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[Music] addiction drug of no choice and this is from a 12-step perspective um oftentimes in uh i think you know primarily the treatment center industry has adopted the term drug of choice and i did do some research to try to find out where that term came from and um didn't find anything but uh i do think it's interesting and always have found it interesting that uh when it comes to addiction the one drug that people usually have no choice over people call their drug of choice so what i thought i would just cover today is primarily things that we hear uh that may not necessarily line up with what we know about addiction biologically but also from a 12-step perspective and one of the first things that i thought about you know one of the things that we hear often is or sometimes even say as clinicians is that a patient and and by the way as we're talking about addiction we're also we're talking about any kind of addiction whether it be an eating disorder self-harm um substance use disorder um any kind of of addiction gambling things like that one of the first things that we often hear or maybe we even hear ourselves saying is a person just they haven't had enough consequences yet and once they have uh you know experienced a certain number of consequences then they'll choose to stop using or choose to stop engaging in their behavior and my experience in working with patients and i think also uh what aligns most with the science and and also the big book of aa which is was really the the is really the seminal text on addiction in terms of if we're looking at things from a 12-step perspective and one of the things that we see is that there really isn't any kind of consequence that can prevent somebody from engaging in their addiction that uh i've seen people who have had three dui's and they go right back to drinking or i've seen people have massive reconstructive surgery on their nose from cocaine use and they have the surgery and the first thing that they do after they heal from their surgery is they return to use or somebody will have a gastric bypass surgery and the first thing that they do after they heal from the surgery is they return right to binging and sometimes purging as well and so the question is why would anybody choose to do this and the answer is that they're not choosing that the part of their brain that's responsible for executive function the prefrontal cortex in a person with addiction that part of the brain is compromised and so if we also look at you know this idea that they can just choose not to drink use or act out or what we hear a lot of times from patients is i can stop if i want to um or i relapsed because i changed my mind and that's one that i hear a lot of times in sessions and typically when i hear that in particular i i just changed my mind what i'll ask a patient is did you change your mind or did your mind change you because there is a flip that happens in the mind of somebody with addiction that um that occurs and um it isn't really that they're changing their mind it's that their mind is changing them and this idea that i can stop if i want to that may be true for a certain period of time the question is can they stay stopped and so i've just pulled some quotes from the big book of aa that we can apply to any addiction and this first quote here is um really addresses everything that i've just been saying here so the quote is the fact is that most alcoholics for reasons yet obscure have lost the power of choice and drink our so-called willpower becomes practically non-existent we are unable at certain times to bring into our consciousness with sufficient force the memory of the suffering and humiliation of even a week or a month ago we are without defense against the first drink so they're not talking about somebody having already started to drink or having started to use or having started to binge or having started to restrict or whatever it is they're talking about the condition that uh hopefully all of us are in right now which is sober um that the most insane thing that that somebody with an addiction will do uh is to pick up or to relapse um from a state of consciousness that is uh called sobriety um the other one that i that i like to challenge is this idea of calling somebody before you use and i think that while you know there's good intentions behind that i think sometimes that uh in the interest of compassion and all of us as clinicians want to have compassion for our patients that sometimes in the interest of compassion that truth sometimes suffers and uh though the idea of calling somebody before somebody uses it sounds good it's not really consistent with science because what we know is that a relapse ends when somebody picks up and so by the time they're getting ready to pick up or act out it's already too late that what we really want to look at is okay what was going on in the days and weeks before were you working with a sponsor were you going to meetings where were you in the steps um and the the quote that i've pulled here from a big book is well this is from a chapter called more about alcoholism and it's at the end of step one step one is we admitted we were powerless over whatever their drug of no choice is dash that our lives have become unmanageable and the quote here is once more the alcoholic at certain times has no effective mental defense against the first drink except in a few rare cases neither he nor any other human being can provide such defense his defense must come from a higher power and so i just want to uh say you know forgive the the sexist language this was before they knew better and i think you know if if this was written today uh we would probably be using uh you know other pronouns but um the message behind it here is that uh an alcoholic or an addict or somebody with any kind of who's afflicted with any kind of addiction can get taken to a place where they have no mental defense against that first drink or the first drug um and that sometimes a person with addiction could get taken to a place where there's actually no thought about using at all and they just sort of find themselves in the middle of a binge and there was no effective thought or premeditation before using or acting out another one of the things that we hear a lot is that a is religious uh and because of that reason it won't work for me and you know it's it's one of those things that that we hear very frequently and i think we as clinicians have to work really hard to talk about uh what the difference is between religion and