“HERE’S HOW IT
WORKS”
12-Step Recovery Viewed through the Lens of Psychology
Quinn T. Chipley, M.A., M.D.
prepared for CAPTASA conference, January 23-24, 2009,
Lexington, Kentucky
DISCLOSURES:
This presenter has no funding from any
institution, corporation, or agency regarding
the content of this presentation.
Although he loves his work at the University
of Louisville as the Counseling Coordinator
for the Health Sciences Center students, that
institution should in no way be held
responsible for the content of this
presentation.
“PSYCHOLOGY 201: THE
FOUNDATIONS IN NORMAL”
Reinforcement Schedules from
Behaviorism:
variable rate, fixed rate, variable
interval, fixed interval
Cognitive-Behavioral Theory
Triad of 1) Behavior, 2) Cognitions, and
3) Affect
Reinforcement Schedules from Behaviorism
variable rate (slot machine), fixed rate (soda
machine), variable interval (chaotic family), fixed
interval (monthly paycheck)
Cognitive-Behavioral Theory
Triad of 1) Behavior, 2) Cognitions, and 3) Affect
Changing any one will change the other two, but it it
easier to target Behavior and/ or Cognitions EXCEPT
that pyscho-active drugs will target Affect directly
behavior
affect
cognitions
Cognitive-Behavioral Theory
(cont.)
Basic Facts
1) Behavior and/or Cognition are easier to target for
conscious control than Affect
2) Behavior targets should be simple and clear
3) Cognitive interventions: must be short and sweet
“PSYCHOLOGY 301: SOCIAL
PSYCHOLOGY”
Social cues
(e.g. – an audience or a group)
amplify the responses of an important brain center
(the medial pre-frontal cortex).
Finger, et al. Neuroimaging 2006 Oct 15, 33 (1): 414-21
Guilt and embarrassment (a.k.a. – Shame)
are “social emotions requiring the ability to represent
the mental states of others” and “embarrassment
might be a more complex process than that of guilt.”
Takahashi H., et al. Neuroimage. 2004 Nov; 23(3): 967-74
“Psychology 541: Personality
Theory”
Regions of reward and salience: prefrontal cortex
(PFC) and orbital frontal cortex (OFC)
“REWARD” is strongly associated with the ventral
tegmental dopamine projections to the PFC.
“SALIENCE” is a complex path that includes the
striatum, the thalmus and the OFC. That pathway
balances 1) novelty 2) pleasure and 3) irritation. It
is the mechanism the personality uses to manage
“shoulds” and “should-nots” of life.
Normal ego is auto-reinforcing with “sustained
recruitment of the reward system during selfrelatedness”
De Greck M. et al. Neuroimage. 2008 Feb 15; 39(4): 206675
“Psychology 345: Child Development”
Normal Child Development Steps
Sensory interaction
Independent play
(tries to eat the toy)
(manipulates the toy)
Parallel play
(2 toddlers manipulate 2 toys, passively
aware of each other)
Interactive play
(2 kids play with the same toy and are
actively aware of each other)
Social interaction
(2 or more manipulate words and
feelings; toy not required)
“Psychology 291: Neuropsychology”
Neuroplasticity and Time Course:
fast to slow
Neurotransmitters GABA/glutamate (milliseconds)
Neuromodulators such as dopamine, serotonin (seconds)
Steroid Hormones (days, if signaling to the nucleus)
Protein Receptor reduction/ multiplication (weeks)
Axonal-Dendritic pruning/ proliferation (months to years)
Take home lesson: lasting brain change takes ample time
under sufficient pressure. This fact is why personality
characteristics are basically stable across time and why
Arnold Schwarzenegger’s character in “Total Recall”
remains in the domain of science fiction.
“Psychology 541: Abnormal”
The alcoholic/ addict brain is probably
abnormally primed to respond to the substance.
The active and early detoxified user has
disturbed salience.
Continued use of the substance displaces
accurate sense-of-self.
Displaced sense-of-self disrupts social
interaction, interactive play, parallel play and
will even degrade solitary play.
“Prediction of Reinforcing Responses to
Psychostimulants in Humans by Brain Dopamine D2
Receptor Levels”
 23 healthy men (mean age=34
years, SD=7)
 No drug abuse histories
 Measured D2 receptor levels
 Intravenous methylphenidate
(0.5 mg/kg).
1999 Volkow and Wang
D2 Receptor Levels
(Bmax/Kd) in 23 Healthy
Male Subjects Who
Reported the Effects of
Methylphenidate as
Pleasant, Unpleasant, or
Neutrala
The researchers postulate
that while there are
certainly many other
factors which contribute to
addiction, baseline levels
of dopamine activity may
create a window within
which the effects of drugs
of abuse become
reinforcing.
1999 Volkow and Wang
Model proposing a network of four circuits involved with addiction:
reward, motivation/drive, memory, and control. These circuits work
together and change with experience. ..
