Bandura, A. (1977). Self-efficacy: toward a unifying theory of behavioral change. Psychological Review, 84, 191-215.
Barrett, B. E. (1911). Motive force and motivation tracks. Longmans: Green & Company.
Dimidjian, S. & Linehan M. M. (2003). Mindfulness practice. In O’Donohue, W., Fisher, J.E., & Hayes, S.C. (Eds.). Cognitive behavior therapy. (pp. 229-237). Hoboken, NJ: John Wiley & Sons, Inc.
Frankl, V. (1969). Will to meaning: foundations and applications of logotherapy. New York: The World Publishing Co.
Jellinek, E. M. (1972). The disease concept of alcoholism. New Haven, CT: College and University Press
Klingemann, H. et al. (2001). Promoting self-change from problem substance use: practical implications for policy, prevention, and treatment. Dordrecht, the Netherlands: Kluwer Academic Publishers.
Langer, E. J. (1989). Mindfulness. Perseus Books, Cambridge, MA.
Llinas, R. R. (2001). I of the vortex: from neurons to self. Cambridge, MA: The MIT Press.
Lonergan, B. J. F. (1957). Insight: a study of human understanding. London: Longmans, Green & Company..
Marlatt, G.A., & Gordon, J.R. (Eds.) (1985). Relapse prevention. New York: Guilford Press.
Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: preparing people to change addictive behavior. New York: the Guilford Press.
Molina, F. (1962). Existentialism as philosophy. Prentice-Hall, Inc. Englewood Cliffs, NJ.
Ouspensky, P.D. (1949). In search of the Miraculous. New York: Harcourt, Brace, & Co.
Ouspensky, P.D. (2000). In search of the Miraculous. Moscow: Fair Press
Peele, S. (1989). Diseasing of America: How we allowed recovery zealots and the treatment industry to convince us we are out of control. Jossey-Bass Publishers, San Francisco, CA.
Prochaska, J. O. & DiClemente, C. C. (1986). Toward a comprehensive model of change. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors: Processes of change (pp. 3-27). New York: Plenum Press.
Satterfield, J. (2000). Optimism, culture, and history: the roles of explanatory style, integrative complexity, and pessimistic rumination. In J. E. Gillham (Ed.), The Science of Optimism & Hope, Research Essays in Honor of Martin E. P. Seligman (pp. 349-378). Radnor, PA: Templeton Foundation Press.
Saunders, B., Wilkinson, C., & Allsop, S. (1991). Motivational intervention with heroin users attending a methadone clinic. In Miller, W. R. & Rollnick, S. (Eds). Motivational interviewing: preparing people to change addictive behavior. (pp.279 – 292). New York: the Guilford Press.
Somov, P. G., & Somova, M. J. (2003). Recovery equation: Motivational enhancement/choice awareness/use prevention: An innovative clinical curriculum for substance use treatment. Imprint Books.
Somov, P. G. (2007). Meaning of life group: Group application of Logotherapy for substance use treatment. The Journal for Specialists in Group Work, 32 (4), 316-345.
Somov, P. G. (in press). A psychodrama group for substance use prevention training. The Arts in Psychotherapy.
Schaler, J. A. (1999). Addiction is a choice. Open Court.
Speeth, K. R. (1989). The Gurdjieff work. New York: Jeremy P. Tarcher/Putnam
Tengan, A. (1999). Search for meaning as basic human motivation: a critical examination of Viktor Emil Frankl’s logotherapeutic concept of man. Frankfurt am Main: Peter Lang.
Tillich, P. (1952). The courage to be. Clinton, MA: Yale University Press.
Walters, G. D. (1999). The addiction concept: Working hypothesis or self-fulfilling prophecy? Allyn & Bacon, Needham Heights, MA.
Wells, H. M. (1927). The phenomenology of acts of choice: An analysis of volitional consciousness. Cambridge University Press, London.
Wilshire, B. (1998). Wild hunger: The primal roots of modern addiction. Rowman & Littlefield Publishers, Inc., Lanham, MD.
Wheeles, A. (1958). The quest for identity: The decline of the superego and what is happening to American character as a result. W. W. Norton & Company, Inc. New York, NY.
]]>
In my work as a clinical director of a drug and alcohol treatment program in a county jail and in my current outpatient work with substance use clients I continuously come across a certain iatrogenic (treatment-related) legacy of powerlessness which stems directly from the 1st of the 12 Steps of the AA/NA philosophy ("We admitted we were powerless over our addiction - that our lives had become unmanageable").
I get it: admitting that you have a problem is a psychologically healthy thing. But admitting that you are powerless to solve it?! What a self-deflating stumble of a step to start a journey of recovery... What were Bill W. and Dr. Bob thinking?!
Perhaps, Bill W. and Dr. Bob were trying to pull off a bit of East-West synthesis? Perhaps, the thinking was that surrender or letting go of one's attachment to the idea of being in control is power? That passively accepting and witnessing the urge to drink (or use drugs) rather than directly fighting the urge head-on would be akin to psychological judo or jujutsu, the "soft method" martial arts that harnesses the opponent's strength and adapts to changing circumstance?
If this is the East-West synthesis that they had in mind, then, what a failure of articulation!
Perhaps, perhaps, perhaps...
Or, perhaps, this confession of powerlessness over addiction is nothing more than a failure to appreciate the psychology of a craving.
Let's take a look!
Just the other day, a guy I've been working with, who's been through the revolving door of the 12 step programs and who had decided to seek psychotherapy in addition to "working the program," triumphantly announces that he "did" the first step. Again!
Now, he's known about my approach to substance use treatment and he has showed himself to be an open mind capable of critical thinking. So he seemed entirely non-defensive when I asked him about what he meant when he "admitted to being powerless over the Disease."
Keep in mind that by now he and I have spent many a session working exclusively on craving control skills. He paused... and, with a sheepish smile, dared: "I am powerful over the Disease, Doc?"
You have to appreciate the weight of 12 Step dogma that he was trying to raise from! Had he leaked this hypothesis at a meeting or in a session with a 12 Step "recovery zealot" he would have likely been accused of being in denial, "slipping," or "lapsing." So, for him to even dare to think that he might be, in fact, powerful over the Disease took guts...
It's basic and axiomatic: if you've been drinking and/or using for any length of time, you'll have craving thoughts. Nothing you can do about that. They'll pop into your mind, uninvited, particularly, when you are around certain "people, places, and things" or when you are in a certain state of mind.
This is plain ol' Classical Conditioning stimulus-response. And indeed, a person who has been using and/or drinking develops numerous conditioned associations between various stimuli and his/her drug of choice.
Naturally, until such person gets used to ("habituates to") these stimuli (in his/her post-cessation, post-drug-use life), he or she will experience conditioned cravings. So, in this sense, up to a point, you are powerless to entirely prevent and/or eliminate craving thoughts from their initial occurrence (after having been exposed to drinking/using stimuli).
But...
But just because you are powerless to prevent the craving thought from occurring in the first place, it doesn't mean that you are powerless to manage or control this thought.
Bottom-line: you are not powerless over how to respond to these cravings, over whether to act them out or to manage them. In fact, the Buddhist mindfulness meditation has been researched, clinically piloted and increasingly mainstreamed into the craving control repertoire of the contemporary drug and alcohol rehabilitation programs.
So, how about this for a first practical step: step aside (from the craving thought) and sit down (in mindfulness meditation) to restore your mind to its non-craving baseline.
Let's review what we got here... Addiction is a habit. Habits are stimulus-response patterns. If you have had any given habit for some time, when you decide to stop, your mind will keep reminding you to engage in a certain conditioned response whenever you are triggered or exposed to certain stimuli. But just because, your mind reminds you that you used to do this or that in this or that situation, it doesn't necessarily mean that you are powerless to avoid doing this or that, once triggered. So, while you are powerless to completely avoid these mental reminders, these craving thoughts, you do have power to manage these thoughts (through good ol' self-talk or by merely witnessing these thoughts and controlling your experience through mindfulness and/or relaxation).
Now, take a look at the following equation:
Using/Drinking Episode = Access to the Drug + Desire to Use/Drink/Consume the Drug
In order for you to use/drink, two things have to be absolutely present: you have to actually have the booze or drugs in your immediate possession and you have to have an active, immediate desire to consume the substance.
For example, if I got some drugs on me but I've been pulled over for speeding, my desire to use is on hold. Right now, all I care about is to get back on my way preferably without a speeding ticket, let alone without a possession charge. So, even though I have immediate and direct access to the drug, I have lost my immediate craving to use. As such, there is no using episode.
Similarly, if I actually got busted for possession and now I am sitting in the county jail, and I got a "whopper" of a craving but no immediate access to drugs, there's not going to be a using episode as I have no direct, immediate means to satisfy my craving.
Or, say, I am sitting at home getting ready to shoot up. But then I think: I gotta see my PO (probation officer) tomorrow and pee in the cup. If my urine's dirty, the PO is gonna "violate" me and send me back to jail. So, here I am: I got access to the drug and I sure have a craving for it. But - based on my pragmatic calculations - I gotta wait till after I see my PO. So, I have the tactical motivation to control my cravings (even if I have no strategic, long-term commitment to recovery) and, if I have the skill-power to control the craving, the basic know-how of how to manage this moment of desire, I might just avoid a using episode (if only for a day).
Where's the unmanageable disease here? Which part exactly am I so fundamentally unable to control? So, even though I have direct access to the drug, by controlling my craving - albeit for an arguably myopic reason - I am able to avoid a using episode. No disease here: just applied, situational morality of avoiding adverse circumstances. Mere interplay of tactical motivation and craving control skill-power.
But what a laudable, promising self-regulatory precedent to build on! What a clinical treasure trove of the distinction between "can't control the craving" and "won't control the craving" to process and analyze!
What all this means is that in order to avoid a using/drinking episode, you have to either eliminate the access to the drug and/or to control the craving to use.
The former - elimination of the access to the drug - is a Stimulus Avoidance strategy best accomplished through a tried-and-true AA dictum of staying away from "people, places, and things."
The latter - elimination of the immediate desire to use the substance in question - is the Response Control strategy best accomplished through craving control.
It goes without saying that if you've been using for long, let alone drinking, avoidance of internal and external stimuli that may trigger a craving is simply impractical.
After all, even if you don't go to the block corner any more, you still got your cell phone. And even if erase your contacts on the phone, you still hear all about it wherever you go - at a meeting, in the movies, you name it... And even if you were to go on a 7-years-in-Tibet retreat, you still have your mind to remind you of the good ol' times, right?
So, the Stimulus Avoidance strategy, the strategy of avoiding access to the drug - let's face it - is limited. What's left - and that should be plenty enough - is craving control. If you work on cultivating a solid, no-nonsense craving control skill-power, you need no will-power or God-power, and you definitely have no need for this dubious relapse prevention scare-tactic of "powerlessness."
"What craving control methods are out there?" you might ask.
I am glad you finally asked: psychological and chemical.
Psychological craving control methods, in the descending order of my clinical preference, are Mindfulness (best, in my opinion), Relaxation (good), Self-Talk (satisfactory), Distraction (so-so).
Chemical craving control methods: you name it - from methadone to Cyboxin...
I can almost hear it: "Busted! Gotcha, sucka! You said "methadone," you said Cyboxin... See! See! It's a disease. A Disease!!! Not a habit! How can you be in control of a disease?!!! It's physical, not mental, don't you see?!!!"
I see, I see... I'll take an unpopular stab at this mind-body Cartesian non-sense in a minute... But for now, let me just reminisce a bit...
Back when I was running a non-12-step drug and alcohol program in a county jail, I'd get challenged on my assumptions (like above) all the time. In adrenaline overdrive for two years, at least, I had to fend off these Disease Model counterarguments from my inmate clients. There's nothing, nothing like Antisocials' thirst for justice... The energy, the righteousness, the hunger to stump the expert! I enjoyed that work greatly: it paid off: while imprisoned, many of these minds were admirably free...
So, back to this notion of disease... It's just, frankly, silly Cartesian mind-body dualism. Thoughts and feelings are real, they exist - there-fore, they have a chemical (physiological) signature in this three-dimensional reality. Of course! No one's arguing with this - it is banally self-evident. So, just because somebody can show you what your "addicted" brain looks like on drugs, it doesn't mean that your habit is a disease.
I might be in a habit of tearing up every time I see a picture of that couple - holding hands - leaping out of the Twin Towers on 9/11. Think about it: I see the image and have a sad thought, and my eyes make water! A thought in my mind results in water pouring out of my eyes! Some fleeting event in my consciousness and look at this mess: I need a tissue, my eyes are red. A change in the state of mind led to a change in the state of body. Mind and Body are the Twin Towers: they stand together and they collapse together.
Need another example? Okay, here's one. I took a leak but forgot to zip up my fly. Now, when a client (God forbid!) points this out to me, I have a thought: "Oh, man! How could I?!" A fleeting event in my consciousness - and my face, my face (!) reddens as I blush. A thought of embarrassment - and blood, blood (!) re-distributes its flow and floods my face... What the hell... Must be a case of... "emotional-vascular" disease...
This mind-body connection is so tight that it's time we took the hyphen from this "mind-body" dualism...
So, what am I getting at? What I am saying is that addiction is a habit, and as any habit, it is a stimulus-response pattern, and as any human habit, addiction involves both mind and body (or better yet, the un-hyphenated bodymind), and that there is no difference between mind and body, they are a one indivisible whole, so when you control one part of this whole, you control the other part of this whole. That's how the whole thing works - as a whole! That's why craving control can be achieved either through psychological or chemical pathways. All roads lead to Rome, don't they?
You might say: "but what about the withdrawal effects, what about tolerance?" Again, everything you feel or think or do, has a physical/physiological manifestation.
If you want to have a sip of coffee, the thought "I want some coffee" translates into a complicated physiological cascade until this thought of yours eventuated in a motor behavior of your hand picking up a cup of coffee from a table and bringing it to your lips. If you drink coffee a lot, then eventually your bodymind adjusts to this ongoing and habitual intake of caffeine.
