RELAPSE PREVENTION BASED ON NEUROSCIENCE OF DESIRE AND

RELAPSE PREVENTION BASED ON NEUROSCIENCE OF DESIRE AND HABIT FORMATION John Wanner, BS, MSCh. E, MBA, MA Psychology, LCAD-C JWanner 7@Comcast. net

DEFINITION; DISEASE OF ADDICTION • AMERICAN SOCIETY ADDICTION MEDICINE DEFINES ADDICTION AS A PRIMARY, CHRONIC DISEASE OF THE BRAIN REWARD, MEMORY, MOTIVATION AND RELATED CIRCUITS. ADDICTION IS CHARACTERIZED BY INABILITY TO CONSISTENTLY ABSTAIN, IMPAIRMENT IN BEHAVIORAL CONTROL, CRAVING, DIMINISHED RECOGNITION OF SIGNIFICANT PROBLEMS WITH ONE’S BEHAVIORS AND INTERPERSONAL RELATIONSHIPS, AND A DYSFUNCTIONAL EMOTIONAL RESPONSE

WHAT IS A HABIT • AUTOMATIC RESPONSE TO IMPROVE WELL-BEING THAT DOES NOT REQUIRE CONSCIOUS ATTENTION. IT IS LEARNED AND MAINTAINED BY REWARD • REINFORCEMENT IS NOT PLEASURE. IT INCREASES LIKELIHOOD OF REPETITION OF PREVIOUS REWARDING BEHAVIOR. NOT ALWAYS ASSOCIATED WITH POSITIVE AFFECT • REWARD IMPROVES IMMEDIATE STATE OF WELL-BEING • RESPONSE CAN BE REWARDING W/O FEELING GOOD OR REWARDED • ENDING A BAD HABIT IS NOT ABOUT JUST TAKING SOMETHING AWAY THAT PROVIDES PLEASURE OR PAIN RELIEF. IT MUST BE REPLACED BY SOMETHING POSITIVE. DEPRIVING YOURSELF WILL NOT WORK. • MUST OPTIMIZE LIFE PATTERNS SO YOU ARE AS HEALTHY AND HAPPY AS POSSIBLE

HOW BRAIN MAKES CHOICES • WEIGHS OPTIONS AND CONSIDERS THEIR EXPECTED VALUE. • IT TRACKS OPPORTUNITIES TO IMPROVE OUR LIVES BASED ON PAST EXPERIENCES. IF OPPORTUNITIES ARE RARE BRAIN SEEKS ANY REWARD EVEN IF IT IS SHORT TERM. IF YOU FEEL DEPRIVED, HELPLESS, HOPELESS OR STRESSED IT IS HARD TO RESIST INSTANT GRATIFICATION • IF LIFE IS FULL OF OPPORTUNITIES TO IMPROVE

HOW BRAIN DETERMINES VALUE OF DIFFERENT BEHAVIORAL OPTIONS • PREVIOUS EXPERIENCES • OUR BELIEFS AND EXPECTATIONS • SOCIAL NORMS • SOCIAL APPROVAL • ASSOCIATIONS • PHYSIOLOGICAL STATE • EMOTIONAL STATE • LONG TERMS GOALS, VALUES • DRUGS OF ABUSE

A. FIRST EXPERIENCE OF DRUG REWARD B. NEXT DRUG EXPOSURE AND CUE C. REPEATED EXPOSURE TO DRUG CUE REWARD - - -- - - - -- - - - NATURAL REWARDS SECOND STAGE OF ADDICTION

HOW BRAIN WORKS • LIMBIC SYSTEM IS SURVIVAL DRIVEN. FOCUS IS ON NEXT 30 MINUTES. INSTANT GRATIFICATION. IT WILL FEEL GOOD OR AVOID PAIN NOW. • EXECUTIVE SYSTEM LOOKS AT LONG/ SHORT TERM FACTORS, LIFE GOALS/VALUES TO DECIDE BEST ACTION TO TAKE NOW • EXECUTIVE AND LIMBIC SYSTEM WORK TOGETHER TO OPTIMIZE OUR WELL-BEING AT ANY GIVEN MOMENT • EXECUTIVE INHIBITS LIMBIC EXECUTI VE LIMBIC

