Sunsets in Recovery: Something I can’t explain with science

dawn sunset beach woman
Photo by Pixabay on Pexels.com

It has been a massive week. HUGE! Usually I would have written this post a few days ago and then spent a couple of days editing it. This week I am late and there will be no time for editing. Straight from my brain to the page.

It has been a massive week because of work, but also because we went away for the weekend. One thing I appreciate very much since getting sober, and something that seems to be pretty common among those in recovery, is an appreciation of nature. So I was really looking forward to going away for the weekend, getting away from the traffic and busyness of the city, and spending some time in nature. Unfortunately it rained pretty much the whole weekend.

Today was sunny though, and as I was hanging out the washing I turned around to see the most beautiful sunset, and took a few moments to appreciate it. This is something I don’t remember ever doing when I was drinking – back then it was as if I just didn’t notice the world around me. Possibly I simply wouldn’t have been out hanging washing at that time because I would have been inside drinking, so I just didn’t have the same opportunities to appreciate nature. Now if I’m angry, or frustrated, or just feeling waaaaay too many emotions (y’all in recovery know what I’m talking about!), taking a walk and getting among nature is right up there as one of the best things I can do to work out those stresses, along with exercise and writing about it.

Going for a walk has saved me from drinking a number of times. I remember the first BBQ I went to after I got sober, and I found myself getting really agitated. Everyone was fine (my friends actually accept the fact that I don’t drink anymore – they are far more grown up than I ever used to be) but I was getting antsy. Then I thought, why not just go for a walk? So I did. I walked and walked and walked until I stopped on a bridge, and saw the most spectacular sunset I had ever seen. It was mesmerising. It even made me understand for a second why people could feel that there was a higher power guiding them, sending them messages and so on.

When I saw that spectacular sunset in early recovery, I certainly felt a sense of connection with nature, but for me this was not necessarily spiritual. I am sure there is a scientific reason out there for this feeling, and that it is discoverable, but I haven’t come across it myself. Indeed at the time, I tried to think of scientific ways I could make sense of this connection. For example, I reasoned that everything in nature is connected in a sense, as everything living shares a certain amount of DNA. But the sun doesn’t have DNA. And even for things that do, what is the mechanism by which shared DNA might make us feel connected?

At the end of the day though (see what I did there? The end of the day! That is when we see the sunset!!! Ah ha ha ha ha ha ha. Just me? OK just me), it doesn’t matter why. It doesn’t matter what the mechanism is, the most important thing is that we feel that awe of nature, or some type of connection when we need to. And that we don’t pick up, of course.

So that’s it for this week. No ‘sciencey bits’ as I really have no knowledge of any science that speaks to the fact that we didn’t notice nature in addiction but do in recovery, and I haven’t had time to research any. Happy to hear about it if anyone knows of any studies? Or your personal theories! I’m super busy so I can’t promise extremely detailed responses, but I will read I promise.

Have a great week 😀

 

Overthinking and Drinking

 

overthinking

If you’re anything like me, then there are times when you start thinking about something…. then something else… then that same thing you first started thinking about again… around and around in circles without getting anywhere and you wish your brain would just shut the hell up! Especially at night when I’m done with work and chores for the day, and all I can think about is what I have to do at work over the next few weeks, all the chores I haven’t gotten around to yet, that bill I haven’t paid, and the fact that it’s library day at my daughter’s school tomorrow so I must remember to put her library book in her school bag. Fun.

Then there’s the longer-term and more serious kind of rumination (basically a fancy term for overthinking) that my brain appears to involuntarily indulge in. I am definitely a ruminator. I can have conversations with people and still be thinking about something stupid I’ve said hours later and what I should have said instead. I also ruminate about work. A scientific career is one ripe for rumination: about how I’m not good enough, how I should have X many publications and grants by now, how people are going to rip me apart next time I give a talk, how people don’t take me seriously because I’m female in a still relatively male dominated field, how if they do take me seriously then they end up finding me pushy or arrogant or resting bitch facey.

If you like being happy (because so many people love being sad), then rumination is a problem. In fact, it can lead to quite serious anxiety and depression. Or maybe it’s caused by anxiety or depression, or maybe its both caused by it and causes it. Regardless, it is highly correlated with anxiety and depression.

This is why alcohol can be so appealing for people who like to overthink. Just a few sips of alcohol and suddenly, all those unnecessary extra thoughts go away. You get to be present in the moment and stop worrying about tomorrow, as put so elegantly by Sia in her song Chandelier: “IIIIIII’m gonnna swing from the chandelier…. I’m gonna live like tomorrow doesn’t exist”. A kind of alcohol-induced mindfulness.

*Warning sciencey bit*

Like most things (everything) in life, there’s good reason why alcohol helps us quiet our thoughts. This is because it is a GABA A receptor agonist, meaning that it activates GABA receptors, and GABA is the primary inhibitory neurotransmitter in the brain. Activation of these receptors therefore causes hyperpolarisation of the neuron. In lay terms, it means that alcohol makes the neuron less likely to fire and therefore slows or reduces its communication with other neurons. This is similar to what anxiety medications such as Xanax or valium (or other benzodiazepines) do. (As an aside – some neurons that release GABA are known as “chandelier cells”. I wonder if Sia knew this when she wrote her song?)