Namely (you are better off skipping this psychophysiological mumbo-jumbo straight from Wikipedia unless you've already had a cup of coffee yourself this morning): "Because caffeine is primarily an antagonist of the central nervous system's receptors for the neurotransmitter adenosine, the bodies of individuals who regularly consume caffeine adapt to the continual presence of the drug by substantially increasing the number of adenosine receptors in the central nervous system. This increase in the number of the adenosine receptors makes the body much more sensitive to adenosine, with two primary consequences. First, the stimulatory effects of caffeine are substantially reduced, a phenomenon known as a tolerance adaptation. Second, because these adaptive responses to caffeine make individuals much more sensitive to adenosine, a reduction in caffeine intake will effectively increase the normal physiological effects of adenosine, resulting in unwelcome withdrawal symptoms in tolerant users" (Wikipedia).
My point? Just because we are not consciously supervising all this psycho-physiological re-calibration, it doesn't mean that it is a disease. When I cry, I do not consciously direct my tear glands to produce water. Nor do I instruct my circulatory system to divert a pint of blood to my face when I feel embarrassed. That's just what happens. The Cartesian mind-body paradigm of modern medicine, particularly, addiction medicine, latches on to the fact that what we do has a physiological signature and imbues it with the significance of the disease.
Just because my body reflects the workings of my mind in the mirror of flesh it doesn't mean that these workings are independent and uncontrollable. To think of addiction as a disease (rather than a habit with a physiological signature) is to presuppose a ghost in the (human) machine.
You might object: "But don't you see, drug use changes the bodily chemistry... Haven't you read the very passage you posted from Wikipedia... See, here they say, the increase in the number of adenosine receptors... These are actual structural changes!"
Yes, they are, indeed, structural changes. Real as they can be. Some structural changes are reversible as the postural crossing of the legs as I adjust my posture in the chair. And some, not so much: as you alter the pigmentation of your skin with the tat of your girl-friend's name on your shoulder.
The body documents what the mind does and the fact of this physiological signature is not a disease but a reality of our corporeal psycho-somatic organization.
But let us get back to the point of this blog (and, by the way, if you want a more definitive de-construction of the Disease Model, read Stanton Peele's "Diseasing of America" and Jeffrey Schaler's "Addiction is a Choice;" while at it, you might also check out Santoro's "Kill the Craving" exposure-response prevention protocol).
So, the "steps." I am not opposed to them. In fact, I clinically treasure the vast networking and support resources the 12 Step paradigm has on tap for the folks embarking on recovery. But three of these steps, in my opinion, could stand a bit of revision.
With the above considerations in mind, the 1st, 2nd, and 11th Steps of the 12 Step approach could be reformulated as follows:
Step 1: "We admitted that while our minds become unmanageable when we are intoxicated, and while we are powerless over having an occasional conditioned craving for drugs and/or alcohol, we do have the power to control our cravings and thus to prevent drinking/using episodes in the future."
It is, of course, true that once intoxicated, a person's capacity to render effective, strategically-savvy decisions is debilitated to the extent proportionate to the degree and type of intoxication as well as to the degree of one's metabolic processes and tolerance. Consequently, a person is powerless over drugs and/or alcohol when he or she, in fact, ceases to exist as an intact psycho-physiological entity that he or she is at a non-intoxicated baseline. That, however, does not mean that once the person sobers up he or she is powerless to prevent future substance use. The extent of your intoxication yesterday has nothing to do with whether you will or not control your craving to use again tomorrow. Sure, it's harder to control your cravings when you are "jonahing" than when you are not: but harder doesn't mean impossible...
Step 2: "We came to know that we, ourselves, could restore us to our functional baseline"
Note that in paraphrasing step 2, I have replaced the phrase "re-stores to sanity" with "restore to functional baseline." The term "sanity" implies that substance use is madness and therefore retrospectively invalidates substance use as a legitimate, albeit imperfect, form of coping. After all, in order to change, clients need a belief in their sanity; any implication of prior insanity only contributes to unnecessary sense of hopelessness. After all, if past predicts the future, then past insanity predicts future insanity. Clients should not be robbed of their phenomenology as being rational.
Step 11: "Sought through mindfulness meditation (or other craving control) to improve our conscious contact with ourselves and to control our cravings"
Re-processing of the Powerlessness legacy in such a way may allow the client with strong prior allegiance to the 12 Step philosophy to retain a modified version of the steps. Most of the 12 Steps, in my opinion, definitely take a person in recovery in the right direction. But, as the evidence on the use of mindfulness in craving control suggests, perhaps, it's a good idea to take a few mindful steps and then to sit down in Zane (Buddhist "sitting meditation") once in a while.
So, to all you, steppers: march on! Just don't goose-step past the obvious. You have the power to control your cravings. Craving is but another train of thought: step aside and sit down....
The journey of recovery, a millions steps no less!, perhaps, begins with, first, sitting still - transfixed in meditation...
]]>
]]>
These reactions provide a touching glimpse into how these correctional substance use clients (most of whom had been previously exposed to the Disease Model of addiction and to the 12 Step programming) responded to the proposition that they are fundamentally free to choose and, thus, to change. It should be noted that the participation in the pilot program was not accompanied by any legal assistance in the form of early release or sentence reduction. It should be noted that The Weekly Fix was entirely produced by the inmate population and the program staff exercised absolutely no editorial control over this in-house initiative.
Inmate client J. K. (The Weekly Fix, Issue 1, at the beginning of the program pilot) reveals the paradigm clash: “I must say that the program here <…> is not at all what I expected. <…> I’ve been brought up being told that AA and NA were the only solutions for my drinking and drug using… The biggest difference leading me to problems is step one of NA… This step differs immensely from what is taught here. We have the power to choose to use or not… In retrospect I can see how my belief that I’m powerless is harmful to me. It was an easy way out. All responsibilities for the consequences of my using <are> avoided by this simple belief. In all actuality these consequences are a direct result of an active choice I made to get high. Time will tell if I can adapt to this new way of thinking or not. I believe I can.”
Inmate client H. T. (as early as in the second issue of the Weekly Fix) begins to zoom in on one of the core ideas of Choice Awareness Training. In his article “A Really Old Habit” H. T. reframed his substance use from a disease to a habit: “Most of my life, ever since I can remember, I have had the habit of biting my finger nails. <…> I am now 39 years of age, incarcerated for another habit, this one being potentially life threatening.” So, the denial of having a disease of addiction without the denial of the detriment of one’s habit of substance use can, in fact, co-exist!
Inmate client K. W. (The Weekly Fix Issue 3) opens with an editorial entitled “Turning the Auto-Pilot Off:” “I believe the more aware you are, the better chance you have in recovery. Being aware of the smallest things can help: like how you dress, how you brush your teeth or how you tie your shoe laces can keep you from going back to sleep. <…> I’ve learned that when I am aware of my options, and take time out to weigh them, and see what fits for me, it seems to make it a better day. I’m not always going to make the right choices, but as long as I’m awake and aware, I can no longer be on auto-pilot or unaware of my actions.” These thoughts are a clinical treasure trove.
In the same issue (The Weekly Fix 3), inmate client who anonymously runs the column “Fact or Fiction, by Someone,’ challenges his peers: “Choice awareness practice keeps me switched off the auto-pilot. And makes me aware that there is a number of options available to me, and when I choose an option, it is chosen mindfully.” This “someone” is obviously no longer another anonymous statistic of powerlessness in the Alcoholics Anonymous or Narcotics Anonymous, but a “somebody” aware of his power to choose and to change.
In the same issue (The Weekly Fix 3), J. S. H. announces the arrival of his agency with the following title: “I Have the Strength Within.” He continues: “The power is within me. I realize that I can’t look to others for 100% guaranteed support. <…> In recovery there might not be anyone there (for you) at all. In times of weakness, I need to search myself and then look to others.” Note the wisdom: the client is sober that he can’t solely rely on home groups, sponsors and support networks. His recovery is portable because it is based on his own strengths. Note that this is not reactive pouting to a lack of conjugal visit: the client is not dismissing others’ help, but merely no longer willing to rely on it as an exoskeleton to carry his weight.
The former anonymous “Someone,” now a “Somebody,” per his pseudonym, albeit still anonymous, offers a unique take on the Choice Awareness Practice exercise in the Weekly Fix issue 4: he offers a game of “Dare and Catch Yourself.” For example, “dare – to try and break an old habit, to not keep repeating the words “for real… for real;” and “catch yourself – tapping or humming, reacting over and over in the same way, asking question that have already been answered.” This “somebody” is certainly showing some (creative) mind. Choice awareness, by virtue of opening up new options, has the effect of opening up the mind.
Speaking of opening the minds: inmate client D. F. (The Weekly Fix, issue 5) observes – “It’s kind of funny how our minds work.” He offers a choice awareness prank. Ask a peer: “How do you spell “silk?” Then, ask: What do cows drink? The usual response will be milk. Then you say: that’s what people drink, cows drink water.” D. F. is catching on to the vulnerability of mindlessness. His writing echoes a sentiment that was frequently noted by clients: they were quick to realize that stimulus-bound mindlessness is rife for exploitation.
The Weekly Fix, issue 8: an alpha-male inmate client “G.” champions a full-on head-on with the notion of addiction being a disease. “I am glad to have the confirmation that I don’t have a disease. For a long time I subscribed to the disease concept of addictions. This came from a lot of cognitive distortions I’ve picked up from attending N. A. and A. A. meetings. I am not doomed! <…> I am truly excited to learn that there is another way of staying clean. <…> The more I learn, the more it makes sense to me. A big part of my life, my decision making process has been to act on impulse <…> almost as if I had no choices. Rational recovery introduces me to phrases like “auto-pilot,” “choice awareness,” and “self-regulation,” along with plans for lapse and relapse prevention, just to name a few. (This) gives me a “wonderful opportunity” to flex my “choice muscles.” Come to think of it: this is all I ever wanted to do in the first place.” This “testimony” speaks for itself.
C. P. asks in The Weekly Fix (issue 11): “Have you chosen to be free?” The misleading simplicity of this question conceals this client’s in-depth understanding of the issue at hand: freedom manifests through an act of conscious choice.
Inmate client D. F. (The Weekly Fix, issue 11), in a drawing entitled “Mind Garage,” amidst the drawings of a bicycle, a lawnmower, a garden hose, and an oil spill, has thrown in a self-affirming pearl: a call out that reads “You are not a victim.” D. F. carries the theme over to the next issue (The Weekly Fix, issue 12): in the same “mind garage,” among the same objects, in the driveway, he writes: “Potential impact of the disease? Inescapable fate…” D. F., here, seems to be in the midst of spring cleaning of his “mind garage,” getting rid of the clutter of the victim identity and the disease identity.
H. T. (The Weekly Fix, issue 13) proclaims: “Choice awareness expands our options. <…> I find that there are seemingly endless choices.” Well said.
In the same issue, we learn of the identity of the anonymous “Someone” who began the rubric “Fact or Myth.” Having initially signed off as an anonymous “Someone,” and having then progressed to a still anonymous “Somebody,” he finally reveals his identity: he is N. M. In challenging his peers, he asks: “Choice awareness is all about being told what to do… Fact or myth?” We can safely guess his answer. What remains a mystery is the progression from anonymity to reclaiming one’s identity: could it be the effect of a humanistic treatment approach? One thing is for sure: N. M. took the responsibility for his penmanship. Nobody told him what to do…
D. F. (the “Mind Garage” author, in the issue 14 of The Weekly Fix) offers a very cogent insight: in an article, entitled “Preset Recovery,” he writes: “ I was listening to my radio the other day trying to find a song <…> and realized how used to the pre-set channels I was. So I figured: what a wonderful opportunity to practice my Choice Awareness, so I changed the pre-set stations. <…> Each and every day I am getting closer to not living a pre-set life.” D. F.’s essay is a glimpse into a mind free of pre-set recovery dogma.
Issue 5 of The Weekly Fix has a telling and humorous cover element. You see the following text encased in a rectangle: “I made a choice to put a rectangle around these words.”
Issue 16 features clear thinking from J. F.: “Some things are not comfortable when not run on an auto-pilot. <…> But with pain, there’s gain. I need to exercise my choice muscles which make me mindful so that I don’t limit myself with mindless decisions. <…> When you take the time to consciously look around at everything around you, there are many options and life is limitless.” J. F., who also signs off on this article as the “3d Eye” has his vision back.
D. F. (in The Weekly Fix issue 16) shows the readers his new acquisition for his “Mind Garage:” “It helps to be willing to change.” Indeed.
M. H., in the same issue, shares: “When I come to jail I just get into the mix of things. <…> Then I get out and go right back to the same thing. It just becomes a cycle of using and coming back to jail. <…> This time I make a choice to use this time mindfully. <…> I know something is different this time. That something is me.” M. H. here speaks of the revolving door of incarceration, but he might as well be speaking of the revolving door of the kind of recovery that takes the agent of change out of the equation of change. After all, what use would there be for M. H. in the equation of disease?
The editors of The Weekly Fix devoted the 21st issue to Choice Awareness Practice (which in the program was known by the acronym C. A. P.). The cover features a ferocious baseball cap, the bill of which is drawn in a manner of tooth-ful scowl. The text above the C. A. P. reads: “Put On a Mean Cap.” The text below deciphers the in-house acronym: “Choice Awareness Practice – mornings, evenings, afternoon, nights.”
Jumping ahead (for the interests of space) to the 32nd issue, we see the following thoughts by T. G.: “When I first heard about auto-pilots, the idea was to break them. By breaking them I slowly began to wake myself up. I found a lot of good out of becoming the thinker behind the thought. <…> I feel that this is going to be the one most important thing to keep me on top of my recovery.”
Inmate client M. S., writing in the same (32nd) issue notes: “Before I never thought I had options <…> because I was in a deep sleep. I lived most of my adult life absent from my thoughts. <…> I have learned how to switch off my auto-pilot by doing two or three five minute choice awareness practices a day. It (practice) lets me be more aware and awake. <…> When I do some simple C. A. P. (Choice Awareness Practice), it lets me know that I am my own agent of change and that my life is up to me.”
