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…
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.
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.
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.