“here’s how it works”


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“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. DISCLOSURES: - PowerPoint PPT Presentation


  • HERES HOW IT WORKS12-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


    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.


    Reinforcement Schedules from Behaviorism:variable rate, fixed rate, variable interval, fixed interval

    Cognitive-Behavioral TheoryTriad of 1) Behavior, 2) Cognitions, and 3) Affect

  • Reinforcement Schedules from Behaviorismvariable rate (slot machine), fixed rate (soda machine), variable interval (chaotic family), fixed interval (monthly paycheck)

  • Cognitive-Behavioral TheoryTriad 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 directlybehaviorcognitionsaffect

  • 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

  • PSYCHOLOGY 301: SOCIAL PSYCHOLOGYSocial 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

  • Psychology 541: Personality TheoryRegions of reward and salience: prefrontal cortex (PFC) and orbital frontal cortex (OFC)

    REWARD is strongly associated with the 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-relatednessDe Greck M. et al. Neuroimage. 2008 Feb 15; 39(4): 2066-75

  • 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)

  • Psychology 291: NeuropsychologyNeuroplasticity 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 Schwarzeneggers character in Total Recall remains in the domain of science fiction.

  • 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.

  • Prediction of Reinforcing Responses to Psychostimulants in Humans by Brain Dopamine D2 Receptor Levels1999 Volkow and Wang 23 healthy men (mean age=34 years, SD=7) No drug abuse historiesMeasured D2 receptor levelsIntravenous methylphenidate (0.5 mg/kg).

  • 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

  • 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

  • CUEDResting stateoverdrivehypofunctionalDouble pathology of the addicts salience

  • A NORMAL SOCIAL DANCEthat involves taking turns for for attention

  • XXXThe Ego of the Dependent is replaced by substance;The Co-dependent shares the same gravitational center.There is no dance: everyone avoids orbit interferenceCo-dependentDependent

  • The Game Plan of addiction

    Cocktail party conversation : no toy but all interaction

    Its 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

  • The 12-Step ResponseToThe Problem

  • What happens every time I say,Hi, Im Quinn and Im 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 persons unique name

  • 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. Thats 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.

  • 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.

  • Big Book of Alcoholics Anonymous, 3rd edition

  • 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.

  • 12-step meetings run on time.

    They have a predictable format.

    People have to take turns.

    They are readily available.

  • 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

  • 12-step Recovery and Homespun Cognitive-Behavioral Therapy

    CBT: Behave differently and you will eventually feel and think differently12-Steps: Fake it till you make it

    CBT: Identify Dysfunctional Thoughts12-Steps: Stinking Thinking

    CBT: Interrupt Dysfunctional Thoughts12-Steps: Dont give them free-rent!

  • 12-step meetings become the opportunity to find:

    New playgrounds, Playmates, and playthings

  • 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 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

    ReferencesFinger, 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): 414-21De 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

  • Project MATCH secondary a priori hypotheses. By: Group, Project Match Research, Addiction, 09652140, Dec97, Vol. 92, Issue 12"Matching alcoholism treatments to client heterogeneity: Project MATCH three-year drinking outcomes." Alcoholism: clinical and experimental research 22.6 (1998):1300-11.Evidence-Based Addiction Treatment: How Research Supports t