Ethanol_and_GABA_Receptor.png

These effects of alcohol on GABA are further compounded by the fact that it seems to suppress glutamate, the main excitatory neurotransmitter of the brain. This is another way in which alcohol depresses neural transmission. Thus when people say that alcohol is a depressant, and they don’t mean that it makes you feel depressed, they actually mean is that it slows neural transmission. In fact, because it can cause your brain to shut the hell up for a second, it can make you feel happier, especially for those prone to rumination.
*End sciencey bit*

It is this reduction of neuronal excitability that makes alcohol particularly appealing for overthinkers like me. All those thoughts, worries about what you said yesterday, about what you have to do tomorrow etc, get dampened down and all that neural noise just shuts down for a little while. Want to sleep? Just lay your head down on the pillow…. And voila. Sleep. Aaaaaah bliss.

But there’s one more piece of this puzzle that I haven’t explained yet, but that is really key. Alcohol only shuts your brain up for a little while.

What happens when the drunk feeling goes away? The overthinking and anxiety and depression come back stronger than before. The thing is, the body and brain don’t like being artificially ‘thrown out’ of their normal state of equilibrium by alcohol or any other drug, and it will fight to get back to where it was when the alcohol wears off. This means that although when you are drinking all that neural noise shuts up for a minute, the next day it comes back harder, stronger, and more forceful. Not only that, but you are now possibly also dealing with a hangover so you are overthinking whilst your body feels like shit. Not only that but you also have to deal with the very possibly stupid things you did last night that you regret, or have the vague feeling that you might have done something stupid but you can’t remember. I certainly spent many ‘next days’ trying to piece together what I said to whom, or did the night before (getting in bed with my parents naked anyone? Nope just me).
Of course, because alcohol can make your brain shut up for a little while, many people who suffer rumination in anxiety and depression are drawn to drinking it. But then when the effects of it wear off the next day, you feel more anxious, and if you’re like me, you drink again to get over it. Before you know it BOOM you have both anxiety and a drinking problem. FUN FUN FUN!!

When I got into recovery, I was very pleasantly surprised to find that many of my anxieties just went away by themselves. At social events I stopped forgetting what I said to people, and was more sure of what I did say because it was under my control. Therefore I didn’t need to ruminate over it later. I also just learnt to put the thought out of my mind before giving into rumination. If I start thinking about the stupid thing I said to someone, I just immediately counteract that thought with “that person will not still be thinking about it, so you don’t need to”. Sometimes this works better than others of course, but ya know. Progress not perfection. At work too, I’ve found that I believe in myself a lot more. I also work harder and my thoughts are clearer, so that helps a lot. Plus I have been more successful at work in sobriety (who knew right?) so I have received positive reinforcement from my successes.
The one final thing I will say with regards to overthinking is that, in sobriety, I do think it is very important to find some kind of mindfulness in life so that you have a certain amount of time each day when you are completely absorbed in a task and not thinking about what you have to do tomorrow or what you did yesterday. Science has shown that we are happiest when we are totally absorbed in a task. I have never been particularly good at meditation or tried particularly hard to get good at it, but that’s one avenue that a lot of people swear by. The science about meditation in particular is overall a little mixed but certainly there’s some positive studies and plenty of anecdotal evidence out there suggesting it works. What works best for me, however, is exercise, particularly vigorous exercise at the gym with other people. When I am working out, my mind is completely focused on how many reps I’m doing/what weight I’m doing/how gassed I am etc. Working out with other people also provides a social aspect, and lots of people who aren’t that into drinking go to the gym. Exercise is also amazingly good for your brain and general fitness etc. I really couldn’t have gotten sober without it.

So whatever you do in sobriety, my advice is find something to do that helps you shut your brain up for a second in a healthy way. Exercise, meditation, singing at the top of your lungs, or even watching a scary movie. All great things to do with the added bonus of not producing a hangover tomorrow.

Relapse Part 1: Romanticising alcohol

Exercise-for-Brain-Health

How long does it take your brain to return to normal in sobriety?

One question I see asked a lot within the recovery community is, “How long does it take for your brain to return to normal when you quit drinking/drugging?”. The answer I see given most often is one year, but like anything to do with the brain, the answer isn’t that simple. The truth of the matter is, some recovery of normal function will occur within 24 hours, whereas some synaptic pathways laid down during addiction may never change within a lifetime. This isn’t reason to despair – remember that every time we learn something/make a memory, there are changes in the brain that accompany that. So all the learning that occurs in addiction, such as all the associations between relaxing and drinking for example, or even between the label on your favourite brand of beer and getting drunk, those associations might potentially last for a lifetime. This is why you might hear old-timers 20 years into recovery suddenly reporting a craving after catching sight of a beer they used to drink, or the thought or drinking seeming to randomly pop into their head when celebrating an occasion or milestone.

I say this isn’t reason to despair, because we do a lot of learning in recovery too. We form new associations, new coping mechanisms, and new habits that counteract the old ones. All of these changes are also associated with plastic changes in the brain, such as new synaptic pathways, and the increased/decreased likelihood of an existing pathway firing. So what I’m saying is, we can and do change our brains for the better as we go through sobriety. Unfortunately, however, this learning isn’t always enough to prevent a relapse, although I do believe that through relapse we also learn, as I will explain.