NOW APPEAL • DELAY DISCOUNTING • HUMANS VALUE IMMEDIATE REWARDS OVER DELAYED REWARDS • DISCOUNT NEGATIVE CONSEQUENCES • DISCOUNT FUTURE PUNISHMENT OR PAIN OVER IMMEDIATE ONES • DELAYED DISCOUNTING = NOW APPEAL=ADDICTION • NOW APPEAL IS STRENGTHENED BY NEGATIVE EMOTIONAL STATES AND HIGH LEVELS OF

NOW APPEAL, CONT. • NEGATIVE EMOTIONAL STATES LAY THE FOUNDATION FOR RELAPSE. SIGNALING THE BRAIN THE ENVIRONMENT IS DEVOID OF WAYS TO IMPROVE IMMEDIATE WELL BEING. • HIGHLY NEGATIVE EMOTIONS MAKES IT MORE LIKELY TO ACT ON RELAPSE TRIGGERS • STRESS CAN CAUSE BRAINS FOCUS TO SHIFT TO SHORT TERM AND PRIORITIZE ANYTHING THAT WILL IMPROVE WELL BEING IMMEDIATELY. SENSE OF CONTROL OVER STRESSOR DETERMINES SEVERITY OF THE STRESSOR • THE ENVIRONMENT YOU EXPERIENCE IN EARLY CHILDHOOD CAN EFFECT STRESS SENSITIVITY. • RECOVERY IS ABOUT OVERCOMING NOW

WILLPOWER/EGO FATIGUE • WILL POWER IS GREAT FOR INCREASING PERSEVERANCE THROUGH A DIFFICULT TASK. IT IS NOT GREAT FOR NOT DOING A BAD HABIT • WILLPOWER STALLS A BAD HABIT BY ACTIVE FOCUS AND HOLDING INTENTION IN WORKING MEMORY. WHICH GIVES QUICK ACCESS TO INFO NEEDED TO ADDRESS CURRENT TASKS AND PRIORITIES. • YOU CAN SUPPRESS DESIRE, HIDE EMOTIONS AND IGNORE IMPORTANT INFO FOR A TIME WITH WILLPOWER BUT EGO FATIGUE WILL RESULT. EGO FATIGUE IS LOSS OF SELF CONTROL THAT RESULTS FROM RESISTING TEMPTATIONS • EGO FATIGUE INCREASES ACTIVATION OF BRAIN AREAS DEVOTED TO EMOTIONAL MEANING, DESIRE, WHILE DECREASING ACTIVATION IN AREAS ASSOCIATED WITH SELF-CONTROL AND INSIGHT. IT BECOMES PROGRESSIVELY HARDER AND HARDER TO RESIST INSTANT GRATIFICATION

BIOLOGY OF DESIRE • EMOTIONAL SIGNIFICANCE OF AN EXPERIENCE IS THE SWITCH THAT TURNS ON LEARNING BY FOCUSING ATTENTION AND CONCENTRATION. • WANTING IS NOT THE SAME AS LIKING. FUEL OF WANTING IS DESIRE • IF DESIRE CREATED BY ADDICTIVE DRUGS IS NOT RESISTED LONGER TERM GOALS ARE SACRIFICED IN PURSUIT OF IMMEDIATE ONES • NOW APPEAL CREATES DESIRE BY PUMPING DOPAMINE INTO MOTIVATIONAL CIRCUITS OF BRAIN. DA PROVIDES THE MOTIVATION TO RECREATE A REWARDING EXPERIENCE. THE HIGHER THE DA RELEASE THE HIGHER THE VALUE THE BRAIN

BIOLOGY OF DESIRE, CONT • BRAIN ASSOCIATES DA RELEASE WITH ENVIRONMENTAL CUES(TRIGGERS) PRESENT AT TIME OF RELEASE. • WHEN BRAIN OBSERVES THESE CUES IN FUTURE IT TRIGGERS DESIRE BY PREDICTING THAT A REWARD IS POSSIBLE. • DESIRE CAUSES THE MOTIVATIONAL CIRCUITS OF THE BRAIN TO DISCONNECT FROM THE INHIBITORY CONTROL ONES DRIVING BEHAVIOR INDEPENDENT OF JUDGEMENT AND HIGHER GOAL • AS DESIRE FOR IMMEDIATE REWARDS INCREASE DESIRE FOR NATURAL REWARDS DECREASES • ADDICTION DEVELOPS WHEN IMPULSIVITY COMPULSIVITY WHICH RESULTS WHEN IT BECOMES HARDER TO RESIST THE TEMPTATION OF A REWARD AS A RESULT OF INCREASING DESIRE FOR THE REWARD