In reviewing the last, 33d issue of The Weekly Fix, at the very back of the issue we find an anonymous vignette entitled “Recovered or Recovering.” The very phrasing of this item highlights an awareness of an option that for most of the participating clients did not phenomenologically exist. Choice Awareness Training is designed to help clients recover their sense of control, and with it their prognosis of recovery.
]]>
Chess is also a rare interpersonal opportunity for silence and offers practice opportunities for emotional self-regulation of the emotions associated with victory or defeat. Finally, it is one of the few games that offers more than a binary/dichotomous outcome of win or lose. With its possible outcome of a tie, the game highlights the notion that not every form of competition is a zero sum game.
But above and beyond these already built-in choice-awareness and psychologically invaluable teaching moments, chess can be turned into a power-tool for choice awareness with a little bit of “tweaking.” The following is a description of how chess was piloted as a choice-awareness enhancing tool in the context of the correctional/residential drug and alcohol treatment program. Upon admission, clients were provided with a brief overview of the choice awareness enhancing properties of chess and were, consequently, encouraged to learn to play chess. Chess, as a game of skill, was programmatically endorsed over such games of chance as cards. Regular chess tournaments were held each week with the first and second place winners earning various program privileges or nominal gifts, in proportion to the resources, policies, and logistics of the correctional setting.
Having assured that the majority of the program clients have learned to play chess, the program staff introduced a Choice Awareness Chess Tournament which involved an arbitrary change of board rules. For example, the knight and the bishop chess pieces exchanged functions. As a result, the players – who by now had arranged themselves in a natural hierarchy of regular chess competence – were essentially equated in their playing power. With the new set of rules, the most choice-aware player was the most likely one to win. As the clients progressed through the program, they continued to be presented, from time to time, with Choice Awareness Chess tournaments with ever-unpredictable arbitrary modifications to the rules of the game, with each tournament being conducted on a set of new board rules.
Choice-Awareness Chess Modifications
A variety of modifications to chess rules are possible. For example, it could be agreed, for the purposes of the Choice Awareness Chess tournament, that pawns are allowed to always move two squares, or that a pawn can take over a piece both diagonally and directly in front of it. Furthermore, contrary to the classic premium on time during chess tournaments, Choice Awareness Chess tournaments would set time minimums to encourage clients to play “slow chess” as yet another way of leveraging choice evaluation, impulse control and strategic thinking.
Choice-Awareness Chess Tournaments as a Follow-Up Intervention
Substance use programs may consider holding Choice Awareness Chess Tournaments as a form of clinical follow-up. Such events may be held on an ongoing basis and follow the format of a chess club. Such chess tournaments would be offered as a post-treatment self-help opportunity for the graduates and alumni of substance use treatment, and may be facilitated or autonomously run by former clients, with organizers surprise-announcing the modifications of the rules on the days of the tournament.
]]>
The purpose of Choice Awareness Check Group is to allow treatment participants to consolidate their belief in their power of self-determination as well as to allow group participants to become inoculated to any arguments designed to undermine their sense of self-efficacy.
Finally, the purpose of the group is to create a moment of accountability with a corresponding motivation-enhancing dissonance. The intended effect is to place a group participant in a situation in which he or she ardently defends his or her freedom and verbalizes the need for choice awareness, as a dissonance-inducing contrast for any unsystematic or inconsistent practice of choice awareness. In other words, as a group participant finds himself in a position to “preach” choice awareness, he feels compelled to at least attempt a systematic practice of the skill in question.
Additionally, Choice Awareness Check Group allows for vicarious learning and interpersonal feedback. Group participants are exposed to their fellow group members’ “theses” on choice awareness and ideas about choice awareness practice – such excessive but idiosyncratic review of the material allows group members to further internalize the underlying clinical message by learning from their peers.
The duration of the group corresponds to the number of the group participants with each participant taking a single session to present his understanding of the need for choice awareness and his choice awareness practice routine. Following the introductory session, a list of clients’ presentations is created and the clients are given a “choice awareness check” form to guide their preparation and presentation on their respective dates. Each session begins with a “presentation” and is followed by a Q & A session that is moderated by the group facilitator.
]]>
The discussion of the potential benefits of mindlessness and automaticity allows clients to develop a balanced view of the pros and cons of being on an auto-pilot. It is paramount that clients avoid the sweeping generalization that all automaticity is unhealthy. Habits are necessary and essential for adaptation. Clients are helped to appreciate the utility of both change-facilitating and change-maintenance recovery habits. Clients are encouraged to recognize that by the very virtue of their participation in treatment they are choosing to “program” themselves to respond with a certain pro-recovery automaticity in the face of possible future challenges to their recovery goals.
With this in mind, later sessions of Choice Awareness Training, aside from concluding comments about choice awareness, is also an opportunity to integrate various skills clients are learning in the Program into a kind of “recovery habit.”
Recovery Autopilot as a Maintenance Tool
While clients are encouraged to develop a Recovery Autopilot, facilitators clarify that the purpose of the autopilot is to help clients transition from a structured therapeutic environment to independent self-care. With this in mind, the Recovery Autopilot is seen as a temporary measure to be used in the immediate post-treatment future. The Recovery Autopilot format can, however, eventually serve as a platform for client’s general mental health hygiene and self-care.
Recovery Autopilot Exercise
Recovery Autopilot may be presented to clients graphically as a the following equation:
Recovery Autopilot = Daily Recovery Ritual + Weekly Recovery Event(s)
Facilitators explain that a recovery autopilot consists of a daily recovery ritual (which with time may become a platform for generic self-care) and a weekly recovery event.
Time Allotments
Let us assume that a client is willing to spend thirty minutes a day on a Daily Recovery Ritual and at least one additional hour per week on some kind of Weekly Recovery Event.
Daily Recovery Ritual Samples
It is recommended that a client spends this half-hour on a combination of Relaxation/Meditation, Self-Motivation, Social Support, Choice Awareness activity, Review of Program Materials or some Recovery-related Reading or Study. The following are a few sample break-downs of what your Daily Recovery Ritual could be:
Recovery Autopilot Version 1:
5 min: Cue-Conditioned Relaxation
5 min: Practice Choice Awareness
10 min: Analyze the Cravings you had yesterday or today
10 min: Review your Motivation Check form
Recovery Autopilot Version 2:
5 min: Cue-Conditioned Relaxation
5 min: Practice Choice Awareness
10 min: Review Lapse Prevention Plan
10 min: Perform a Relapse Prevention Hypothetical
Recovery Autopilot Version 3:
5 min: Cue-Conditioned Relaxation
5 min: Practice Choice Awareness
10 min: Listen to a portion of your Motivational Pitch Tape
10 min: Plan your Natural Highs for the coming up weekend
It is recommended that any Daily Recovery Ritual should include a relaxation and a choice awareness practice; keeping these items constant assures that the client engages in a key use prevention skill and at least minimally “wakes” oneself up to his/her sense of freedom to change by becoming aware of choices available to him/her in a given moment. The remaining portion of the Daily Ritual may vary and relate to the rest of the Recovery Equation.
While the Daily Recovery Ritual may vary somewhat in term of its content, it is important, however, that the Daily Recovery Ritual follows a predictable pattern or system, time- and format-wise. After all, if it is too random, it would not be a ritual, would it?
Tips for Daily Recovery Ritual:
Clients are encouraged to keep the Daily Recovery Ritual simple but meaningful. Clients would do well to resist the temptation to be too “recovery-greedy.” More is not always better. Clients should keep the Daily Recovery Ritual realistic; a plan that is too tedious will feel like too much of a burden and will eventually collect dust
Furthermore, clients are encouraged to come up with at least two versions of a Daily Recovery Ritual and plan to alternate them every other day. This way clients will be able to make use of most of what they have learned while keeping it interesting.
Weekly Recovery Events
In addition to a Daily Recovery Ritual, it would be a good idea for a client to also get in a habit of scheduling at least one hour worth of Recovery Events per week. The following is a list of potential ideas that may be provided to a client as a generic menu for them to pick and choose a Weekly Recovery Event on a regular basis.
]]>
Choice Awareness Practice
The first part of Choice Awareness Training (facilitation of the strategic, philosophical, ontological appreciation for one’s fundamental freedom to choose and to change) can be accomplished within four to six semi-didactic, semi-experiential sessions. The practice part of the Choice Awareness Training was an ongoing treatment modality that an inpatient substance use client availed himself of until the day of the discharge from the program. As such, facilitated practice of choice awareness (through the attendance of the Choice Awareness Practice group and through corresponding choice-awareness clinical homework) is recommended as an ongoing programmatic element in structured drug and alcohol rehabilitation. The following is a discussion of how an initially Logotherapeutic intervention designed to facilitate the appreciation of the fundamental freedom-to-change transitions to a form of modified mindfulness practice designed to institute an appreciation of the here-and-now opportunities for choice as well as to facilitate an “installation” of a personal choice awareness practice habit.
Choice Awareness Practice Group Session Format
Choice Awareness Practice (CAP) was originally designed as a group modality (Somov & Somova, 2003), as part of an overall clinical curriculum of group-based modalities, such as motivation-leveraging Logotherapy group, “Meaning of Life” (Somov, 2007), Relapse Prevention Psychodrama (Somov, in press), and others. While the description of CAP below is customized to group setting, Choice Awareness Practice is just as well-suited for individual applications. The CAP group, piloted in the correctional drug and alcohol treatment program, consisted of an ongoing discussion of the importance of developing a choice awareness routine interlaced with in-session practice of choice awareness that involve the practice choice awareness enhancing exercises.
Choice Awareness Practice Group sessions consist of four potential elements: a) ongoing review of the rationale of the choice awareness change variable and of its interplay with other aspects of recovery; b) assisting clients with initiating and fine-tuning their daily choice awareness practice; c) helping clients process the experiential fall-out/insights from their increased choice awareness; and d) providing clients with an in-session structured choice awareness experience both to raise their level of choice awareness and to model ideas for choice awareness applications and practices.
From Strategic Freedom to Change to Tactical Freedom
Having assisted clients with establishing their strategic awareness of their fundamental freedom to choose and change, facilitators begin to qualify the thesis of “you cannot not choose” by discussing various exceptions to this existential axiom. While the strategic sense of freedom-to-change is undermined by the client’s all-or-nothing view of their self-control attempts, as well as by subscribing to the choice-disempowering Disease Model of addiction and choice-incompatible language, the tactical freedom to change is undermined by lack of choice awareness, i.e. by habitual, schematic, stimulus-response, unconscious, mindless responding to internal and external stimuli.
The overall goal of this section is to help clients realize that while they may be strategically free, they are not tactically free unless they are actively (or mindfully) aware of the choices imbedded in the here-and-now, particularly at various micro and macro crossroads of life.
Exploring the Barriers to Tactical Freedom
In exploring the barriers to Tactical (actionable, operational) Freedom, clients can be asked to ponder if there, in fact, some exceptions to the previously established existential maxim that “one cannot not choose.” The following answers typically emerge, with minimal prompting:
We cannot not choose unless we are: a) dead (given particular beliefs about the after-life or absence thereof); b) comatose, unconscious, or asleep; and c) acting on an impulse, reflexively, automatically, mindlessly, in a scripted, pre-programmed, pre-rehearsed, rote, conditioned manner, out of habit, without the awareness of the choice options available in a given moment. This type of discussion of the barriers to the tactical, in-the-moment, here-and-now awareness of choices primes clients for the metaphor of conditioned, habitual, mindless behavior as a kind of sleep, and for the metaphor of choice awareness and mindfulness as a kind of awakening. The metaphor of mindlessness as sleep existentially upgrades the mandate of Choice Awareness Training to a goal of self-awakening from the lull of automaticity.
Tactical Choice Awareness Training & Gurdjieff-Type Mindfulness Training
Long after the days of the Buddha, the utility of here-and-now, tactical mindfulness would be echoed by many of the philosophical and psychological brokers of the East. Few came as close to a practical choice-awareness training system as Georgy Gurdjieff, a charismatic early 20th century Russian guru, nicknamed the “rascal sage” (Speeth, 1989). Gurdjieff likened an un-awakened human being to a machine, self (personality) to a collection of habits, and awakening or self-understanding to, at best, a lucid dream, or an awareness of being asleep. Gurdjieff did not believe that un-awakened human machines phenomenologically experience choice and denied the human machine a power of self-determination: “We have no capacity to do, no ‘free will’ – in fact, no function of will at all” (Speeth, 1989, p. 33). Gurdjieff posited that “Man is born, lives, dies, builds houses, writes books, not as he wants to, but as it happens. Everything happens. Man does not love, hate, desire – all this happens;” a person does not choose: “the situation chooses” (p. 33). But, according to Gurdjieff, the human machine can study itself, and can develop a capacity for true will (Speeth, 1989; Ouspensky, 1949). Gurdjieff emphasized self-study through self-monitoring of one’s motor-behavioral and cognitive-affective habits. More specifically, he prescribed such de-automatizing activities as assuming and holding of an uncomfortable sitting or standing position, the use of non-dominant hands to perform various routinized tasks of daily living, and modification of one’s writing. Thus, Gurdjieff taught freedom from automaticity. Langer (1989), the author of “Mindfulness,” writing at the end of the twentieth century echoes Gurdjieff’s early twentieth century formulations and recommendations: “the automatic behavior,” she writes, “has much in common with habit” (p. 16) and notes that acknowledges that “proper meditation techniques are said to result in a state that has been called de-automatization” and in a state of freedom from stereotypes and rigid distinctions (p. 78; Langer’s italics).
But Gurdjieff, of course, wasn’t the only one to write about automaticity. Wells, as far back as 1927, in her work entitled “The Phenomenology of the Act of Choice,” observes the so-called “habitual” choices: “with repetition the development of the processes entering into volitional consciousness tends quickly to become habitual.” (p. 92). Wells preferred the term “habitual” choices are really a misnomer since they involve no consciousness per se and are nothing other than cognitive-behavioral defaults, or automaticity.