As I mentioned in my first blog post, I have had a few relapses since I made the decision to quit drinking for good, perhaps 4 or 5. Perhaps 2 of these relapses have involved drinking over a few days, whereas the others were only a single day. In the recovery community it is often stated that relapsing is part of the journey, and I think that this is one area in which the science and recovery wisdom match up. Before I explain why, I want to say that I really don’t want anyone reading this to use this information as an excuse to relapse. I can’t have that on my conscience!! I am JUST talking about what I have learned from the relapses I have already had. I DO NOT intend on relapsing again ever.

In fact, whilst I was writing the first draft of this blog, something happened that really drove home to me how dangerous relapse can be. One of the lovely men in one of my online recovery groups relapsed after many, many years of sobriety, and he died. It actually makes me really sad to write that sentence, because although there are around 5,000 people in this particular group so it’s hard to know everyone, I had had some really lovely chats with this man. A lot of us had, and he had written a book as well as given an interview for a podcast, so a lot of us felt like we knew him. So of us did actually know him.

So PLEASE don’t read this and relapse! Don’t do it. OK? OK good thanks for that.

What does it mean to say relapse is a part of your journey?

When it is said that relapse is a part of your journey, it’s hard to know exactly what is meant. Like anything in recovery, it probably means different things to different people. I think part of it is probably intended to take the shame out of relapse. I see in the groups that people seem to suffer great shame when they relapse, and are very hard on themselves. If they can turn around and take the positives out of the experience, then it removes some of the shame. Also the identification of the fact that relapse is something most of us experience helps remove some of the shame. Personally I have never felt shame about my relapses, because I focus on how much sobriety I have had over the last year. A hell of a lot more than I had the year before that, that’s for sure! But I’ve also learned a lot from each and every incidence of relapse.

Incubation of craving – otherwise known as ‘romanticising of drinking/drugging’

My first relapse was a glass of wine I drank at a wedding, and it was because I was hungry. I was also angry, or “hangry” more accurately, and “Hungry, Angry, Lonely, Tired” are the common signs to watch out for in relapse. I was suffering two of them. OK, don’t to to weddings hungry. Lesson learned. My second relapse was at a 40th birthday. I didn’t start drinking until 10pm. I was stressed, and anxious, and lonely and wanted to hang out with my friends. Next time go home, post online, write. Wait until the morning and give my husband and daughter cuddles. Lesson learned.

The third time was different. I was stressed and working far too much, but that wasn’t the reason for the relapse. I had started romanticising drinking in my mind. I would see a glass of wine and I could almost taste it on my tongue, and it tasted like heaven, like nothing I’d ever had before. I started imagining this ‘old’ world in which I could drink and escape from all my problems for a few hours (never mind that alcohol was the thing causing a lot of these problems, and never mind that for the last few years it didn’t offer much of an escape anyway).

*Warning sciencey bit*
In the behavioural neuroscience literature this romanticising of drinking/drugging is known as ‘incubation of craving’. We can model this in rats. Of course we don’t know what the rats are actually thinking or feeling, but if a rat or mouse are trained to press a lever for ethanol (alcohol) or cocaine for example, and when the animal receives the drug, a light in the box will also turn on. If you then don’t give the animal the drug for 24 hours, then allow them to press the lever for the light they will press less than if it had been 3 weeks since they last had the drug. Similar effects have been shown when animals are tested 6 months later, which is a quarter of the lifetime of a rat or mouse, so these are long-lasting associations.

From this work we know that within the nucleus accumbens, there are changes in the way that neurons communicate with each other via synapses, and even the way in which particular neurons receive messages from other neurons, after long periods of withdrawal from drug. These are long-term plastic changes in the nucleus accumbens; specifically the way in which various types of glutamate receptors respond to neuronal inputs (see diagram of gluatamatergic synapse below). In this way it has been shown that addiction involves more than just dopamine as is commonly thought, but also involves changes in glutamate transmission, glutamate being main excitatory neurotransmitter of the brain.
glutamatergic synapse

What is especially exciting about this research is the possibility of developing medication that could specifically target these (metabotropic) receptors that have specific effects in incubation of craving weeks and weeks after withdrawal to prevent relapse. But that is still a way off into the future.
*End Sciencey bit*

Similarly, in my personal experience I found that after getting over the initially strong cravings, I honestly didn’t think about drinking that much. I thought I was cured! Yet at around the 4 month mark suddenly I would walk along the street and see someone in a café drinking a glass of wine out of the corner of my eye and it was like everything else in my vision went dark and I could only see the wine. I could almost taste it in my mouth and it tasted like heaven. I could feel the warmth as the wine trickled down my throat into my stomach, and I missed it. A lot.

I resisted these cravings for a long time, but then came a particularly stressful time at work and I couldn’t resist any longer. I needed a mental escape from my life. So I drank.

Relapse Part 2: When reality doesn’t meet expectation

Heartbreak          

When I gave in and drank, surprise surprise, it was not as good as I had imagined. It didn’t taste as good, it didn’t make all my problems magically disappear, even for a little while (duh) and it just made me feel a bit fuzzy in my brain! After 6 or so months of being relatively clear-headed, I really did not like this feeling at all. I experienced what, in behavioural neuroscience, is known as ‘prediction error’ – the ‘error’ between predicted and actual outcomes. In other words, the reality of the alcohol I drank did not match up to the romanticised representation of drinking alcohol I had been imagining in my mind.