spirituality but sometimes even the word spirituality is hard for somebody to hear um because most of our patients a lot of our patients come into treatment with a lot of uh trauma religious trauma spiritual trauma and so the focus that i think we want to place is on not necessarily spirituality or even religion sometimes but having an open mind and so the quote that i've pulled from the big book here is and this is from the appendix on spiritual experiences most emphatically we wish to say that any alcoholic capable of honestly facing his problems and the light of our experience can recover provided he does not close his mind to all spiritual concepts he can be defeat only be defeated by an attitude of intolerance or belligerent denial we find that no one need have difficulty with the spirituality of the program willingness honesty and open-mindedness are the essentials of recovery but these are indispensable and you know this this really points out i think uh willingness honesty and open mindedness are often the things that um a newly sober person or a person who's just coming to treatment for the first time or just coming into recovery for the first time um may not have any of these things other than the willingness to show up and so uh you know i think it's it's important to keep that in mind that no matter where somebody is we can meet them where they're at and just underneath this uh what the book says is there's a principle which is a bar against all information which is proof against all arguments and which cannot fail to keep a man or person in everlasting ignorance that principle is contempt prior to investigation and i'll talk about that a little bit more in a few slides here so another one of the things that we hear a lot is uh i only use drink or binge or restrict or self-harm on the weekends um and so when somebody talks about that it's very hard for them to see sometimes uh the severity of their disease and so usually with somebody like this what i try to ask them is okay so you only binge on the weekends sometimes you binge sometimes you don't my question for you is are you in charge of the times you do and the times that you don't if you aren't in charge of the times that you do and you aren't in charge of the times that you don't it doesn't really matter that you're a binge user because it's just happening beyond your mental control another uh element that i that i think is important to look at is when we hear from a patient uh i don't use that much that when i use um it isn't that much and the thing that i would challenge with that is uh intent and the question here is when you set out to use or to engage in a behavior and you have an intent does it go the other way and that's where we want to look at three words that are synonymous power choice and control if i've lost one of those things i've lost all three in other words i can't be powerless over drugs and have a choice but those two thoughts don't really go together um and so i can't be powerless over something and have the ability to necessarily call somebody always another idea that that i think is really relevant to our work as clinicians who also who treat complex co-occurring disorders is that this idea of i only use to self-medicate my trauma or my depression or my anxiety and we can very easily forget that addiction is primary and can have a life of its own and so while it's true that uh most of us have never met somebody who struggles with addiction who doesn't have trauma that if the addiction isn't treated there's really no hope of treating that trauma and also addiction as i said can really take on a life of its own and it's comprised of three things a mental obsession which means when i'm not engaged in my addiction my mind takes me to the addiction whether i want to or not so the idea here is yes uh i use when i want to but also i use when i don't want to and sometimes i use when i'm not thinking about using it all then there's also a physical craving or the big book calls it an allergy so in treatment language a lot of people use the word craving uh did you have a craving today in 12-step language a craving can only happen after you've started to ingest alcohol or after you've already started to engage in whatever the behavior is something gets activated and we don't have any control over the amount that we take and then the third piece is a spiritual malady and that's what a lot of people describe as feeling like i never felt like i fit in or i've always felt like there was something wrong with me or i always felt like everyone else got the manual to life and somehow i missed that day and that really is the unmanageability that we talk about in the first step is the same thing as the spiritual malady that the unmanageability of a patient's life isn't just all the crazy things that they do when they're engaged in their addiction more than maladaptive behaviors it's how they feel right now which the big book describes as restless irritable and discontent so it's i i want to dispel this myth that somebody has to uh use a lot that the quantity is important or that they have to have been engaged in an addiction for years and this quote i've pulled here is from page 34 in the big book to be gravely affected one does not necessarily have to drink a long time nor take the quantities some of us have certain drinkers who would be greatly insulted have called alcoholics are astonished at their inability to stop or i would say to stay stopped we who are familiar with the symptoms see large numbers of potential alcoholics among young people everywhere so this the word potential is is another important piece for us to look out for because somebody who is just at the very beginning of the progression of their disease uh where it isn't full-blown uh it may be harder to spot um and so it's important as clinicians that we're looking for the red flags so i've just pulled uh speaking of red flags i've sort of um distilled down three attitudes that uh we can look for as clinicians when it comes to the 12 steps and addiction um an attitude the word attitude if you think about what it means in terms of uh an angle of approach like when an airplane is coming in for a landing the pilot will ask or the control tower will ask the pilot what's your attitude in other words what angle are you coming in at um and so when we're working with a patient we want to look at what is their attitude and there's three main attitudes that i think that we see and the first attitude is the attitude of uh the bigot which is somebody who is uh stuck in this uh place of