Wells, unlike Gurdjieff, apparently did not like the de-humanizing analogy to a machine, and felt that the term “habitual” choice, rather than the term “automatic,” “better expresses the psychological constitution of the process” (p. 92). Barrett (1911) did not feel he had to be apologetic about the terminology of automaticity as he saw it not only normal but adaptive: “automatism is the natural issue of normal motivation… a manifestation of the protective economizing tendency of volitional functioning” (1911, p. 141).
Gurdjieff drew a distinction between people who experience events as if they “happen” to them and those who are free. This semantic distinction between people who “do” and people for whom “everything happens” is tantamount to a distinction between choice-ful-ness and choice-less-ness.
It should be noted that the practical part of the Choice Awareness Training proposed by Somov & Somova (2003) was inspired by Gurdjieff’s teachings and can be reasonably construed as a form of modified mindfulness training the purpose of which is to increase a baseline of here-and-now awareness of choices, as an existentially-prophylactic catalyst of habit-modification.
Choice Awareness as Modified Mindfulness Training vs. Classic Mindfulness
While both Mindfulness and Choice Awareness Training are awareness training technologies, the two are somewhat different in focus. Mindfulness is awareness, “awareness of simply what is” (Dimidjian & Linehan, 2003). Choice Awareness is choice awareness, or awareness of the opportunity for a choice and of self as a Chooser behind the choices
Buddhist mindfulness is an awareness of the external object with the purpose of assisting the meditator to eventually lose the sense of being an observer and to unite in the moment, with the moment, in a state of object-less, subject-less non-duality. Choice Awareness, by definition, is an awareness of choice, a meta-cognitive awareness of the fact that one has a choice (options at any given moment) and a capacity to choose. Therefore, choice awareness does not aim to blur the boundary between the subject and the object. On the contrary, it aims to reinforce one’s sense of oneself as a subject, as a self-determining agency. Therefore while mindfulness meditation represents a period of non-judgmental observation passivity or non-doing, free of discursive, interpretive inner narrative, choice-awareness practice is an active process that infuses an awareness of choice into what was previously automated, characterized with discursive self-narrating of the options that one is tactically aware of and their alignment with one’s strategic goals. Whereas mindfulness is a state of accepting willingness (Dimidian & Linehand, 2003), whereas choice awareness is a state of purposeful, psychologically healthy, and self-efficacious willfulness. In summary, mindfulness training is training in the awareness of being here-and-now, Choice Awareness Training is training in the here-and-now awareness of being free.
Demonstrating Automaticity, Mindlessness, and “Choice-less-ness”
The following are a few experiential ways to demonstrate automaticity, mindlessness, and “choice-less-ness” that can be used either as part of Choice Awareness Practice group or in the context of individual psychotherapy.
Pointing Out the Here-and-Now Automaticity
“Catch” clients in the middle of head nodding, leg shaking, and in the middle of their gestures. Point out the seeming mindlessness and automaticity of these motor behaviors. Help clients appreciate the fact that while they, in theory, had choices (about what leg to shake, how quickly to shake it, etc.), the behaviors “happened” on their own without their having been any conscious processing of the choice options or any conscious choosing. This type of immediate behavioral feedback is used to facilitate to a greater state of choice-awareness. As clients begin to become self-conscious, they, by definition, become conscious of their Selves: such moments of meta-cognitive self-awareness and self-observation afford an empowering glimpse of the dormant Chooser that is coming back “on-line.”
Circle of Choice
Give clients four sheets of paper and have them draw a circle. Then, in rapid succession, have clients draw another one on a separate piece of paper, and another one on the last piece of paper. Following this, invite clients to comment on the similarities of these three circles (“In what ways are these circles similar?”).
In most cases, the mindlessly drawn circles will reveal a range of similarities on the following parameters: clock-wise or counter-clock-wise direction of the circle, its diameter (large, small?), its relative position on the page (centered, up or below the center line?), and its starting point (twelve o’clock, three o’clock?). Ask clients if they consciously intended for these similarities to occur or if these similarities just happened. Ask clients to ponder what that means.
Following this discussion of mindlessness and automaticity, have clients draw a fourth circle, this time making conscious choices of where to start the circle, which direction to draw it, consciously choosing its diameter size and consciously choosing where to place it on the piece of paper. Have clients discuss how the experience of mindfully drawn circle differs from the previous experience of mindless drawing. Highlight any statements that indicate a sense of presence, a greater sense of control over the drawing. In discussing the experience of mindful circle-drawing some clients might convey a sense of being somehow alert, awakened, and attentive. Ask the semi-rhetorical question: “What if you could be this alert, this attentive and thoughtful at a baseline, with matters and events that have much impact on your life?”
The choice of a circle as a figure to highlight mindlessness is not a random one in this case, and the facilitator is encouraged to capitalize on the metaphorical and existential significance of a circle as a metaphor for mindlessness. After all, what makes a “vicious cycle” vicious is its circularity. Help clients appreciate that motor-behavioral and cognitive-affective habits are in essence circular stimulus-response patterns of “always doing the same thing without realizing it.” Most substance use and compulsive spectrum clients readily relate to the phenomenological entrapment of being caught up in a repetitive cycle of doing the same thing over and over again, despite the sincere intent to break out of this behavioral loop.
Congratulating for Choices Made
As a means of highlighting the fleeting and subtle phenomenology of the actual act of choosing, the facilitator are encouraged to rely on their observation skills and congratulate clients for any apparent novel choices. Note that the emphasis in this technique is on the fact of a conscious choice rather than on its rationale. With this mind, clients are helped to transition from the perspective of content-based assessment of choices to a perspective of assessing the choice in terms of whether it was a true, conscious choice or a pseudo-choice, i.e. a stimulus-response reflex. Thus, the only “bad” choice is the choice that is not made.
Processing of the Meaning of the Word “Just”
While facilitators refrain from judging client’s choices, they are encouraged to inquire about whether, in the client’s own opinion, a given choice, if in fact consciously made, is in line with his or her treatment goals. Thus, clients are helped to appreciate the fact that a choice does not exist in a vacuum but is, in fact, indicative of the underlying motivations which maybe current and up-to-date or existentially out-dated.
Processing the meaning of the word “just” is one way to help clients learn not to confuse mindless actions with choice-based actions. Clinicians should be careful to make sure that this exercise is not experienced as a form of picking on the seemingly benign behavioral moments. To preempt the defensiveness, clinicians should introduce this clinical moment in explicit terms as a choice awareness exercise. For example, by asking a client’s in a choice awareness practice group about the rationale for his or her sitting position in the room, you are likely to hear a defensive “just” of “I just decided to sit here.” Patiently and non-reactively assist the client with the realization that by saying that he “just” sat there, he is, fact, saying that he sat in a given place for no particular reason and is, thus, in Gurdjieff’s terms, claims that his behavior “just happened,” without any conscious participation from him. Therefore, paraphrasing the word “just” as meaning “for no reason,” the client is helped to appreciate the paradox of the moment: nothing happens without a reason and yet it somehow “just” did.
By inviting clients to unravel the mystery of clients’ seemingly un-caused (“just happened”) behavior, facilitators work to demonstrate how the behavior, even when not consciously chosen in the present, reflects possibly outdated motivation that might be in conflict with current recovery goals. These “just-s” can be also related to what Marlatt & Gordon (1985) referred to as “seemingly irrelevant decisions” that may lead to a lapse or a relapse. Consequently, clients are helped to see the potential role of choice awareness in relapse prevention.
The Arbitrary Choice: Practice of Spontaneity
If you were to be asked “What would you rather have: red or blue, one or one point three, a glass or a cup?” you would probably respond with a degree of annoyed bewilderment: “Red or blue what? One or one point three of what?! A glass or a cup of what?!” While this “offer” appears meaningless it is not without some choice awareness training value. Such offers represent the opportunity for a pure choice. If you were to be offered a $20 or $100 bill, “no strings attached,” your choice would be more or less predetermined by the pragmatics of financial common sense. Presenting a purely arbitrary choice, on the other hand, is challenge to common sense and pragmatics, and, as such, is a valuable opportunity to “wake up” and make a conscious choice.
In choice awareness practice, facilitators may offer clients meaningless choices that cannot be guided by the previously conceived considerations of pragmatics, commons sense, or value. Such un-motivated choices, in a way, represent what Tillich (1952) referred to as “freedom beyond freedom,” an ultimate manifestation of spontaneity. A spontaneous choice is free the logic of the past. In its freedom from historical pre-determination, such choice has no past to rely on and, thus, can only rely on the here-and-now assessment of one’s motivation, which requires presence and awareness. Evaluation of two equally meaningless options results in a choice of the purest kind. The capriciousness, subjectivity, irrationality, moodiness, unpredictability of such a choice highlights our freedom to choose in a manner that does not have to reflect our socio-economic, socio-cultural, and psycho-biological predispositions.
Who’s Doing It?
The “Who’s Doing it?” choice awareness exercise involves a simple task of repetitious execution of a motor behavior. For example, the facilitator may ask the client to clench his fist, but only after consciously choosing to do so. The facilitator tells the client: “clench your fist only after you have made a conscious choice to do so each and every time, and do that for a while.” As the facilitator observes the client, he or she suggests that the client speed up the pace. Clients are likely to notice that they are able to increase the pace but they are not necessarily able to match the increased pace of the motor behavior with the pace of conscious choosing. In a manner of speaking, at a certain speed of behavior, they allow the behavior to begin to “happen” without consciously initiating it. Facilitators invite clients to process this experience in terms of their experience of choice and automaticity. Facilitators may also engage the client while the client is continuing with the exercise and ask: “Who’s doing it? Who’s clenching your fist while we are talking?” This demonstration of automaticity-on-demand is discussed in terms of our capacity to self-program, and, thus, self-reprogram, and its pro-recovery habit-formation value.
Thought Choice
In this exercise, participants are asked to repeat in their mind the word pronounced by the facilitator or to think the word opposite to the one pronounced by the facilitator. For example, as the facilitator says “black,” clients will be, if choosing to accept the conditions of the exercise, choosing between “black” (same word) or “white” (opposite word).
With these instructions clarified, the facilitator begins to say the words “black” and “white” in random order, and continues to do so for a period of time (1-2 minutes). Following this facilitator stops the exercise and asks participants to share their experience. The theme to watch is the notion of trying to organize an otherwise chaotic stimulation. Some clients will report that after a few moments of stressful indecision they decided to always think the same word or to always think the word opposite to the one announced by the facilitator. The facilitator would do well to recognize this as a self-imposed autopilot that represents a trade-off between mindfulness and tension relief.
Following this discussion, the facilitator resumes several more mini-sessions of this kind, each time encouraging clients to choose freely on an ad-hoc basis, encouraging them to track the initial tension associated with ad-hoc choice and the temptation to initiate some kind of chaos-organizing autopilot.
In one such series the facilitator may choose one word, say, “black,” and repeat it 20 times in a row, and process the participant’s clinging to the arbitrary expectation of fairness and balance. In particular, some may note that they were waiting for the word “white” to balance out the “black.” Discussion of how the client’s expectation of somewhat intermittent sequencing of these words from the prior series is, too, an autopilot. Parallels with general expectations of fairness, balance, symmetry could be also discussed. Some clients may also report a sense of hopelessness or surrender, an increased temptation to switch to autopilot, be it “same” or “opposite,” given the sameness of environmental stimulation. Acceptance of “same” autopilot might be likened to surrender to peer/environmental pressure; while acceptance of “opposite” autopilot might be tentatively likened to oppositionality.
Finally, in the last presentation, the facilitator shall being with same black-white sequencing and then suddenly switch to north-south, right-wrong, left-right semantic dichotomies. Discussion of this will reveal the fact that clients – while trying to be awake in the sense of whether to “go same” or to “go opposite,” – fell asleep in terms of potential variability of semantic dichotomies. Some will report the feeling of the inertia or momentum of the black-white semantic auto-pilot. The discussion of this semantic resistance, of this clinging to a familiar auto-pilot can be easily generalized to the dynamics of substance use.
Arbitrary Abstinence and Arbitrary Maintenance
Gurdjieff encouraged his students to give up “something valuable” but “not forever” in order to create a constant “friction between a ‘yes’ and a ‘no’’’ (Ouspensky, 2000, p. 45). This suggestion offers a valuable choice awareness training opportunity as long as it is not misconstrued as an exercise in Stoic ascetism. Arbitrary Abstinence and Arbitrary Maintenance exercise is an opportunity for clients to practice both making choices (of what to quit and what to start), and serves to also hone their craving control skills for resisting temptations. In recommending this exercise as a choice awareness practice clients are emphatically encouraged: a) to make only arbitrary choices about what to quit and what to start, b) to commit to a pre-specified, time-limited abstinence or maintenance (timelines should be initially short and plausible, i.e. a week or a month); and c) to feel free to break the commitment any time, if they wish to do so, as long as this is done via a conscious choice. Clients should be explicitly cautioned against misusing this exercise for dieting or going off medication and any other physiological parameters of their living that may jeopardize their health.
“I” Statement
Ask clients to attempt to mean the pronoun “I” each time they use it in speech. Engage them in a simple discussion and help them raise their awareness of whether they use the pronoun “I” by choice or mechanically, in mindless, un-free execution of speech autopilots. Suggest that clients may incorporate the “I” Statement technique into their daily speech as a choice awareness routine. Process the phenomenology of meaning the “I.”
Uncomfortable Chair
This is an exercise that illustrates the choice in delaying gratification, an omnipresent problem for substance abusers. Participating clients are encouraged to assume a somewhat uncomfortable posture and become mindful of the discomfort and the desire to change posture. Doing so would create a sense of relief.
Process the choice in delaying the gratification of relief. Make parallels with substance use. Have clients re-engage in the exercise and experiment with the choice of the timing of the relief.
Choice Step By Step: Walking Meditation
Process mindlessness of walking, explore various choices of pace frequency, stride length, pronation, toe-first versus heel-first stepping, etc. Ask a client to choose each step. Suggest that actively choosing one step whenever one gets up from a chair or bed during the day might serve as a rather generalizable choice-awareness routine.
Crossing Arms
Ask participating clients to cross arms on their chest. Then ask them again. Process the habitual, automatic, mindless crossing (which arm goes over which arm). Highlight the mindlessness of habit.