Of course like a trouper I didn’t stop drinking there and then, but instead I drank for a few more days, then stopped again, then repeated the whole pattern again a couple of weeks later. Unbelievably, it STILL didn’t match my expectations, and still didn’t cure all of my problems! I know, shocking right?

*Warning Sciencey bit*

In science, the common wisdom is that when there is an ‘error’ between predicted and actual outcomes, learning occurs. In fact, this is the process that has been shown to be most closely aligned to phasic (i.e. ‘quick’) dopamine firing. In my case, I experienced negative prediction error, meaning that the outcome (alcohol) I predicted was more valuable than the alcohol I actually experienced. When there is negative prediction error, we start to unlearn associations between stimuli/contexts/internal stimuli and alcohol, and I’m pretty sure this is what happened with me. I realised that the outcome was not as valuable as I had expected, so when I saw things/thought things that had previously triggered me to drink, that triggering was now vastly reduced. So much so that my last relapse honestly ended with me leaving half of the bottle of wine I was drinking halfway through because I just wasn’t into it. Something that NEVER would have happened a year ago.

*End Sciencey Bit*

So I think this process worked, because since then I have not craved alcohol. Glasses of wine have stopped jumping out at me when I am around them. I have been to several dinners with people drinking and haven’t even paid attention to their drinks. This is progress!

However, although I can be pretty arrogant, I am not so arrogant to believe that I will never experience a craving ever again, or begin to romanticise alcohol in a way that is not realistic. In fact, science also supports the notion that these associations between cues and alcohol are still there lurking underneath (it makes sense for the brain to retain information about things that predict reward, as I’ve talked about previously). Also of course there’s the possibility that the craving will incubate again, or that times of very high stress will cause cravings again. But I am hoping that I have learned enough to remember that alcohol doesn’t really provide an escape, or taste like heaven, or solve world hunger. It just makes me feel fuzzy in the head.

*Warning Sciencey bit*

As mentioned, it is this process (prediction error) that is linked to dopamine firing, although more recent research suggests that this function is confined to a subset of dopamine neurons. However, I have also mentioned that dopamine doesn’t straightforwardly represent a ‘reward’ pathway as many people believe. This is because if outcomes are perfectly predicted, there is no (phasic) dopamine response. You can see this below (from Schultz, 1998, J Neurophysiol), where the dopamine response is strongest (i.e. where the dots are closest together on the rasta plot) for the ‘CS’, i.e. ‘conditioned stimulus – in addiction this could be the pub, sight of glass of wine etc. When the reward is actually delivered, where it is labelled ‘R’, there is no phasic dopamine responses (i.e. the dots are the same as before and after reward delivery).

In real life terms, this means that if you are an alcoholic and you walk past a pub, then your dopamine will fire to the pub, and other cues (e.g. beer label/taps etc) that predict alcohol. When you drink the alcohol itself, however, because it is perfectly predicted by these cues, there is no dopamine firing. If dopamine was a straightforward ‘reward’ circuitry, it should spike whether alcohol was predicted or not. Rather, it is thought that dopamine in fact ‘teaches’ other parts of the brain about what stimuli to associate with reward, and therefore provides motivation or incentive to seek out those stimuli in future to maximise reward.

 

Screen Shot 2018-05-28 at 1.26.45 pm

*End Sciencey Bit*

So as you can see, the neural circuitry of addiction is far, far more complicated than simply having a ‘reward’ circuitry or a ‘pleasure’ circuit. We still have so much to learn about addiction even in rats or mice, whose brains are far less complex than humans.

Having said all that, I really don’t recommend relapsing just so that you can learn to like drugs/alcohol less! It is not a good idea. There were a couple of times in my relapses I really felt out of control and had to email friends/my recovery coach/others and beg for help. Luckily I was able to get it back under control and get sober again, this time. Perhaps next time I won’t be so lucky and perhaps the consequences will be severe. So why play with fire? I have seen relapse lead to so many bad consequences for so many people. It just isn’t worth it.

 

 

Am I really an alcoholic?

adult alcohol alcoholic beauty
Photo by Pixabay on Pexels.com

Dangerous Thinking

Soooo my last post about alcoholics anonymous created a bit of controversy, which was not altogether unexpected. A lot of people are very passionate about AA. What did surprise me, however, was that it raised an old question within my mind that I had previously struggled with for a long time: “Am I really an alcoholic? If all these people are so convinced that you need AA to get sober, but I didn’t need AA, then maybe it’s because they’re ‘true’ alcoholics and I’m not?”.

This kind of thinking is dangerous for me. It inevitably leads me down a path where I start making excuses and start justifying my drinking. Excuses include: that I never drank everyday, I tried to have one or two days off most weeks (it was a struggle, and many weeks I didn’t succeed), I still went to the gym, I still had a good job, I still had a loving family. Despite all that, however, I’m pretty sure my drinking was not normal.