From: Volkow: J Gin Invest, volume 111(10).May 2003.1444-1451
Double pathology of the
addict’s salience
CUED
Resting
state
overdrive
hypofunctional
A NORMAL SOCIAL “DANCE”
that involves taking turns for
for attention
The Ego of the Dependent is replaced by substance;
The Co-dependent shares the same gravitational
center.
Co-dependent
Dependent
XXX
There is no dance: everyone avoids
orbit interference
The “Game Plan” of addiction
“Cocktail party conversation” : no toy but all
interaction
“It’s Miller Time” : interactive use is coupled
sequentially to the toy (football, etc.)
“Ping Pong Shots”: interactive drinking interlaced
with the toy
“Belly shots, Slammers; chugging”: the substance
replaces the toy in interaction
“Bar stool buddy”: parallel drinking
Isolated drinking: solitary play with substance
Finally, the child is consuming the toy substitute
The 12-Step
Response
To
“The Problem”
What happens every time I say,
“Hi, I’m Quinn and I’m an alcoholic”?
EVERYONE: “Hi, Quinn!”
The self is reinforced. The pathology is
not reinforced. But the pathology is not
denied. It is a Fixed Rate reinforcer of
the essential identity: Not the Family
name, but the person’s unique name
What happens if (in a 12-step meeting,
I go on to say, “I think the sky is purple
striped and really odd and that all the
grass blades are too sharp on my feet
this year and it makes me irritable with
my kids. I just needed to say
something. That’s all.”
EVERYONE: “Thanks, Quinn!”
i.e. - The behavior of participating in
the social structure is reinforced, and
no shaming statements about the nearpsychotic content are made.
The 12 step approach distinguishes
between “salience” and “behavior” and
uses both. The only requirement for
membership is… ”a desire to stop
drinking. “
Note that “drinking” is a summation of
many behaviors and “desire” is a product
of “salience.” 12-step recovery
recognizes salience as a necessary -- but
not a sufficient --- condition for a
solution.
Big Book of Alcoholics Anonymous, 3rd edition
The most frequent behavioral prohibition
(usually phrased as a First person statement) is
“do not pick up.” This a very specific,
measurable unit of behavior so it becomes
manageable.
The most frequent behavioral prescription
(Usually phrased as a warm imperative) is “keep
coming back.”
There are others… “take what you like and leave
the rest.”
Note how this recognizes that there is a “slotmachine” payoff regarding meetings and their
content: The 12-step program has a variable rate
reinforcer schedule in its structure.
12-step meetings run on time.
They have a predictable format.
People have to take turns.
They are readily available.
12 step Folklore makes sense in
the light of our review of
Psychology
“90 in 90” Why 90?
Or why the old joke, “It takes 6
months to get some blood back
into your alcohol system.”
Answer: remember the time
frame of neuroplasticity
12-step Recovery and “Homespun”
Cognitive-Behavioral Therapy
CBT: Behave differently and you will
eventually feel and think differently
12-Steps: “Fake it till you make it”
CBT: Identify Dysfunctional Thoughts
12-Steps: “Stinking Thinking”
CBT: Interrupt Dysfunctional Thoughts
12-Steps: “Don’t give them free-rent!”
12-step meetings become the
opportunity to find:
“New playgrounds, Playmates,
and playthings…”
References
Finger, et al. “Caught in the act: the imp[act of audience on the neural response to
morally and socially inappropriate behavior.” Neuroimaging 2006 Oct 15, 33 (1): 41421
De Greck M. et al. “Is our self based on reward? Self-relatedness recruits neural activity
in the reward system.” Neuroimage. 2008 Feb 15; 39(4): 2066-75
Takahashi H., et al.”Brain activation associated with evaluative processes of guilt and
embarrassment.” Neuroimage. 2004 Nov; 23(3): 967-74
Volkow, Nora D. MD; Wang, et al, Prediction of Reinforcing Responses to
Psychostimulants in Humans by Brain Dopamine D2 Receptor Levels, American Journal
of Psychiatry, Volume 156(9), September 1999, pp 1440-1443
Volkow ND. Fowler JS. Wang GJ. The addicted human brain: insights from imaging
studies. [Review] [62 refs] [Journal Article. Research Support, U.S. Gov't, Non-P.H.S..
Research Support, U.S. Gov't, P.H.S.. Review] Journal of Clinical Investigation.
111(10):1444-51, 2003 May.
UI: 12750391
"Matching alcoholism treatments to client heterogeneity: Project MATCH three-year
drinking outcomes." Alcoholism: clinical and experimental research 22.6 (1998):130011.
Project MATCH secondary a priori hypotheses. By: Group, Project Match Research,
Addiction, 09652140, Dec97, Vol. 92, Issue 12
Evidence-Based Addiction Treatment: How Research Supports the Use of the Twelve
Steps Marvin D. Seppala M.D. Medical Director, CEO,Beyond Addictions, Slide
presentation to 2008 CAPTASA conference
Alcoholics Anonymous, The Story of How Many Thousands of Men and Women Have
Recovered from Alcoholism, 3rd edition, AA World Services, Inc.