Signature
Have clients sign their name, once or twice. Then have them sign it mindfully. Process how the mindful signature looks less valid because it is not automated enough. Discuss the benefits of mindlessness – such as signature authenticity; discuss drawbacks of mindlessness – such as the ease of signing whenever asked to sign, such as in the beginning of the exercise, and possibly jeopardizing one’s privacy by making publicly accessible one’s stamp of authenticity for possible replication.
The Choice to Let Go
The following choice awareness exercise provides a useful interface with anger management:
The apparent value of the Choice to Let Go choice awareness exercise is that, if practiced on a regular basis, this choice awareness ritual:
a) In the spirit of progressive muscle relaxation, teaches clients to recognize bodily tension which they may use as a turning point at a moment of stress;
b) conditions the notion of freedom-to-change to psychophysiological relaxation and as such reinforces the idea that awareness of choices, at any given time frees one up, relieves one’s tension about being trapped, or locked into a given internal or external circumstance; and
c) re-conceptualizes tension, stress, and anger as a choice, a response option that does not have to be a default, as an affective autopilot that can be overridden.
The Choice to Let Go choice awareness exercise also yields to secondary metaphors. For example, asking clients to use their other hand to open the clenched fist may be metaphorically likened to seeking help or support. “Flipping the (proverbial) bird,” by opening the fist with beginning with the middle finger, can be likened to displacement of anger, a tension-relieving, albeit less constructive, strategy for letting go of tension. Finally, continuing to clench the fist can be seen as a choice to hold on to the grudge or anger, and not wanting to release it.
In summary, the clinician may reiterate that tension or relief are but invisible choices if one is asleep. Consequently, regular practice of this exercise will allow clients to turn tension into a kind of choice awareness alarm clock that will awaken the person to the fact that he or she has a choice to stay tense or to let go.
The Choice Eye
The visual imagery, relaxation, and hypnosis literature make references to the metaphor of a “mind’s eye.” The present choice awareness practice involves the metaphor of a Choice Eye and, in format, vaguely follows Yapko’s (2003) format for the Mind’s Eye hypnotic induction technique.
More specifically, the client is instructed to close his eyes and imagine that he has a Choice Eye. This Choice Eye is likened to a physical eye, but inside one’s mind. This Choice Eye sees automaticity, schematic behaviors, habits, and mindlessness. The client is instructed to let the eye roam, around and inside himself, in search of any behavioral autopilots or schemas, or habits, or mindlessly executed behaviors. Each time the Choice Eye sees an autopilot, a mindlessly running behavioral or affective routine, it makes a choice. The Choice Eye chooses to continue to run the routine or to discontinue its operation for the moment. For example, the Choice Eye may see that the subject is tapping his or her foot. The Choice Eye then chooses to continue to tap the foot or to stop tapping it. And so and so forth. The person is instructed to perform this exercise for a few minutes, letting the Choice Eye take a panoramic view of the person’s current moment.
A Different Way to Get 4
Write on a piece of paper the following and give it to the client: “___ + ___ = 4.” Instruct the client to fill in the blanks. A typical response is, of course, “ 2 + 2 = 4.” Discuss that the “two plus two equals four” is an autopilot. Challenge the client to “get 4 a different way,” and allow them to work on that problem for a couple of trials. The client may, for example, arrive at the following equations: “7 – 3 = 4,” “569.5 – 565.5 = 4,” “8 x 0.5 = 4,” etc. State that if the client chose to, as of this moment, he could come up with a different way to obtain 4, each time, for the rest of his life, if this is all he did. Allow the client to ponder the infinity built into this simple algorithm.
Offer to the client to each day “find a new way to get four,’ and make parallels with recovery. State that there’s more than one way to get to Rome (more than one way to get 4). “Choosing another way to get what you want” and/or “appreciating that another way is possible makes for a good choice awareness practice.
Pattern Interruption
Facilitators may use a variety of pattern interruption elements to create opportunities for choice. For example, moving one’s podium or easel in the group room to a new location allows clients to make a choice to adjust and to make a choice to regulate or not regulate any discomfort or inconvenience that a given pattern interruption might have created. Similarly, silence can be used to highlight clients’ automatic preferences, such as a desire to break the tension of silence on group’s behalf, to wait it out, hoping for someone else to do it on their behalf, etc. Clients may be asked to process the choices they had in the moment, and how they guided themselves through those choices. Similarly, Zeigarnik effect can be an effective method of pattern interruption to increase client’s choice awareness. An example of a simple implementation of such pattern interruption strategy would be to start but not finish an utterance at any point of the choice awareness practice group.
Another variation on pattern interruption is starting a previously automated routine from an arbitrary point of entry. De Bono (1970) suggests that changing a choice of entry point may lead to insight. And indeed, if the choice of entry point is kept constant, the determinism of the behavioral algorithm leads to one and the same result. Einstein’s definition of insanity (as doing one and the same thing but expecting a different result) illustrates the futility of mindlessness and automaticity quite well.
In working with substance use clients who have developed a habit of using the Serenity prayer, I have frequently recognized the philosophical/spiritual value of it, but also suggested a simple modification to turn this already recovery-oriented routine into a freedom-to-change potentiating choice awareness routine. In particular, I would instruct clients to each day make a conscious choice to start the Serenity prayer from a different point of entry. For example, a client could choose to start the prayer from word # 7. To accomplish this, he or she would have to first mindfully and mentally “walk through” the prayer structure to identify word # 7. Following this, the client would begin the Serenity prayer from an unusual point of entry. Quite often clients reported both enhanced choice awareness and state of wakefulness and a new appreciation of the actual text of the prayer. On occasion clients would discover new meaning possibilities. And almost always, clients would report a Zeigarnik like effect of needing closure after this pattern interruption. Knowing the lingering tension of the Zeigarnik effect, I would typically recommend that the clients choose not to redo the prayer but leave it as imperfect as it is, with the idea that this lack of closure from the pattern interruption would provide the lingering of an otherwise therapeutic meme. Several clients have confessed that they did, after all, “order” the sequence after some time of resisting to do so. My sense is that most, or at least the majority, of individuals in the state of lack of closure would at some point bring the pattern to completion. The therapeutic value here is obvious: in addition to choice awareness, the client is “tormented” with a benign and clinically meaningful obsession.
Get to Know Your Robot
One of the best correlates to Gurdjieff’s method of de-automatizing that I have found in the self-help literature is the chapter “Get to Know Your Robot” in the book The Psychological War on Fat by Cordell and Giebler (1977). These authors provide a well-popularized discussion of automaticity and offer the readers to essentially catalogue their programs or habits. I have used a similar cataloguing technique in guiding my clients’ choice awareness practice, by offering them to think of automaticity in terms of simple “if A, then B” algorithms that can be reprogrammed to read anything from “if A, then A” (viewing reality as is, through separation of Self into Subject and Object) to “if A, then (fill out the blank with a more adaptive alternative response).” It should be noted that the difference between Cordell and Giebler’s use of the knowledge of one’s robot is that they reprogram the robot through behavioral reinforcement, whereas the Change Equation reprograms the robot through choice or agency.
Pressing Flesh
In group setting, have two clients shake hands. Help them deconstruct the experience. Discuss the unintended, un-chosen communication imbedded in a street-style high-five handshake/hug. Explore the handshake as a link in the potentially long and treacherous chain of small-talk if in the presence of stimulus-laden people, places, and things. Have clients press flesh in a de-automatized, choice-aware fashion.
Demonstrating the Emotionally Pragmatic Appeal of Mindlessness and Automaticity
As part of Choice Awareness Training, the following “Word Choice” exercise can be used as both an opportunity to demonstrate the emotional pragmatism of choosing not to choose and as a choice-training exercise. Participants are instructed to repeat in their mind the word pronounced by the facilitator or to think the word opposite to the one pronounced by the facilitator. For example, as the facilitator says “black,” clients will be saying to themselves the word “black” (same word choice) or “white” (opposite word choice). With these instructions clarified, the facilitator begins to say the words “black” and “white” in random order, and continues to do so for a period of one or two minutes.
Following the exercise, the facilitator offers to discuss the experience. The theme to highlight is clients’ attempts of trying to organize an otherwise chaotic stream of stimulation. Some clients will report that after a few moments of repeated stressful indecision they decided to always think the same word or to always think the word opposite to the one announced by the facilitator. The clinician facilitates the discussion of this dynamic, of its existential meaning and its parallels with substance use. In particular, clients are helped to appreciate the freedom-escaping allure of the self-imposed autopilot that represents a trade-off between the stress of conscious, mindful choosing and tension relief.
Following such discussion, the facilitator encourages clients to “claim” their freedom to choose, to not go on auto-pilot, to choose freely on a moment-to-moment basis, and resumes the exercise. This “Word Choice” exercise can be used repeatedly as a choice-conditioning, with the term “conditioning” here being akin to muscle conditioning. Methods for self-administration of this choice-conditioning exercises (such as making a recording with a random presentation of these word stimuli or involving a support person to work with the client) can be discussed as well.
Emotional Deepening: The Costs of Automaticity
Mindless, reactive, habitual, mechanical, schematic, rote, conditioned, fixed, rule-governed, impulsive, stimulus-bound, auto-piloted existence is not unlike being asleep or sleep-walking, at best. This can be a rather existentially-poignant and, thus, motivationally-enhancing realization: most would be appalled at the notion of sleeping away their life. To deepen the appreciation for the need to be more awake and aware, clinicians can offer a kind of existential accounting to help clients ballpark how much conscious time they have actually lived (by factoring out actual nighttime sleep and conditioned sleep of mindlessness that pervades our lives). Pushing the existential button of time loss allows the facilitator to heighten clients’ motivation for the need to wake up and to stay awake, if they are to live as themselves, prudently apportioning time, their only existential resource, to what, indeed, matters.
Daily Choice Awareness Habit: Setting an Alarm-Clock for the Mind to Awaken the Sleeper
By this point in Choice Awareness Training, clients realize that knowing the value of choice awareness does not make one choice-aware. An existential sleeper is asleep and is unaware of that fact and, short of outside help, will remain asleep. While counting on others to rouse oneself from cognitive-behavioral auto-pilots is certainly possible (through therapy and/or self-help meetings that remind one of his or her goals and priorities), learning to wake yourself up to the here-and-now freedom to choose and to change is the ultimate goal of Choice Awareness Training. Gurdjieff offered an elegant self-help solution for this problem. He believed that “it is possible to change certain aspects of overt behavior and to use such changes as reminders for flagging attention” (Speeth, 1989, p. 77). In particular, Gurdjieff suggested that an individual can set up a kind of mental alarm-clock that would awaken the individual continuously throughout life, at various selected time-points (Ouspensky, 1949).
Gurdjieff’s suggestion, in the context of Choice Awareness Training, takes the form of cultivating a habit of de-constructing and consciously re-constructing various habits of daily living as an opportunity to infuse choice awareness into various routines of daily living.
On a practical level, the client might begin with de-constructing their evening hygiene, re-sequencing its various steps, and including such “choice awareness twists” and mindfulness-raising alterations as brushing with a non-dominant hand, brushing and washing with one’s eyes closed, making a conscious choice to not use the mirror on occasion, etc. For weeks, if not months, the client consciously varies his or her evening hygiene routine until he or she either tires of it or the new routine begins to feel old (i.e. too familiar to be of choice-awareness and mindfulness-facilitating value). At this point, the client makes a conscious choice to target a new daily habit. Once the client appears to have exhausted all available targets, he/she can recycle the previous targets. The opportunities for anchoring choice awareness in one’s daily routines are practically limitless.
Helping Clients Select a Target for Daily Choice Awareness Practice
In selecting a choice awareness practice clients are encouraged to consider habits that are high in frequency and are likely to occur on any given day of a client’s life regardless of circumstance and surroundings (such as hygiene routines, for example). Furthermore, it is recommended that clients try to anchor their choice awareness practice in high-frequency that are also reasonably paced throughout the day (e.g. mindful, choice-aware eating).
Portable Choice Awareness Practice
Conscious drawing of a circle (see more detailed explanation above) is recommended as a portable choice awareness practice that can help clients both internalize the metaphor of the self-reinforcing circularity of habits and provide an easy, on-the-go meditation on choice awareness.
]]>
Reframing the Addiction as a Habit, not a Disease
Facilitators take clients on a conceptual head-on collision with the Disease Model of addiction. Addiction is reframed in the context of operant conditioning theory and the Disease Model of Addiction is challenged. This is accomplished through the review of the history of the Disease Model of addiction (for excellent coverage of these topics, please, refer to Peele’s “Diseasing of America,” Schaler’s “Addiction is a Choice,” and Walters’ “The Concept of Addiction”). The logical inconsistencies of the concept of addiction as a disease and of the 12 Steps are reviewed.
In particular, facilitators should be prepared to recognize the following errors in logic. Petitio principii is the logical fallacy of tautology in which the same premise serves as both the premise and the conclusion (Walters, 1999). Facilitators need to familiarize themselves with the tautology of the loss of control argument (in which the loss of control serves both to describe and explain addiction), the prediction tautology (a problem drinker can never drink in moderation and any drinker that can drink in moderation is not a problem drinker), and the denial tautology (any disagreement with the Disease Model of addiction constitutes proof of disease) (Walters, 1999).
Review of Self-Change Literature
Clients are introduced to self-change literature, the study of the phenomenon of self-change among drug and alcohol users, an emerging empirical body of research that contradicts the postulates of the Disease Model of addiction. The self-change literatures helps address the logical fallacy of the argumentum ad verecundian (an argument that involves an appeal to authority to establish credibility, in the case of the Disease Model of addiction, this argument involves an appeal to medical authority, whereas in the case of the 12 Step paradigm, the argument involves the appeal to the spiritual authority of the “higher power”) (Walters, 1999). Studies show that self-change “appears to be the dominant pathway to recovery” (Klingemann et al, 2001, p. 21). Facilitators present self-change statistics with a particular emphasis on the longitudinal stability of natural recovery.