I’m pretty sure

I’m pretty sure that most people’s husbands don’t end up having to drive home on their own birthday when you were the designated driver, and pull over half way for you to vomit by the side of the road. I’m pretty sure that most people don’t have regular blackouts and spend every weekend with crippling anxiety about what they said to whom and whether they did anything stupid. I’m pretty sure most people don’t start drinking more and more alone at home (well my husband was there, but usually asleep and never drinking with me) and less and less when out with other people, so that if I did do something stupid no-one was there to remember it. I’m pretty sure most people don’t become so obsessed with alcohol when they stop drinking that every time they drive past a liquor store, or a restaurant/cafe in which people are drinking, they feel like the whole street goes dark so that all they can see is the alcohol and it’s like nothing else on the street exists.

And around and around I go, on the same thought loop I have been on many times before. Sometimes this has ended with me drinking again, later realising that I definitely do have a problem and stopping again. More recently it tends to end with me skipping the drinking bit, realising that I definitely do have a problem, and just not picking up.

A Problem and a Solution?

I have a problem with alcohol. Whether you want to label it as being an ‘alcoholic’ or not, I have known for a long, long time that I don’t drink normally. I was also constantly reminded of this by my husband. Oh how frustrating I used to find it that he would refuse to get wasted with me on a Tuesday night! In sobriety of course I thank my lucky stars that he’s not a big drinker. In fact since I have stopped drinking he also barely drinks at all, and never at home. I really don’t think I would have been able to stop by myself if he was drinking in front of me all the time.

My life has also changed dramatically since I stopped drinking: I have achieved many work goals, I do SO much more with my family now, and I have hit many personal bests in terms of fitness and strength at the gym. I actually deal with my problems in a mature manner (well more mature than before at least!) instead of just drinking and ignoring them. Now when I have a problem I write a list of what I can control, and a list of what I can’t control about the situation, then make a concerted effort to ‘let go’ of what I can’t control. I then try and work out a productive way of dealing with what I can control. If I have a talk to prepare for example, I stop procrastinating because of what people are going to think of me etc (I can’t control that anyway) and work on the talk itself – that bit I can control. As a result, when I give the talk I am calmer, more practised, more comfortable, and less anxious. What a revelation! Everything I was looking for in the bottom of the bottle happened when I put the bottle down! So I guess what I’m saying is, would my life really have changed so much if I didn’t have a problem with alcohol in the first place?

A Continuum of Alcohol Use Disorder (*mildly sciencey bit*)

So what I have decided is that ruminating over and over about whether or not I am a ‘real alcoholic’ and comparing myself to others is counterproductive. If I just compare myself drinking to myself sober (small sample size so not very scientific I know) then I can see that pretty much every aspect of my life – relationships, work, happiness, motivation, fitness, health – is better when I am sober. With regards to science, one thing that helps me understand myself in this area is the knowledge that most scientists don’t see the line between ‘normal’ and ‘problem’ drinkers as a hard line anymore. Rather, there is a continuum of ‘alcohol use disorder’ (AUD), and you can place ‘mild’ ‘moderate’ or ‘severe’ on the continuum according to the most recent edition of the DSM-V: the diagnostic manual used by psychologists and psychiatrists. When I take the DSM-V questionaire (page 2) and apply it to my drinking days, I answer yes to around 6 of the questions, putting me at the bottom of the ‘severe’ category. Alcoholism, even more so even than other types of drug addiction, is progressive. It certainly took me many years before my drinking become problematic, but the more I drank the more problematic it became. When I first became sober I watched a documentary called ‘rain in my heart’ about end-stage alcoholics in hospital dying of liver disease, and it occurred to me that if I didn’t stop drinking, this is where I was going to end up. Better to stop now I think.

NIAAA spectrum of alcohol use disorders.jpg

*End mildly sciencey bit*

I think that’s about all the science I’m going to include in this post for today. Next week I will include more. However I also wanted to respond, particularly to some of the more passionate posts I received in response to my last blog about AA and say: I am just telling you what has and hasn’t worked for me. I am just presenting my opinion, as a neuroscientist, I am not presenting the opinion of the entire scientific community. If you attend AA and it works for you, please do not stop! I’m sure if I attended I would get a lot out of it. I wrote the last blog entry simply because I remember when I first got into recovery and I felt like AA was pushed onto me very hard. I know that others in recovery felt the same. Because of all the reasons I outlined in my last post however, I wasn’t sure that it was right for me, and the pushing just made me resist even more. The first time I heard someone’s story who got sober without AA was when I read “I swear I’ll make it up to you” by Mishka Shubaly and I actually cried a little bit from relief. It IS possible to get sober without AA. It IS possible to get sober without a higher power. Maybe it’s not possible for everyone, but I say each to their own! I would never tell someone else that there is a right or wrong way to get sober, or that there is only one way. There are many paths.

Lastly, to those who are questioning whether you are an alcoholic or not, I hear you, I get you. But if that question even enters your head, I would suggest that in all likelihood, you are probably at least on the continuum of AUD and  would probably benefit from quitting drinking. I can tell you that my life has gotten a 100000000+ times better since I did.

Alcoholics Anonymous: Part 2: The good, the bad, and why I didn’t join.

pexels-photo-924004.jpegA quick note before I begin: I have received feedback that the science can be a bit hard to follow in this blog. From now on I will signal the sciencey bits with *Warning Sciencey bit” and signal the end of it with *End Sciencey bit* and if you choose to skip these bits, the rest of it should still make sense. Hope that helps, but open to more feedback if anyone has better suggestsions.