obstinacy or sort of unreasonably attached to a belief or opinion and what that person is blocked by is contempt prior to investigation the second attitude that we sometimes see is an attitude of a pious person and what this person is surprisingly enough blocked by is acceptance they just believe anything that anybody tells them uh including their peers let's say a peer says something like i tried aaa it doesn't work so i'm doing smart recovery and that person picks up on it and they don't investigate um you know they're recommending the recommendation of their therapist who's recommending 12 steps first um and they're kind of like the person um sitting between um members of two different political parties and when they're talking to a democrat they're a democrat and when they're talking to a republican they're a republican um not to bring politics into it but it's just a um we pick up on something somebody else says and we just run with it without taking it inside and actually having our own experience and the last attitude is the attitude that i think we eventually want to arrive at and that's being the the person of consideration that i'm willing to consider um all different sides of an argument or a question um if i'm asking the question am i alcoholic well maybe i am and maybe i'm not um and when i'm willing to look at both sides of a question it places me in the middle where the truth is so as we start to meet with our patients we want to look at you know what kind of attitude does this person have because that will um inform our our clinical decisions decisions in terms of how we want to intervene so uh we're coming to the end here and i just want to talk about what it means to be fully engaged in a 12-step program and what it means to be fully involved in recovery here you see what 12-step programs call the circle and triangle this is primarily a a uses this but it's still an important um piece of information i think that in order to be fully uh immersed in recovery that we need to be involved in sponsorship and that's somebody who takes you through the steps uh that we want to be involved in a home group and that means i'm going to uh the same group every week and people would notice if i wasn't there and also that i'm involved in all three sides of the this triangle that you see here recovery uh is the mind we need a new mind fellowship is where we take our body um and uh to be of service is to be engaged in uh acts of spiritual service and so a lot of times when people first engage in recovery they've brought their body to the fellowship but they have a mind that takes them back to their addiction so you see unity that unity there people are going to meetings but their mind keeps taking them back to a drink or a drug or back to their drug of no choice and so they need a new mind and that's what they find in recovery through the steps and then you bring that awakened mind or awaken spirit back into the fellowship and out into the world to be of service and that's the meaning of the circle that one day we can become whole why try 12 steps first because there are a lot of other programs and it isn't that any of them are bad it's just uh you know when we look at a lot of the studies particularly this most recent study that i found is stanford university study from 2020 found that aaa 12-step programs 12-step facilitation reduced mental health costs by 10 000. a person and that same study found that aa or 12-step facilitation was 60 percent more effective than cognitive based approaches like dbt or cbt for addiction and that study uh was comprised of over 10 000 people and that isn't to say that dbt or cbt are bad uh what the study found though is that when it comes to addiction that 12-step facilitation is 60 more effective lastly i just wanted to mention some myths that uh are busted by the big book and if you're interested um i can send you a copy of this um presentation and you can look up these pages first that it's religious um that even though you know the word god is used in 12 steps that uh it really is roomy and you get to pick uh any kind of higher power that works for you including um if it's just a group the idea that members are forced to stay in a position of powerlessness um that's you know powerlessness is only mentioned once and it's in the first step and the paradox of step one is that if i can concede that i have no power that i receive more than i've ever been given that i'm actually given the ability to make choices in my own life that members can't trust themselves as another myth that we do get taken to a place through the recovery process where we can start to trust our own mind where we can have access to our intuition which can help us then heal from our own trauma also that members are discouraged from having therapist doctors and other sources of support and that members are discouraged from taking medications the big book is pretty clear if you go to page 133 that if you need outside support uh that it's really important that you get that including medication assisted therapies so that's it i'm gonna stop sharing my screen here and check in with everybody and see if anybody has any questions hey shell um really nice job that was really excellent um i think i just wanted to add that i know a lot of times much more than in the past than now there were a lot of aaa meetings where there was a lot of thought about not being on meds and sponsors were telling patients not to take psych meds but i think that's pretty much lifted you know from my understanding of the people i work with you know but that's an old and old wise you know an old reality yeah i think that well i think that it still does happen sometimes um and you know i think that a good thing to remember for us to tell our patients you know and and what i've always heard in recovery is that if you can't reconcile uh what somebody says with the actual literature then you can disregard it um and that that message that if you're on medications you're not sober is not consistent with any of the literature in any 12-step program so thanks for bringing that in anybody else have any questions or comments i know we just we're just about out of time thank you shale that was great hey thank you very good very nice well versed on the big book thank you my pleasure i think all of patients would really benefit from you know seeing this i think that would be really powerful if you if we had it be where it was like something for all the patients too i was thinking that same thing this would be really good for our patients to see 100 percent you