Langer, in her 1989 book, entitled “Mindfulness,” shares the results of a study that supports the importance of exposing individuals in recovery to various conceptualizations of recovery. In particular, Langer shares that in a study of forty-two patients attending an alcohol clinic, the individuals “who had been exposed to only one model of alcoholism” (early in their lives) “appeared to have developed mindsets so rigid that the options offered by therapy did not seem available to them,” whereas “those who had been successfully helped in therapy virtually always came from the multiple role-model group” (1989, p. 52). Langer suggests that subscribing to a genetic/medical view of addiction constitutes a counter-therapeutic “premature cognitive commitment” to a particular model of recovery, and notes that “alcoholics who see the cause of their problem as purely genetic seem to give up the control that could help their recovery” (p. 51). Helping clients review the findings of self-change literature introduces alternative views on recovery and safeguards against an unnecessarily fore-shortened clinical diagnosis.
Review of Client’s Personal Self-Change/Success Data & Challenging of All-or-Nothing View of Self-Control
Furthermore, clients who express skepticism about the validity of self-change literature are encouraged to explore their own self-change data. The clients’ belief in their powerlessness over addiction is likely to be a function of a) an uncritically adopted belief that they are powerless, a kind of iatrogenic ideological side-effects of past treatments that were informed by the Disease Model of addiction, and b) dichotomous/perfectionistic/all-or-nothing thinking that led clients to dismiss the partial success of their past self-change efforts.
With this in mind, the Review of Personal Self-Change Data allows the client to learn from his successes rather than to continue to focus on his failures with an inevitable sense of loss of control. More specifically, clients are encouraged to think of at least one precedent of controlling their desire to use. It is simply inconceivable that a substance user had never to postpone his using, that he or she always used whenever he or she desired to use.
The facilitator explores clients’ abstinence histories, times when they had to wait until the next day to use because they had to “pee in the cup,” and they could not afford another dirty urine out of fear of losing employment or violating the conditions of their parole. Facilitators may focus on the times when the clients wanted to use but had no financial means to cop the drug and, therefore, had to figure out ways to get money be it by stealing, or taking the TV or their car stereo to the pawn shop, or by doing some work to get the money.
The review and verbalization of these use-postponement precedents is significant in that each such episode demonstrates to the client that – regardless of the intensity of their urges – they had been able to control their behavior for varying periods of time on numerous occasions. The conclusion – as logically inevitable as it may seem – is likely to require additional processing. The client should be assisted to appreciate the meaning of these brief and not-so-brief periods of abstinence: they have, in fact, exercised control over their using behavior. If they can control an urge for a brief duration of time, they can control it for any duration of time, given the proper motivational incentive, and, particularly, when augmented with more than intuitive skill-power and self-regulation tools.
In review, the idea behind this particular strategy is to de-dichotomize the all-or-nothing cognitive distortion: just because the clients could not control their using behavior all of the time, it does not mean that is not controllable, as evidenced by the numerous times in the life of any substance user when he or she does, in fact, succeed in controlling their using behavior for some duration of time. The consistent objection that is voiced at this point is a sudden re-interpretation of the problem: whereas in the past the problem was conceptualized behaviorally (drinking or drugging, using behavior), now it is re-interpreted cognitively as a problem of the constant craving. In particular, the clients concede that, yes, they now realize that, assuming adequate motivation, they can control their behavior, what they cannot control, however, is the desire to use. This objection, if voiced, is the opportunity to normalize and de-pathologize the fact of the craving. Drug and/or alcohol craving can be re-interpreted as a perfectly legitimate desire for relief of stress, for a sense of well-being, that can be fulfilled in psychologically-, legally-, physically-, and financially-safer ways. Craving for a relief or well-being is, therefore, portrayed as a normal vital sign, a human response to the intermittent reality of pain and suffering.
Discussing the Implications of the Disease-Model Explanatory Style
Individuals with a pessimistic explanatory style develop a sense of helplessness and give up in the face of failure or extreme challenge (Satterfield, 2000). The disease concept of addiction is a paragon of the pessimistic explanatory style. The attribution theory research defines pessimistic explanatory style as a causal model that attributes the causes of a negative event to internal, stable, and global factors (Abramson, Seligman, & Teasdale, 1978). The disease model of addiction encapsulates all three. A sense of powerlessness, therefore, is a logical by-product of the pessimistic explanation of addiction as a disease and constitutes learned helplessness. Choice Awareness Training, in a manner consistent with positive psychology, helps clients appreciate that learned helplessness is not factual helplessness, and helps clarify the distinction between feeling helpless and being helpless.
Tackling the Issue of the Pre-Disposition
The notion of a pre-disposition is often misunderstood by clients. Pre-dispositions pre-determine certain needs, not the specific means with which these needs are met. If a person is predisposed for anxiety spectrum disorders, he or she has at least four options to self-regulate: 1) psychological self-help, 2) psychopharmacology, and 3) chemical self-help through substance use (as a form of self-psychiatry).
Facilitators work to counter the fatalistic understanding of the notion of pre-disposition, reinforced by the fear-mongering Disease Model of addiction, and help clients realize that whatever pre-dispositions they might have, they are still fundamentally free to choose a particular method for addressing any biological, genetic, or chemical deficits that they might have.
Taking on the Issue of Addictive Personality
The notion of Addictive Personality failed to acquire empirical support in over half a century of scientific investigation (Miller and Rollnick, 1991). Clients are helped to see that the pathologizing connotation of “addictive personality” is merely a function of social stigma attached to a given appetite. Furthermore, with the word “addiction” seen in the context of operant conditioning, the very construct of “addictive personality” can be reframed as “habit-forming personality,” which, of course, is universally possessed.
Discussing Habit Formation
If “addiction” is to be effectively re-conceptualized as a habit, not a disease, discussion of the process of habit formation is of paramount importance. Discussion of habit formation (of habit psychology) offers a normalizing, validating, explanation of how over-learned habits can lead to a sense of loss of control, without the counter-therapeutic externalizing that stems from the notion that has no control because of a presumed disease of addiction.
Habits have been often referred to as “second nature.” The notion of “second nature” is a semantic gold mine that holds a phenomenological clue to the mystery of the sense of loss of control. Tengan (1999), in clarifying Lonergan’s teachings on habit formation, notes that “a habit gives an inclination to an otherwise indeterminate potency (the will),” and, as a result, “predetermining us to act in certain directions” (p.97). Consequently, what was once a novel, mindful, idiosyncratic response pattern becomes an over-learned natural default.
In its defaulted-ness, the acquired response pattern becomes automatic, it serves as an energy conserving short-cut. Barrett, as far back as 1911, likened the “automatism” of habits to a state “arrived at by the will when it functions evenly, simply, and regularly in a manner more or less independent of conscious attention” (1911, p. 105-141). Llinas (2001), “a founding father of the modern brain science,” writing ninety years later, used, instead, the term Fixed Action Patterns to describe modules of activity “that liberate the self from unnecessarily spending time and attention on every aspect of motor and non-motor activities” (p. 134). Llinas states clearly that the rationale behind Fixed Action Patterns is “the economizing of choices” (p. 144). Whether we refer to the habits as autopilots, or schematic behavior, or second nature, or learned behavior, or fixed action patterns, this automatization “liberates” us from having to make an infinite number of minute choices. As any default, this automatization spares the mind the work of any unnecessary deliberation or decision-making, thus creating the phenomenological sense of loss of control. In a sense, a “second nature” response pattern is experienced as “happening” to the person rather than “being executed” by the person. This kind of resource-saving automatization is a hallmark achievement of the human mind. Auto-piloting or automating of various cognitive-behavioral-affective routines enables human mind to multitask as it plows through the never-ending environmental bombardment of stimuli. The loss of the sense of control (or of the sense of agency) is the cost of this optimization.
As a side note, clients are offered to examine how their uncritical acceptance of the Disease Model of addiction, in a way, represents an attempt to economize. After all, the concept of a disease (“I am doing this because I am sick) is a simple emotional conceptualization to be contrasted with a cognitively harder concept of a habit (“I am doing this because I have been conditioned to do this”).
Clients are helped to appreciate the fact that the momentum of the habit, its baseline behavioral orientation, its default inclination, its automaticity with its accompanying sense of “loss of control,” does not, in and of itself, negate the underlying fundamental freedom to choose same or alternative course of action. As noted above, just because an action feels “out of control,” it does not mean that it is, in fact, beyond control.
Lonergan described this momentum or force of the habit as the “antecedent willingness” or “unwillingness” to act in a particular manner. The “antecedent” qualifier in Lonergan’s explanation is synonymous with an inclination or a default orientation towards a specific response, given a particular stimulus. The “antecedent willingness” is that phenomenological pull or drive or action-urge that predetermines a response. It should be noted and reiterated, however, that pre-determination does not equal determination. Tengan’s (1999) use of the term of “voluntary habits” therefore can be understood as meaning that while, in retrospect, the execution of a habitual response might be remembered as an involuntary action, no habit is truly involuntary since any habit can be voluntarily overridden by an act of free volition (p. 96).
Consequently, any habit can be likened to pseudo-involuntarism or pseudo-choicelessness, to coin a couple of terms. Explicit discussion of how habits are experienced as involuntary defaults while being entirely within the potential control of the individual is likely to produce a self-accepting sigh of relief when clients realize that they never lost the control but that they merely neglected it.
Discussing the Power of Context (the Placebo Effect)
Clients, indoctrinated by the Disease Model of addiction, may be both curious and stunned to know that the degree of intoxication is contingent on drinker’s expectations and can be manipulated by modifying drinker’s/user’s expectations (Langer, 1989). On the basis of a review of many investigations, Langer notes that “thoughts may be a more potent determinant of the physiological reactions believed to be alcohol-related than the actual chemical properties of alcohol” (p. 183), and, in summarizing the findings of Shepard Siegel, Langer notes that “the failure of tolerance on the day of the overdose is a function of context,” noting that overdoses are more likely in the unfamiliar environments.
Langer summarizes: if context has the power to change both the degree of intoxication, the severity of withdrawal symptoms, and even the effect a drug overdose, then “addiction may be more controllable than is commonly believed” (1989, p. 184). Presenting clients with the discussion of the power of situational factors offers clients much food for thought as they begin to rethink the presumed medical determinism of their addiction.
Psychoneuroimmunology as Evidence of Mind’s Power over the Disease of Body
Another obvious data source to be angled against the sense of powerlessness that is secondary to uncritical acceptance of the disease model of addiction is literature on the mind-body connection. The very thrust of medicalizing addiction is to call a behavioral problem a body problem. Yet even a body problem is not immune to the solutions of the mind.
A brief sampling of psychoneuroimmunology findings can go far in helping clients who cling to the disease model to enhance a sense of control and freedom-to-change. The evidence that mind can and does solve the problems of the body is abundant enough to roll with the resistance by granting the disease model of addiction a status of “fact,” while still having irrefutable and choice-enhancing arguments to augment the client’s sense of efficacy. The following is a sample of the sort of facts that may help convince a disease-indoctrinated substance user of the “curability” of the incurable.
Paul Pearsall, Ph.D., in his 1987 book Superimmunity, describes the textbook example of a serious skin condition, congenital ichthyosiform erythrodemia, which is characterized by a hardening and blackening of the skin, being successfully resolved within 5 days of hypnosis by Dr. Mason. Pearsall writes that “all major dermatology textbooks report no known cure for this terrible disease” (p. 9). Yet, the fact remained that a bona fide medical problem that had been previously considered incurable was, in fact, curable through a psychological pathway. Dr. Mason’s results were subsequently documented in the British Medical Journal.
Pearsall, a non-physician, reports a mind-body “miracle” in the course of which “a positive Montoux reaction (a reddening and swelling of the skin at the site of the injection of a small amount of tuberculin) was produced through injection of water by suggesting that the water injection was really tuberculin” (p. 10). Ivan Roitt, professor and head of departments of immunology and rheumatology research at the University College and Middlesex School of Medicine, in his 1991 book Essential Immunology, confirms this “popular observation concerning modulation of the delayed-type hypersensitivity Mantoux reaction in skin by hypnosis” (p. 169).
Pearsall reports other research in which a “woman experiencing a severe hay fever reaction to pollen for 12 years was helped to imagine herself free of symptoms. She became completely free of her symptoms for the first time” (p. 10). Imagine what your substance use client can do with his habit-disease if he or she cannot only imagine but evidence his freedom!
The sample of mind-body connection “miracles” above is but an extremely cursory fact-mining. I dove into one book and yanked out several facts that question the depressogenic notion of substance use incurability. If patients with cancer cannot only go into remission but be, in fact, pronounced “cured,” why can’t patients with habit problems? Facilitators that plan to use mind-body connection as an argument against the presumed incurability of the psychological (habit) problem of substance use are encouraged to bring a handful of books or articles from the field of psychoneuroimmunology or psychoimmunology and let clients browse, if they wish.
Choice Moratorium Exercise
Facilitators are encouraged to inter-lace the “fiber” of philosophizing with the “desert” of exercises. One such exercise to offer is the Choice Moratorium. The Choice Moratorimu exercises highlights the inevitability of choice. Clients are challenged to not make any choices for a pre-specified period of time (e.g. one minute). The exercise is followed with processing of the clients’ reactions and insights. For additional instructions for this exercise, please, refer to Somov & Somova (2003).
The “Gun-Point Test” Hypothetical
The “Gun-Point Test” hypothetical compliments the discussion of the claim that a client has no control over drinking or drugging. In this hypothetical, clients are asked to imagine a situation in which they have an intense craving and immediate access to the substance in question. For many users, not yet convinced of the power of choice and of their potential skill-power (of craving control), this moment is well past any feasible self-regulatory “u-turn.” If they are this far into it, with the drug in their hand, many will tell you that they are well on the way to use. To complete the hypothetical, add the following twist: allow the clients to imagine that someone put a gun to their head and stated: “You use – you die.” Ask the clients: “Would you use at this point?” Most clients, whether they will verbalize it or not, will admit to themselves that at a gun-point they would lay down the drug and walk away, not using it.