ADDICTS/ALCOHOLICS LIVE IN A TOMB OF THE PRESENT DRIVEN BY “NOW APPEAL” DEAD BECAUSE THEY LOST THEIR VISION OF THEIR FUTURE THEY DEVELOP AN ADDICT BASED SELF-IMAGE

RELAPSE PREVENTION BASED ON NEUROSCIENCE OF DESIRE AND HABIT FORMATION • RECOVERY IS A DEVELOPMENTAL PROCESS, THE REVERSE OF THE ONE THAT LEAD TO ADDICTION. IT REQUIRES HIGH MOTIVATION FOR SOBRIETY BASED ON STRONG EMOTIONS • LEARN TO OVERCOME NOW APPEAL AND SEPARATE DESIRE FOR IMMEDIATE GRATIFICATION FROM DESIRE FOR LONG TERM WELL-BEING AND ACT ON THEM INDEPENDENTLY • JUDGEMENT, PLANNING, INHIBITORY CONTROL, PERSPECTIVE PUT BACK IN CONTROL. • ADDICT NEED TO EXPAND THEIR PERSPECTIVE FROM JUST THE PRESENT FOCUS TO THE PAST THAT SHAPED THEM AND FORWARD TO A SOBER FUTURE THAT IS SATISFYING AND ATTAINABLE. • CHANGE THE CONVERSATION IN THEIR HEAD

RELAPSE PREVENTION BASED ON NEUROSCIENCE OF DESIRE AND HABIT FORMATION, CONT • MUST CREATE A STRONG DESIRE FOR A BETTER AND MEANINGFUL FUTURE. WRITE THEIR FUTURE STORY. • IDENTIFY WAYS TO ENRICH THEIR SOBER LIVES. • ATTACH THE DESIRE FOR A BETTER FUTURE TO GOALS INCOMPATIBLE WITH ADDICTION- FREEDOM FROM SUFFERING, LOVING RELATIONSHIPS, ATTAINING LIFE GOALS. DESIRE FOR BETTER LIFE MUST BE COMBINED WITH JUDGEMENT AND PERSPECTIVE

RELAPSE PREVENTION PLAN • LINKING RECOVERY TO GOALS AND VALUES • ID PERSONAL VALUES AND ID SPECIFIC RECOVERY GOALS( WHY DO THEY WANT TO BE SOBER. ( 3 -6 MONTHS). THIS PROVIDES MOTIVATION TO CONTINUE THE WORK NECESSARY TO CHANGE THE ADDICTIVE HABIT. DO THIS FORMALLY AND TAKE TIME TO WRITE RECOVERY GOAL AND THEIR VALUES ON PAPER • CREATE NEW PERSPECTIVE • TRY TO WRITE THE STORY OF THEIR SOBER FUTURE • HEARING OTHERS IN AA TELL THEIR STORIES HELPS ENVISIONING A SOBER FUTURE AND “WRITING THEIR FUTURE STORY” • CREATE DISCREPANCIES BETWEEN ADDICTIVE BEHAVIOR AND GOALS AND VALUES= MOTIVATIONAL INTERVIEWING. CREATES DIFFERENT PERSPECTIVE.

RELAPSE PREVENTION PLAN, CONT • LEARN TO HIGHLY VALUE BEHAVIORS THAT PROMOTE RECOVERY AND DEVALUE ADDICTIVE BEHAVIORS • ID DARKEST MOMENT IN THEIR ADDICTION AND FEEL THE NEGATIVE EMOTIONS ASSOCIATED WITH IT • ENRICH SOBER LIFE • SPIRITUAL DEVELOPMENT TO IMPROVE QUALITY OF LIFE • CHANGE PERSPECTIVE BY REFRAMING BELIEFS ABOUT ADDICTION OR ABILITY TO STAY SOBER • ID BELIEFS ABOUT ADDICTION AND REASONS FOR USE • UNDERSTAND FACTORS IN YOUR LIFE THAT LAID FOUNDATION FOR ADDICTION TO DEVELOP • TAKE ANOTHER PERSPECTIVE “RECOVERY =RELIEF, ADDICTION=PAIN”

