drink. This was a positive step toward weakening her habit, but the cue of coming home still triggered the desire to drink. Now that she was aware of it, however, we agreed that if it persisted after a few weeks, she’d participate in a 12-step program so she’d have someone to call to help her past that trigger.
By seeing habit as part of addiction, Jolie was able to work out a treatment plan with me that wasn’t too overwhelming, pathologizing, or frightening for her to commit to. As she recognized her difficulty in moderating her drinking behavior, especially when under stress, Jolie agreed to accept AA as an addiction-recovery resource. She now understood that her drinking was encoded in her brain in a way that went beyond an ordinary habit pattern.
At this stage, neurobiology’s biggest contribution to addictions treatment isn’t so much a distinct clinical method, but a means of increasing motivation for change. By destigmatizing clients’ shame and self-blame, brain-based explanations get resistant clients to listen to treatment recommendations they might otherwise reject. For therapists, this leverage may be brain science’s most important contribution to our clinical toolbox.
Margaret Wehrenberg, PsyD, specializes in anxiety treatment, using a holistic approach for symptom management. She’s the author of the 10 Best-Ever Depression Management Techniques and The 10
Best-Ever Anxiety Management Tech-niques. Contact: firstname.lastname@example.org.
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