Ask the clients: “What does that mean?” Prepare to face the inevitable counter-argument that “Yes, but… in real life no one is going to hold a gun to your head and tell you that if you use, you die.” Counter-argue along the following lines: “The gun – an inanimate object – did not introduce the choice not to use to your life, the choice was there all along, it’s just that the presence of the gun helped you become aware of the choice.”
The “Million Dollar Test” Hypothetical
The “Million Dollar Test” hypothetical is a variation on the theme of the “Gun Point Test.” It can be used in much the same fashion to demonstrate the inevitability of choice. As would be expected, in this vignette, the clients are asked to imagine being at a point of using and having an intense desire to use. At this point, someone makes an offer they can hardly refuse: “you use – you get nothing; you put down the drug and walk away – you get a million bucks.”
A predictable but easy-to-counterargue argument is that “in real life, no one’s going to give you a million bucks for not using.” Counter-argue by asking the client what their recovery and freedom is worth. In this sense, any time the client passes on a drug offer he/she is enriched by priceless freedom, self-control, and clean and sober life on his/her terms. Just like in the case of the Gun-Point metaphor, the Million-Dollar metaphor demonstrates that the choice not to use was there all along, but eclipsed by the motivation to use, until the choice to use was re-eclipsed by the incentive of wealth. The incentive of wealth did not create a choice not to use, it simply brought the choice into focus.
The two metaphors described above are designed to address a substance user’s paralysis of self-efficacy when in the presence of the drug or drug-related paraphernalia. While this paralysis of self-efficacy is technically a mirage of perception, it does have a phenomenological reality. This reality is predicated on numerous precedents of trying to resist the urge to use but surrendering to it when in the proximity of the drug. At this point, the clients have not yet reformulated their self-inefficacy or sense of loss of control as a function of conditioned, choice-unaware, mindless responding, and, in the absence of a better explanation, have primitively attributed the power to the drug. The following discussion helps clarify the power hierarchy between animate (human) and inanimate nature.
Demystifying the Inanimate
Substance use clinicians often hear clients verbalize the aforementioned fatalistic attitude that “once I’ve got my hands on it (“it” here being the drug or the paraphernalia), I can’t stop.” This fetishist reverence for the object is likely a reflection of the stimulus value of the paraphernalia objects with their over-conditioned “pull” to use. As part of trying to “demystify the inanimate,” to highlight the passivity of the inanimate matter and its inherent dependence on the human agency, the facilitator might drop a pen down on the floor and compare the pen to an object of paraphernalia.
If the clients had been already offered Exposure/Response Prevention type craving control craving, the facilitator may more accurately simulate the moment by, say, opening a packet with sweetener and line it up on the table. The facilitator then discusses the intuitive physical reality of the fact that the simulated crack stem on the floor or the simulated line of cocaine or heroin on the table, in and of itself, cannot move or do anything on their own, let alone, control a human being. This seemingly banal discussion resets the chain of command: we, the humans, have power over the inanimate drugs and drug-related paraphernalia, not the other way around. It is the very breath that differentiates a human from a line of cocaine that is required for the inanimate substance of cocaine to become a substance use problem of a given human. This discussion often results in such revelations as “I gave it (the drug or paraphernalia) too much power, power that it doesn’t really have over me.” As obvious as this may sound to a non-using adult, the value of this kind of experiential “clarification” cannot be over-emphasized.
Addressing the Language Trap
“I Can’t” versus “I Won’t”
In the first part of the Choice Awareness Training, explicit attention should be given to how substance use clients restrict their freedom-to-change with the wall of words. Language structures perception and perception, for all intents and purposes, is reality. The facilitators’ task is to help clients appreciate the interplay of language and a sense of freedom-to-change. Case in point: individuals who have internalized the 12 Step dictum of powerlessness and bought into the Disease Model of addiction are prone to confuse the “I can’t” with the “I won’t.”
As part of Choice Awareness Training, clients are encouraged to become aware of the distinction. The “I can’t” statement negates the availability of a given option. “I won’t” is a matter of motivation. Whereas the “I can’t” is an acknowledgement of not having a choice to perform a given act, the “I won’t” is an act of choosing not to perform a given act.
For example, after instruction in and practice of craving control, clients will be assisted with understanding that while there is not a craving they “cannot” control, there might be a craving they “will not” control. While the former is an issue of choice awareness or skill-power, the latter is a function of motivation. Consequently, the fundamental distinction between the “I can’t” or “I won’t” is the difference in freedom-to-change and reason-to-change: while one might be free to change from one state to another at any given moment, one might not choose to change because one might not be motivated to do so. Confusing the “I won’t” with the “I can’t” is a process of self-deflation: each pseudo-“can’t” diffuses one’s sense of freedom and agency.
The Passive Grammar of Irresponsibility
“I am addicted,” is a form of constructivist self-incarceration. This statement represents passive case grammar that, by definition, robs the person of a sense of agency. To persons that embrace this view of their substance use the world is experienced as chaotic, hard to control, unpredictable; things happen rather than get done.
In helping clients appreciate the choice-defeatist meaning of the phrase “I am addicted,” I have often made synonymous parallels with the phrase “I am hooked.” Being hooked means just that: being on a hook. Like a fish lured by the glistening promise of a fake bait (the drug), the user convinces himself that he is on the hook of a fishing rod of addiction. Yes, he can rigorously wiggle his tail and talk about “being sick and tired of being sick and tired,” but he can’t get off the hook, not himself, not without the merciful hand of a treatment provider or higher power. That is the perceptual lot of someone who believes they are hooked. But, I’d ask the client, who is holding the fishing rod of addiction? Who is the owner of the hook? Who is reeling in the client across the turbulent and murky waters to the shore of oblivion? The Inanimate Drug? The Indifferent Drug Dealer? Hardly: the owner of the hook is the client’s own mind that has conceived of a notion of being without power to change.
Just like in the work of cognitive modification clients are to learn that no one can make them feel anything and therefore the passive grammar of “he made me mad” or “he made me sad” is continuously challenged, so does the passive grammar of substance user’s statement that he or she is “addicted” need to be challenged and processed for its phenomenological implications.
The Word “Addict” and Addict Identity
Self-identification as an “addict” or an “alcoholic” is an unfortunate legacy of the 12 Step movement. While it is true that some clients use the term “addict” or “alcoholic” as a verbal short-cut to rapport building (as in “I’ve been through similar things, you don’t have to fear my judgment, I understand where you are coming from”), the majority of self-identified “addicts” or “alcoholics” feel a kind of disempowering chronicity of their condition that does more harm than good.
A 12 Step proponent will rush to object that self-identification as “addict” or “alcoholic” is primarily designed to heighten the client’s hypervigilance, to caution him or her to be on guard and watchful for any signs of lapse. While partially reasonable, this type of vigilance boomerangs. Clients come to distrust their thinking “because their best thinking got them here,” and come to fear their unconscious with its treacherous and sneaky “reservations.” The result is a kind of Stalinist self-regime where one’s self becomes the “enemy of the people.”
It goes without saying that the “addict identity” stems from buying another dangerous combination of words, namely from the notion of “addiction as a disease.” Clients should be assisted with realizing that the “disease model of addiction” is a linguistic metaphor, and not the only one at that. Other metaphors are possible. For example, addiction could be metaphorically conceptualized not as a chronic disease but as an allergy. Alternatively, and in the spirit of the Change Equation, addiction can be conceptualized as a chemical self-regulation autopilot, a kind of mindless execution of a less than optimal coping strategy. With this in mind, the client should be assisted with a choice of the metaphor for their problem, with each metaphor being evaluated for its pro-change and anti-change qualities.
Such discussions often result in a realization that choosing “addict identity” (with the exception of rapport-building aspect) represents a wholesale surrender of choice. Facilitators of Change Equation approach shall respect that constructivist choice, as long as it is consciously thought out, and point out that choosing not to choose is a choice as well, and congratulate the clients on yet another consciously made choice. What shall clients call themselves instead of “addicts” or “alcoholics?” In my opinion, their actual names or the pronoun “I” would suffice. If clients do wish to categorize themselves in relation to substance use, the term “chemical coper” or “ex-chemical coper” provides conceptual continuity with the Change Equation philosophy. By calling oneself a chemical coper, the person acknowledges the fact that substance use served the purpose of emotional self-regulation. To call oneself an “ex-chemical coper” or “former chemical coper” allows the person to reiterate that they have now opted for a different coping pathway.
Discussing the Difference Between Difficult and Impossible
In facilitating client’s understanding of the sense of loss of control, it is helpful to explicitly address the incremental progression of the sense of the control as the person attempts a self-stopping behavior after initiating a habitual response sequence. Zeigarnik (1938) demonstrated that a response sequence is harder to abort at the later sequence points of a given response than at the earlier sequence points. Baumeister et al (1994) clarifies with the example of a sexual response: “refraining from sex is undoubtedly much easier if one backs away after (or before) the first kiss than if one waits to intervene until after an hour of passionate necking” (p. 21). Clients should be helped to understand, however, that just because something is harder it is not necessarily also rendered impossible. Given the awareness of the proper incentive or dis-incentive (e.g. the Gun-Point hypothetical), a person regains the choice to disengage from the target behavior.
Summary: Freedom-to-Change is Ego-Syntonic
Phenomenologically, the outcome of this semi-didactic, semi-experiential Logotherapy designed to help clients appreciate that they are fundamentally free, and, thus, free to choose to change, is an ego-syntonic sense of liberation and a regained sense of being once again possibly in control of their lives. This realization that one is free to choose and free to change is so empowering that once clients are provided with a logical framework to counteract the notion of disease-based determinism, they tend to hold on to this insight. In this sense the realization of strategic freedom-to-change is much like learning to ride a bicycle: once understood, it requires no additional practice and it has no expiration date. It is quite a different story with the tactical, here-and-now awareness of choices available to us in any given moment: the habit of falling existentially asleep and living on a cognitive-behavioral auto-pilot has to be replaced by a habit of waking yourself up. That is the task of the second part of Choice Awareness Training that is discussed further below.
]]>
Bandura (1977) defined Self-Efficacy as a person’s belief in (or confidence in) his or her ability to successfully carry out a specific task. Freedom-to-Change is a belief that one is fundamentally free to change, i.e. that one is free to perform or “can” perform a given task.
The “can-do-ism” of Self-Efficacy and the “can-do-ism” of Choice Awareness Training, as similar as they may seem, are fundamentally different issues. The “can-do-ism” of Self-Efficacy, with self-efficacy being defined as confidence in one’s ability to succeed, is a probability of success issue, whereas the “can-do-ism” of the Freedom-to-Change is a capability issue. The Freedom-to-Change construct is designed to reflect the species-wide range of human capability (is a given endeavor within my human capacity?); whereas the construct of Self-Efficacy is a person-specific estimation of the probability-of-success (will I succeed at this endeavor if I were to attempt it?). With these distinctions in mind, the thrust of Choice Awareness Training is not to nurture the client’s belief that he or she will successfully carry out a specific task, but to nurture the client’s realization that he or she can carry out the task in question. With this distinction in mind, it could be said that the “can-do-ism” of Self-Efficacy is really a “will-do-ism.”
This conceptual differentiation might seem like clinically insignificant hair-splitting. But it isn’t: the difference between Freedom-to-Change (which delineates one’s capability) and Self-Efficacy (which predicts the probability that a given action will be taken) is no less significant than the difference between capability and motivation. If treatment fails to differentiate between the constant of “capability” (can-do) and the variable of motivation-contingent “probability” (will-do), the individual, faced with a lapse or a relapse, is certain to attribute his or her failure to lacking “capability,” i.e. to being globally unable and incapable to meet and maintain the recovery goals. This catastrophized “I can’t do this!” conclusion will, unfortunately, take the place of an otherwise more self-accepting conclusion of “I know I can do this, but I have not yet succeeded in doing so.”
From Freedom-to-Change to Readiness-to-Change
The transition through the initial stages of readiness-to-change (Prochaska & DiClemente, 1986) might be arrested by a client’s sense of inefficacy. Miller and Rollnick (1991) recognized the need to enhance the client’s self-efficacy (i.e. client’s belief in his or her ability to successfully carry out the tasks of recovery) as part of motivational enhancement.
Given the above-delineated distinction between self-efficacy and one’s sense of being fundamentally free to choose, and, thus, to change, it would appear that the ambivalence of the Precontemplation stage might be just as much about whether one can change as it is about whether one will be able to change. The “I want to, but I am not sure if I can” ambivalence appears to be phenomenologically precede the “I can, but I am not sure if I want to” ambivalence. And, indeed, in order to motivationally vacillate as to whether one wants to change or not, one would have to first presuppose that the very change in question is even possible.
Furthermore, a client who appears to be motivationally ambivalent, i.e. seemingly unsure if he or she wants to proceed with the tasks of recovery, might be merely questioning whether he or she can, in fact, change. With these considerations in mind, it is recommended here that Choice Awareness Training (as a means to developing one’s sense of Freedom-to-Change) should ideally precede the cultivation of the Reasons to Change or, at the very least, proceed in parallel with motivational enhancement.
Freedom-to-Change through Lonergan’s Lens
Lonergan’s Operational Range of Freedom
Lonergan (Tengan, 1999) draws a distinction between Essential freedom and Effective freedom that somewhat parallels this author’s distinction between Strategic and Tactical Awareness of Freedom to Change (or strategic and tactical freedom). Tengan clarifies Lonergan’s dichotomy as follows: whereas “essential freedom is concerned with possible courses of action, effective freedom is concerned with the actual courses of action” with the effective freedom being, in essence, an “operational range at a person’s disposal” (p. 94).
Lonergan posits the following 4 barriers to this operational range of freedom.
1) External Circumstance: one’s effective freedom can be restricted by an External Circumstance. For example, if you are five feet tall your chances of being drafted into NBA are inherently limited by the fact that one’s height is an important prerequisite for professional-level basketball.
2) Psychoneural State or Subject’s Sensitivity: Lonergan posits that one’s “capacity for deliberation and choice” can be hampered by such neurotic phenomena as anxiety or obsessions. For example, an otherwise perfectly able youth of adequate height and basketball skill might be hesitant to pursue a career in basketball out of the perfectionistic dread of failure.