The Scientific Perspective on AA
For the most part (although this is not a consensus by any means) scientists do not particularly rate AA. To them it is a program that was made up by a guy a long time ago (1935) without being based on any kind of scientific evidence, and due to its anonymous nature is difficult to study in a systematic manner. What this means is, that the studies that have been done are largely observational, and do not involve participants being randomly assigned to AA vs. other treatments and control groups to infer outcomes in a more causal manner. And then there’s the God thing. For those who don’t know, a large part of the AA program involves putting faith into a ‘higher power’ – defined as a ‘God of your choosing’ which doesn’t necessarily HAVE to be God Himself, but often is.

*Warning Sciencey bit*
The notion of a higher power is inherently non-scientific. This is because it is non-falsifiable. What this means is that, because it can never be proven wrong, it can never really be tested. In other words, the concept of a higher power can be altered to fit any situation. For example, if someone prays for something, and subsequently receives what they asked for, a believer will assume that their higher power has answered their prayers. On the other hand, if someone prays but doesn’t get what they ask for, this doesn’t change the beliefs of that individual. Instead, a believer will assume that their higher power has a different plan or destiny for them. In this way, a person’s faith can be used to justify any outcome, and therefore can never be proven wrong. And although things are never proven ‘right’ in science, if something is non-falsifiable then we also cannot provide solid scientific evidence suggesting its existence. So at least within the realm of our capabilities right now, the concept of a higher power can never be proven or disproven.
*End Sciencey bit*

What the Soberverse thinks of AA
It is worth mentioning that this view of AA and other anonymous programs by scientists is far from a consensus, and some do have a positive view on it. But the soberverse (my made up name for the online recovery world) has a different perspective altogether: anonymous programs are still by far and away the most popular treatments for addiction. They are the most accessible as there are many such meetings at convenient times, all over the world, and all you need to attend is to give a gold coin donation. Even without that, you will not be turned away. Furthermore, within the soberverse you will find many people who have gotten sober using these programs, who swear by their efficacy, and become very attached to the ’12-step program’.

As for my point of view, as a ‘Neuroscientist in recovery’, I suspect the truth lies somewhere in between these two points of view. Whilst it is not the panacea that some people believe it to be (although it can be for many individuals), it is not completely useless either.

The Positives
The biggest ‘pro’, in my opinion, is that AA provides a way for people in recovery to connect. Furthermore, it provides an opportunity to connect with active and ex-addicts, and other people who generally understand what an individual might be going through. It gets people out of the isolation they might have been suffering, which even in basic neuroscience we know to be important because of studies such as the famous ‘rat park’ experiment.

*Warning Sciencey bit*
In brief, rats who were kept in isolation without enrichment were easy to train to self-administer cocaine or opioids and to became ‘addicts’, whereas rats that were given access to other animals in an enriched environment (i.e. rat park) were not. The implication, of course, is that individuals with good social connections and opportunities are less likely to become drug addicts than isolated individuals with little opportunity. I should mention that this finding hasn’t always been well replicated since the original, something else I will touch on in future posts.
*End Sciencey bit*

I think most people in recovery will tell you, and from my personal experience I totally agree, that connections are vital to recovery. So in this respect, AA does a good job. It is often said within the soberverse that “connection is the opposite of addiction” and I agree, although most of my connection has been achieved online.

Another thing AA gets right is that it provides a program of positive reinforcement of ‘good’ or productive actions that are learned in sobriety, such as paying bills, cleaning your house, getting a job and generally getting your shit together. That is, when good things start happening to the addict in recovery (because they are sober, no longer isolated, have help etc), not only do they feel the intrinsic happiness of getting their shit together, but they have the added feeling of a spiritual guide, a ‘higher power’ that helps the addict feel like they are not alone, and that they are being guided on the right path. Moreover, addicts often feel like the higher power affords them a strength to get better that they didn’t have alone. Over the months I have spent in recovery, I have really begun to appreciate the positives people get out of having a higher power. Although my beliefs prevent me not only from believing in a higher power, but really in any type of spirituality, over time I have honestly come to see this as a bit of a shame, because I see how much contentment such beliefs can provide.

These are not the only benefits of AA by any means. It provides a program of accountability, allows a person to address the issues in their past or in their current life with a new perspective (in particular changing from seeing themselves as as a helpless victim), and eventually provides a way for addicts to help others. Therefore I believe the AA program provides many things that even a scientist or skeptically-minded individual can appreciate.

The Negatives
So, given all those positives, why haven’t I been back to AA? In all honesty, I’m not really sure. For a long time I told myself I’m too busy as my job can be very demanding. But I’m sitting here writing this blog when I could be at a meeting, so I guess I would have time right now! Also as I mentioned, as much as I can see the benefits of believing in a higher power, I just can’t. As far as I can tell, even the agnostic or atheist alternatives involve some kind of higher power or spirituality – just not one based on God. This is just a 100% no from me.

I think that another reason for not attending is that I don’t think I need to. Whilst I have no problem admitting that I am an alcoholic, my life is not ‘unmanageable’ and never really has been. I have a family, I have a good job, I have a lot of friends and happiness, and I am relatively fit and healthy. I also have expert knowledge of the neural circuitry of decision-making, and that helps a lot. Further, if I’m going to be totally honest, the idea of walking into a room of people I don’t know to talk about being an alcoholic is terrifying, even if I have done it once before. I know that this is a weak reason, but I’d be lying if I said it wasn’t a factor.