ENRICH SOBER LIFE: TAME BRAINS DRIVE FOR NOW APPEAL • INCREASE OPPORTUNITIES IN YOUR LIFE THAT COULD PROVIDE IMMEDIATE REWARDS • DEVELOP AND USE A GOOD SOCIAL SUPPORT SYSTEM • YOU ARE NOT ALONE- GIVES HOPE • 12 STEP FELLOWSHIP- EMPATHIC SOCIALIZATION: COPING SKILLS • SUPPORTIVE FAMILY/FRIENDS/CO-WORKERS/CHURCH GROUP • IMPROVE SOCIAL STATUS/SELF ESTEEM • ACTIVELY ENGAGE IN A 12 STEP FELLOWSHIP • SET AND ACHIEVE MEANINGFUL GOALS • LEARN NEW JOB SKILLS • SEEK COUNSELING TO WORK ON SELF ESTEEM AND FAMILY OF ORIGIN ISSUES • REMOVE SELF FROM PAINFUL SITUATION- DECREASE STRESS, DEPRESSION, ANXIETY AND PAIN

ENRICH SOBER LIFE: TAME BRAINS DRIVE FOR NOW APPEAL, CONTINUED • DEVELOP A STRONG SENSE OF GRATITUDE- 21 DAY GRATITUDE CHALLENGE • DEVELOP RESILIENCY • LEARN LIFE SKILLS • PROBLEM SOLVING TECHNIQUE- REDUCES STRESS PROVIDES HOPE THAT YOU CAN DEAL WITH LIFE SITUATIONS • SOCIAL SKILLS TRAINING- LEARNING TO FEEL YOU ARE BEING HEARD AND ARE TREATED WITH RESPECT • IMPROVE ASSERTIVE COMMUNICATION AND CONFLICT RESOLUTION SKILLS. • GENERAL LIFE SKILLS- COOKING, FINANCIAL PLANNING, INTERVIEWING, ETC

DEVELOPING GRATITUDE- DR ROBERT EMMONS 21 DAY GRATITUDE CHALLENGE • DAY 1 - 3 BLESSINGS- WRITE 3 GOOD THINGS THAT HAPPENED TODAY THAT YOU CAN CREDIT TO OTHERS. IT CAN BE ANYTHING THAT WENT WELL. WHY YOU THINK THAT IT HAPPENED. WHAT ENABLED THIS POSITIVE EVENT TO HAPPEN AND WHAT DOES IT MEAN TO YOU. WHAT CAN YOU DO TO MAKE IT HAPPEN AGAIN. • DAY 2, - TO WHOM? FOR WHAT? - THERE IS A DIFFERENCE BETWEEN FEELING GRATEFUL ABOUT SOMETHING AND GRATEFUL TO SOMEONE. IN THIS EXERCISE YOU WILL FOCUS ON THINGS IN YOUR LIFE THAT YOU MIGHT BE GRATEFUL OR THANKFUL FOR AND THE PROVIDER OF THESE GOOD THINGS. THINK BACK OVER THE DAY AND WRITE DOWN UP TO 5 THINGS FOR WHICH YOU ARE THANKFUL FOR AND WHO PROVIDED THE GIFT TO YOU. • DAY 3 - THE GIFTED SELF- FOCUS ON BENEFITS/GIFTS THAT YOU RECEIVED IN YOUR LIFESIMPLE PLEASURES, PEOPLE IN YOUR LIFE, PERSONAL STRENGTHS OR TALENTS, MOMENTS OF NATURAL BEAUTY, GESTURES OF KINDNESS OF OTHERS. AS A SECOND PART OF THE EXERCISE ASK “ HOW MIGHT I GIVE BACK TO OTHERS AS A SIGN OF THE GRATITUDE THAT I FEEL”. HOW CAN YOU CAN PASS THE GIFT TO OTHERS. CAN YOU PERFORM A RANDOM ACT OF KINDNESS? • DAY 4 - LOOKING TO THE FUTURE- WHEN YOU THINK SOMETHING IN LIFE IS ABOUT TO END YOU APPRECIATE IT MORE. CHOSE AN EVENT, ACTIVITY, EXPERIENCE, OR RELATIONSHIP THAT MAY BE ENDING SOON. WRITE WHY YOU ARE GRATEFUL •