3) Subject’s Intelligence: Lonergan explains that one’s operational range of freedom is, to an extent, a matter of one’s intellectual development. Consequently, one’s fund of knowledge, education, analytical capacity all play a factor in one’s “capacity for deliberation and choice.” In other words, the more one knows and the better one processes information, the freer one is.
4) Universal Willingness: Lonergan recognizes habit as an impediment to an essential free choice and advocates the development of universal willingness in accordance with which a person is “antecedently willing to learn all there is to learn about willing and learning and about the enlargement of one’s freedom from external circumstance and psychoneural interferences.” In other words, Lonergan proposes that to expand one’s effective freedom, a person has to maintain an overall appreciation of how habits create response inclinations (or response orientations that manifest as a willingness to respond in a specific manner) and to cultivate a kind of universal willingness to act freely rather than out of a habitual response inclination.
Lonergan’s Universal Willingness, if defined as a willingness to act freely (willingly), rather than out of habitual inclinations (automatically), comes satisfyingly close to this author’s conception of Strategic Awareness of the Freedom to Change. The notion of Universal Willingness, however, appears insufficient to enable an awareness of the freedom to change at any given moment in the person’s life. In much the same fashion as the Strategic Awareness of the Freedom to Change, Universal Willingness exists as a dormant realization, as a stored philosophy, a guiding principle that may or may not be incorporated into one’s thought content at any given time-point. And as such, for all intents and purposes, Universal Willingness or Strategic Awareness of the Freedom to Change is only useful as a philosophical and motivational impetus to developing a capacity for Tactical Awareness of the Freedom to Change. Consequently, it could be said that Lonergan’s four impediments to the effective range of freedom need to be complimented by the fifth impediment, i.e. lack of baseline (moment-by-moment) choice awareness. And, indeed, a person who is otherwise non-restricted by circumstance, who is psychoneurally regulated or stable, who is both intellectually adequate, and who, otherwise, knows and appreciates the need to be unimpaired by the response momentum of the habits, might be factually mindless, very much in the process of enacting a given habit, entirely oblivious to the options or possibilities available at any given time. What appears to be required, therefore, is not a philosophical willingness to act freely but an experiential baseline of awareness or tactical awareness of the fact that one can act freely or willingly at any given moment. As demonstrated above, both Bandura’s and Lonergan’s conceptual equivalents of a sense of freedom-to-change (self-efficacy and universal willingness, respectively) suffer from one and the same fundamental problem of application. While both are essentially conceptual reformulations of one’s capacity for freedom and self-control, neither approach provides a method for developing an experiential baseline of awareness or tactical awareness of one’s freedom to change.
William Glasser, M.D., the founder of Reality Therapy, was one of the few 20th century North American psychotherapy designers who appeared to appreciate, at least implicitly, the need for choice awareness training. Responsibility, the second of Glasser’s “3 Rs” is defined as “ability to fulfill one’s needs, and to do so in a way that does not deprive others of their ability to fulfill their needs” (Glasser, 1965). Glasser further notes in the same text that “teaching of responsibility is the most important task of all higher animals, man most certainly included.”
Glasser’s Moralism versus Humanism of Choice Awareness
Glasser’s italics (“a way that does not deprive others of their ability to fulfill their needs”) and the third of his “3 Rs,” Right-and-Wrong, show an alliterative hint of the faintly mo-RRR-alistic g-RRR-owl of his clinical orientation, which, in my opinion, served to be the unfortunate demise of an otherwise perfectly sound idea of choice awareness training. Glasser, in my opinion, in focusing on the Responsibility side of the coin of Freedom, got it backwards. He was basing his therapeutic sales pitch on the Cost, rather than the Benefit, on Responsibility rather than Freedom, on Consequence rather than Choice. With that in mind, his otherwise empowering and humanistic affirmation of “one’s ability to fulfill one’s needs” (choice, freedom) was drowned in the moralistic emphasis on responsibility. It is of note that in its dismissal of the concept of mental illness, and holding clients responsible for their symptoms, Glasser’s take does parallel this author’s dismissal of the notion of addiction as a disease. Similar to Glasser, the position offered in this approach prompts a substance user to take responsibility for their using behavior by highlighting the fundamental capacity for choice that one possesses at any given time, if he or she is sufficiently choice-aware or awake.
Unlike the undisguised moralism of Glasser’s Reality Therapy, the Change Equation approach humanistically normalizes our predisposition for automaticity and mindlessness, with a resultant sense of being out of control and without a choice, and encourages the individual to regain self-control without the suggestion of any particular value-based treatment goals.
Choice Awareness Training vs. Willpower
The act of will, application of willpower, and making of a choice are synonymous. The term willpower, however, has an unfortunate connotation of varying strength, as if to convey that some people have a more powerful will than others. It should be noted that the term “willpower” is not an inherently incorrect term. When used in the sense of “power of will (or volition),” the term heightens, if not extols, the human capacity to make a choice. The phrase “power of will” is free from any kind of interpersonal comparison, it is merely an acknowledgement that as humans we possess a power (a freedom) of self-determination through choice. The term “willpower” becomes problematic, however, when the semantic focus shifts from “power of will” to “how powerful one’s will is.” The Concise American Heritage Dictionary (1987) reflects this distinction by defining “will power” as a) the ability to carry out one’s decisions, wishes, or plans, and b) the strength of mind. While the first meaning of willpower does exist, the second is nothing but a linguistic connotation of the word “power” that does not have a phenomenological reality. Comparative perception of will or capacity for choice as being stronger or weaker is erroneous and psychologically damaging. An act of will or a choice is a binary event: one either acts or does not act in a certain fashion. Consequently, all people are equally strong choosers, with an equal power for will, i.e. of the same willpower. While equal in willpower, i.e. in the capacity for choice, people differ in:
a) how they apply their will/choice, and in
b) the degree of their conscious awareness of their capacity for choice.
Pertaining to a), it is easy to see how judging of others’ actions leads to a conclusion that so and so has weak will. It is the belief of this author that the process of moral comparison is the historical context for the emergence of the term willpower. Say a person is faced with an opportunity to steal something of value. He/she is tempted and, then, he acts upon that temptation. To an outsider, this might seem like a battle between wanting to steal and not wanting to steal that has been resolved in the favor of the presumed temptation: the person could not withstand the promise of easy money, the allure of a financial short-cut. Implicit in such interpretation is that one is weak since he surrendered, gave in to the temptation. A verdict of weak willpower or not having enough willpower is the next logical step in such a chain of interpretation.
An alternative view of the situation is that one did not surrender or give in to the temptation. One merely chose to act upon his desire to steal – for a variety of personal reasons. According to such interpretation there is no weakness of will, there is only socially unacceptable misapplication of one’s will. Consequently, the notion of strong or weak power appears to be a result of moralistic judgment in which there is an automatic semi-religious implication that when faced with socially unsanctioned opportunities (drugs, sex, crime) people are taunted, tempted, lured by whatever is the cultural equivalent of the devil or the dark side and the weakest give in. With this in mind, the notion of willpower has become a kind of implicit morality yard-stick that in the context of substance use treatment represents a circular double-bind, a kind of logical dead-end, a questionable asset in the change process. In reality, people merely make choices that we may or may not agree with – and our disagreement has nothing to do with the measurement of a given person’s capacity for choice. Just because one person insightfully chooses to “numb out” in order not to “go ballistic,” it does not mean that he or she has weak will – all it means is that at this moment this person had concluded (rightly or incorrectly) that drinking or drugging was a strategy of choice, a calculated act of emotional self-regulation.
Pertaining to b) (above), mindless, reflexive, knee-jerk decisions seem “weak” since they are void of the power of conscious choosing. Such unconscious decisions seem “weak” because in their unconsciousness they fail to represent the best interests of the chooser. This is exactly the case when a person in recovery yields to a craving, to an impulse to use. To an outsider, such an easy surrender to a craving appears like an act of weak will. In reality, the weakness of the act stems from its conditioned unconsciousness (or habitual automaticity) rather than from the actor’s actual capacity to resist a craving impulse. An unconscious choice is like a sleeping beauty whose charms are not in play while she is dormant. The “Gun Point Test” is evidence enough that any seemingly weak-willed person would be capable of resisting a craving, given an opportunity to do so in a fully “awakened” state.
The therapeutic importance of deconstructing the myth of willpower cannot be overemphasized. When one buys into the notion of willpower and uses lack of it as an excuse to use, he or she is beyond criticism. In such a case, willpower adopts the rationalizing benefit of the doubt that ensures the belief in addiction as a medical disease. To ask a weak person to do something they do not have the strength for is akin to Baron Munchausen’s pulling himself out of the swamp by his own pony-tail. In other words, change based on willpower is similar to asking one to be strong when one is weak.
People in recovery who have uncritically bought into the notion of will-power are well familiar with this double bind: they are asked to use willpower to stay away from drugs and alcohol, to stay in control; but if they had the willpower to stay away from the drugs and alcohol in the first place they probably would have not been out of control to begin with. With these considerations in mind, it is important to dissect the myth of willpower as a volitional muscle that varies in size from one person to another, and to substitute this hazardous term with a notion that everyone has the exact same capacity for choice. Therefore, when one says “I can’t” they are really saying “I won’t.”
It should be pointed out that traditional substance use treatment models make the error of omission in not directly debunking the myth of will-power. Contrary to this, the present approach incorporates the discussion of the interplay between the notions of will-power and choice into the session curriculum.
Comment on the Strength of Willpower Research
Baumeister et al. (1994) present the findings of research (Wegner et al. (1990), Pennebaker & Chew (1985), Notarius et al (1982), Waide and Orne (1982)) that suggests that self-regulation, empirically defined as self-stopping, involves not only mental but physical exertion as well as evidenced by increased psychophysiological arousal. In interpreting the results of various research teams, Baumeister et al (1994) conclude that chronically weak willpower may be one of the three possible impediments to self-regulation. In particular, they write that “it is almost certainly true that some people have more self-discipline than others, are better able to control their actions and feelings, are more capable of resisting temptation” (p. 19). They further proceed to metaphorically liken self-regulatory capacity (and, by implication, willpower) to a muscle whose strength can be both weakened and strengthened over time by precedents of self-regulation or failures thereof. While the research on the physical exertion aspect of self-stopping/self-regulatory processes appears to be beyond methodological doubt, Baumeister’s conclusion that some people are “better able to control their actions and feelings” and are “more capable of resisting temptation” (Baumeister et al., 1994, p. 19) appears to be an unwarranted leap of logic. The self-stopping research cited by Baumeister et al. made no inter-group comparisons.
Consequently, while Baumeister et al. speculate that differences in will-power would account for the presumed differences in degree of control over actions and feelings, and resistance to temptations, this author believes that whatever interpersonal differences exist in terms of these parameters, they are strictly a function of differences in motivation and skill-power, not in will-power. In equating “capacity for self-regulation” with will-power, Baumeister et al. (1994, p. 19) appear to mistake a decision to self-regulate with the effectiveness of the execution of such a decision which is predicated on the motivation to self-regulate, self-regulation skill-level, and, at risk of being methodologically pedantic, on such additional impediments to effective freedom as psychoneuronal state and subject’s intellectual development (Lonergan).
With this in mind, to justify the conclusion by Baumeister et al. that some people have more will-power than others (not just better self-regulation skill than others), there would need to be a study protocol that finds interpersonal differences in self-stopping after partialing out or controlling for any differences in motivation to self-regulate, self-regulatory skill-level, intellectual development, and subjects’ psychoneuronal reactivity. To this author’s knowledge, no such research has been published to date.
Choice Awareness Training pursues the following three goals:
1) Development of a Strategic Awareness of Freedom to Change as evidenced by an appreciation of choice as a manifestation of fundamental, inevitable freedom that potentiates the change process.
Clients are expected to internalize the fact that they “cannot not choose,” that at any given time they have a choice and, consequently, hold the freedom to act as they choose, in accordance with their goals, and the responsibility for any subsequent benefits and costs of their choice.
2) Reformulation of the Perceived Chronicity of Addiction and Loss of Control as being a function of normal human functioning/habit formation/coping automatization.
Clients discard such self-deprecatory conceptions about their prior inability to change as “lacking will-power” or “being hooked,” and are helped to understand that while they “cannot not choose,” their freedom to change or to make choices can be limited by perfectly human proneness to mindless, stimulus-response bound, conditioned, auto-piloted and schematic functioning. Clients further appreciate that they can both proactively prevent and retroactively terminate auto-piloted, schematic functioning through the practice of choice awareness (overall message of this section is that “you cannot not choose unless you are on a mindless, thoughtless, conditioned, self-unaware autopilot”)
3) Development of a Tactical Awareness of Freedom to Change through: a) the facilitated, in-session, behaviorally-experiential practice of choice awareness, and b) a formulation of and implementation of a choice-awareness regimen (the overall message of this section is that the “daily choice awareness practice is key to executing a target change”).
Choice Awareness Training and Controlled Use
Choice Awareness Training can help save the lives of those who have an unshakable commitment to alcohol and/or drug use, be it for the reasons of their particular world-view, or anti-social personality orientation, or, more commonly, because of convincing personal data that evidenced their capacity for controlled use. Let’s face it: the current establishment of the substance use treatment industry in the United States (with the exception of such isolated controlled use advocates as Marlatt) has little, if anything, to offer to a substance user, who, even after a non-judgmental motivational enhancement, decides in favor of using. When it comes down to a client with a controlled use agenda, it should be appreciated that Choice Awareness training is a control-training system, and as such Choice Awareness Training can help translate the client’s intention for controlled use into a more attainable reality.
Arguments of Spiritual Determinism in the Context of Choice Awareness Training
The content of Choice Awareness Training is non-faith-based. Any religious or fatalistic remarks about pre-determined destiny, fate, or God’s will are to be respectfully re-directed. When such comments cannot be disregarded and require attention, clinicians are encouraged not to disagree but to reframe the notion of choice at a micro (moment-by-moment, day-to-day) level, not at a macro (cosmic/spiritual) level.
]]>