So there’s all my excuses. I recognise that they are all excuses. If I really needed a program like AA, none of these excuses would get in my way – just as they didn’t when I was in Bali. However, my last and most important reason for not attending, I feel is not just an excuse, and this reason is the rigidity/inflexibility of thinking I see it produce in people. Although of course it is possible that it is the addiction that produces such rigidity, not the program, but there does at least seem to be a correlation even if the link is not causal. And of course I should mention that this does not go for everyone who attends AA, there’s plenty of people with their own take on things

*Warning Sciencey bit*
There is evidence in the lab, that even in animals that have been trained to be alcoholics or drug addicts, then their ability to make decisions is impaired. Specifically, if rats learn to press a left lever for sugar water, and a right lever for pellets, when later given a choice between levers a normal rat will choose the one that earns whichever (pellets or sugar water) is most valuable to them at the time. An alcoholic/drug-addicted rat, on the other hand, will choose both levers equally. This demonstrates that on a fundamental level, drug addiction impairs the capacity to make decisions. This impairment appears to be accompanied by alterations in neural activation and other structural changes in the striatum, which is part of the brain’s hub of action selection. Similarly, human drug addicts show reduced activity in prefrontal cortices and striatal regions associated with decision-making (see the figure below for a highly simplified diagram of this pathway, taken from http://addictionpathology.wikia.com/wiki/The_Reward_Pathway). I know for me personally, when I was drinking, a lot of the time my decisions were impaired because I just didn’t really care. All I cared about was my next drink.

The_reward_pathway_3.png
*End Sciencey bit*

So it is possible that the rigidity of thinking was there prior to attending AA. Alternatively, it is possible that because of the alcoholic’s impairment in their ability to make good decisions, it makes sense for them to ‘surrender’ this process to others, and to ‘take the cotton out of their ears and put it in their mouth’ as a common saying goes. Suddenly, when the program works for them like nothing ever has before, they start to believe that this is the only way to get sober.

It is this rigid attachment to the ideas and traditions of AA is that keeps me away. I am sure there is wisdom in the twelve steps, and as mentioned the higher power provides an important service. But the rigidity is very difficult to accept for people like myself, whose entire world view is built around scepticism, questioning, and the necessity of empirical evidence. I have had an MD in recovery say to me that he had to suspend his scientific thinking in order to go through the program, but I just don’t think this is possible (or necessary) for me.

So if not AA then what?
There are a number of alternatives. If you are looking for face-to-face meetings, there’s SMART recovery which is a research-based program. I was quite drawn to the idea of SMART but I couldn’t find a convenient meeting. This is one area in which AA beats SMART hands down, there are far more AA meetings than SMART meetings. Other than that, there are also medications such as the Sinclair method (an opioid receptor antagonist [i.e. blocker] taken in pill form that blocks the pleasurable effects of alcohol). I haven’t had personal experience with these, but the science suggests they are relatively effective.

For me personally to stay sober, I haven’t tried medication, SMART recovery or AA (other than that one time in Bali). But that doesn’t mean I haven’t worked hard on recovery, and I am still working hard. Online connection has been a big part of it. Of course I should acknowledge that, being a functional alcoholic, I was not too isolated already a close family, a good job, and a pretty good social network which already included some sober people. Perhaps if I were missing just one of these factors I would have needed face-to-face meetings to get sober. Perhaps I still will need such meetings one day, I certainly wouldn’t rule it out. As mentioned previously, I have also read every sobriety memoir going, listened to recovery podcasts (especially the Shair podcast), and joined recovery groups on facebook and elsewhere. I also do regular sessions with a recovery coach.

This blog is the next step on my journey. Writing here will keep me accountable, will allow me a way to express my feelings and thoughts. I am not doing this alone by any means. “Connection is the opposite of addiction” indeed. So welcome on my journey, let’s see where it takes us.

Alcoholics Anonymous Part 1: Bali

Bali Cravings
About 4 months into sobriety, I visited Bali with my family (including my parents and mother-in-law). When I got there, a feeling came over me… a peace and tranquillity like I’d never before experienced. Then I got in touch with my spiritual side and found God. Next I saw unicorns flying through the sky whilst pooping rainbows…

NOT!

Yeah OK, that never happened. I mean, I did go to Bali but faaaark me. It was hard. I experienced something that in the lab we refer to as ‘context-induced reinstatement’. Basically, it has been known for sometime, that addictions can be context-specific – one well-known example from real life is when many heroin-addicted soldiers returned home to the United States from the Vietnam war. Surprisingly, once home about 90% of these soldiers were able to shed their addiction, and only 10% remained addicted. However, what this also means is that addictions and can be ‘reinstated’ (i.e. the addict can relapse) when they return to a ‘context’ (place) previously paired with alcohol/drugs, or even visit a new place that is similar to the one associated with alcohol drugs, like a new pub or restaurant etc.