21 DAY GRATITUDE CHALLENGE, CONTINUED • DAY 5 - THE ABSENCE OF BLESSINGS- THINK ABOUT A POSITIVE EVENT OR EXPERIENCE THAT MIGHT NEVER HAVE HAPPENED OR MIGHT NEVER HAVE BEEN PART OF YOUR LIFE. WRITE DOWN WAYS THAT IT MIGHT NEVER HAVE HAPPENED • DAY 6 - THE GRATITUDE LETTER – FEELING GRATEFUL AND NEVER EXPRESSING IT IS LIKE BUYING A GIFT AND NEVER GIVING IT. WE OFTEN DO NOT EXPRESS GRATITUDE TO THOSE WHO DESERVE IT. REMEMBER A TIME IN YOUR LIFE WHEN YOU WERE GRATEFUL FOR SOMETHING THAT SOMEONE DID FOR YOU AND WRITE THEM A LETTER THANKING THEM. IN THE LETTER DESCRIBE SPECIFICALLY WHY YOU ARE GRATEFUL, HOW HE OR SHE AFFECTED YOUR LIFE. WHAT DID THEY DO? HOW IS IT STILL AFFECTING YOUR LIFE? THIS SHOULD BE SOMEONE YOU HAVE NOT PROPERLY THANKED • DAY 7 - BAD TO GOOD- CHOSE AN EXPERIENCE IN YOUR LIFE THAT WAS INITIALLY UNPLEASANT OR UNWANTED. FOCUS ON THE POSITIVE ASPECTS OF THIS EXPERIENCE AND AS A RESULT OF THIS WHAT ARE YOU NOW GRATEFUL FOR? HOW HAS IT BENEFITTED YOU AS A PERSON? WERE THERE ANY PERSONAL STRENGTHS THAT GREW OUT OF THIS EXPERIENCE? HOW HAVE YOU GROWN • REPEAT DAYS 1 -7 2 MORE TIMES

DEVELOPING RESILIENCY • ACCEPT CHANGE AS INEVITABLE • TAKE TIME TODAY TO STRENGTHEN SOCIAL NETWORK • ACCEPT THAT FEW CHALLENGES ARE UNDEFEATABLE • THINGS WILL GET BETTER IF YOU BELIEVE THAT THEY CAN GET BETTER • TAKE APPROPRIATE ACTIONS IN TIME OF CRISIS • TAKE MEASURES TO SOLVE PROBLEMS DO NOT LET THEM JUST SIT. • USE PROBLEM SOLVING TECHNIQUE- ID PROBLEM, ID OPTIONS TO SOLVE PROBLEM, PROS/CONS OF EACH OPTION, PICK BEST ONE, APPLY IT, EVALUATE

DEVELOPING RESILIENCY, CONT • WORK TOWARDS YOUR GOALS WITH BABY STEPS • IN TIMES OF CRISIS THE ABILITY TO TAKE EVEN SMALL STEPS FORWARD IS VERY BENEFICIAL • STAY HOPEFUL AND OPTIMISTIC • WHENEVER YOU ARE WORRYING ABOUT WHAT MIGHT HAPPEN VISUALIZE HOW YOU WANT THE SITUATION TO TURN OUT • LEARN FROM YOUR MISTAKES AND FAILURES • TAKE CARE OF YOURSELF • GUARD AGAINST HALTS=HUNGRY, ANGRY, LONELY, TIRED,

SUMMARY 1. IN RECOVERY YOU MUST START TO SEPARATE ONE SET OF DESIRES, NOW APPEAL, FROM ANOTHER SET OF DESIRES- A BETTER MORE FULFILLING LIFE- AND BEGIN TO ACT ON THESE INDEPENDENTLY 2. USING INSIGHT, JUDGEMENT AND A NEW PERSPECTIVE DEFINE YOUR SOBER SELF AND WHAT YOU REALLY WANT OUT OF SOBRIETY. 3. FIND WAYS TO CREATE VALUE OR ENRICHMENT IN SOBRIETY. 4. ENVISION A DESIRABLE FUTURE AND ARE MOTIVATED TO ACHIEVE. TURN OFF DESIRE OF NOW APPEAL AND ATTACH DESIRE TO GOALS INCOMPATIBLE W ADDICTION- FREEDOM FROM SUFFERING, ACHIEVING LIFE PROJECTS, ACCESSING

REFERENCES • LEWIS, MARC. (2015) BIOLOGY OF DESIRE. NEW YORK, NEW YORK: PUBLIC AFFAIRS BOOKS • EMMONS, ROBERT. (2013)GRATITUDE WORKS. SAN FRANCISCO, CA. : JOSSEYBASS BOOKS • TRAFTON, JODIE, ET. AL. (2011)TRAINING YOUR BRAIN TO ADOPT HEALTHY HABITS. LOS ALTOS, CA: INSTITUTE FOR BRAIN POTENTIAL