Contextually-mediated relapse in the lab
Similar effects have been shown in rats and mice too. The typical experiment goes something like this: the rat or mouse is first trained to press a lever for alcohol, or cocaine, or amphetamine, or whatever the drug of interest is, in a particular context, usually a skinner box with stripey walls, a grid floor, and vanilla odour. That same rat is then put into a different box with spotty walls, a smooth floor, and a peppermint odour, but in this box, the lever doesn’t earn the drug. In fact, in this box, the lever doesn’t earn anything (known as ‘exinguishing’ the lever press-drug association). If you put that rat back into the ‘extinction’ (lever-no drug) box the next day, s/he will press the lever at a low rates. If, however, you put the rat back in the original box, however, responding will be high again.
In drug addiction, this effect is mediated in the brain by circuits that regulates decision-making generally; structures such as the nucleus accumbens (often reported to be the brain’s hedonic ‘hot spot’, although it does more than just detect pleasure) and its projections to the ventral pallidum and lateral hypothalamus. Further, such ‘relapse’ isn’t only bought on by contexts (places), but can be caused by cues such as the sight of a particular beer label or a wine glass. It makes evolutionary sense for a brain circuit to ‘hold on’ to the knowledge that an action previously earned a reward in a particular place, or to explore whether that action earns a reward in a new place, because if it didn’t the person/animal might miss out on a reward. Unfortunately, however, in drug addicts this effect provides another example of circuitry that evolved to optimise receiving useful rewards, like food or sexual pleasure, going awry and supporting drug-seeking when this is not adaptive.

Contextually mediated relapse in real life
If you are an addict like me, the likelihood is that you have experienced this. You might never experience cravings anymore in your normal surroundings, having ‘extinguished’ the association between walking to your local pub and buying a beer. But then you go on holiday, or into a new environment and see a different pub and the craving comes back to you with full force. Well that’s what happened to me in Bali.
Bali ticked a lot of boxes driving me to drink: 1) it was sunny which I always associate with drinking, 2) I was on holiday so I didn’t have work, 3) my parents were there to be responsible adults and help out with my daughter so I didn’t have to be as responsible, and 4) parents were there being parents (i.e. driving me slightly nuts – love you Mum!). It was very, very, very hard. So I posted in my lovely facebook group about my troubles and so many of them said what I often hear in the group: go to a meeting. And I thought, “actually yeah, why the hell not? So I found the nearest meeting that was on in one hour, started walking there before I lost my nerve, got lost on the way so was a little bit late, but I got there. And it was good.

AA
When I got to the meeting I mentioned straight away that I was a first-timer and I was welcomed with open arms. Then people started to share. To begin with, it was only the men that shared, and they talked about many things. Some talked about how they had ended up in jail, or mental institutions, or how they had lost custody of their children and so on. This was bad. I couldn’t identify with this at all. After several days in Bali with a little voice in my brain (which part of my brain? That I can’t tell you sorry!) telling me I am not really an alcoholic, this was not what I needed to hear. Suddenly that voice started getting louder. “I’ve never experienced consequences like those, so maybe I’m not really an alcoholic?” “Maybe I can get out of here and go drink! And party! Woooo Hoooooo”
But then another voice (in my head) chimed in and asked: “why the hell are you sitting here if you don’t have a problem?” “And if you really don’t have a problem, how come pretty much every area of your life (work, health, fitness, relationships, happiness, anxiety) has gotten so much better since you quit drinking?”. If it wasn’t a problem, that wouldn’t have happened, surely.
So I shared. Can’t remember exactly what I said, but I sat there with my fake tan, thinking that all these people just think I’m some dumb blonde with resting bitch face (oops there’s those self-esteem issues again) and here I am talking about the fact I have a good job, and a loving family, but that alcohol has caused a lot of problems for me, so am I really an alcoholic after all?
But after I spoke up the other women in the group started to speak up. It was at this point that I heard my own story reflected back to me, over and over and over. Being there for your kids but not really being present. Waiting until they go to bed so you can drink. Getting angry with their partners over nothing. Dragging their sorry butts to work hungover and giving a sub-optimal performance. I realise now what I didn’t at the time: that alcoholism seems to manifest differently in men and women. I’m not sure why this is (scientific studies in rodents have by far and away used mostly males, although this is now starting to change). I know that in the human research there have been some differences found in how reactive men and women are to cues, but I’m not sure how that might translate to different manifestations of addiction.
In any case, that meeting saved me from a major relapse. I stayed and had coffee with some of the members afterwards, and they all were so welcoming and lovely and non-judgemental. Noone seemed to judge me for my resting bitch face, or blonde hair. No-one seemed to change their manner immediately and start acting a little self-consciously when I said that I was a behavioural neuroscientist, as often happens when meeting new people. Two of the women gave me their email addresses and numbers, and I messaged them a few times throughout the rest of the trip. And most importantly I didn’t drink.

Returning Home
So you would think that after I returned home after such a positive experience that I would continue to attend AA. Initially I did intend to, I looked up the beginners meeting and there was one nearby. I told my husband I was going to go that night. It was all sorted. Then I got to the evening and I just… didn’t. The cravings certainly dissipated when I returned home (i.e. as I returned to the extinction context), but I knew enough to be wary of this lack of craving, and that it could return at any time. However, I did think long and hard about it, and eventually decided instead to sign up to recovery coaching with the person who runs the podcast I had been listening to instead. In my next post I will elaborate on why.