What lies within us are all the experiences, interactions, emotional styles, physicality, nervous system responses, generational memories, styles of behavior, values and beliefs of our primary caregivers – our families.

As more and more studies come forth indicating that addictive disease is a brain disease, that the chemistry of the person with the primary disease is not “normal” and often may have been abnormal even before the drug or alcohol use, one can begin to ask the question, “What’s going on?” What about the genetics? Is the fact that addiction occurring in multi-generational families is totally related to genes that are not functioning properly? If so, how does this start? Who is “patient zero”?

Let us begin to ask some new questions. What, for example, is the impact of trauma in a family on the genetic makeup of its members? Can it change in one or two generations? What is the impact on the central nervous system, the chemistry? Can it be possible that addiction in a family member can have a traumatic impact on other members of the family – the spouse, the parents and the children?

So here, I believe, is the main question. There are some of the most talented people one can imagine — intelligent, caring, compassionate — treating those afflicted with the primary disease of addiction. However, in not making treatment and therapy easily available to those people with the secondary impact of addiction, are we almost guaranteeing that this affliction will go on to the next generation?

Most practitioners who work with treatment and recovery have experienced the simple fact that the alcoholic/addict is much easier to convince to attend 12-step, self-help meetings — often daily — than to convince family members to attend 12-step, self-help meetings related to co-dependency, once a week.

This is the fiction that we live with: “I’m not the person with the problem. If he/she gets better, I’ll be fine. The problem with me is you.” Perhaps the biggest fiction is, “The children are not affected; they are fine, and there is no need to talk to them. We’ll tell them that daddy/mommy is away working or visiting”. Children always know what is happening in a family; what they are often unable to do is articulate their knowing. However, they know and they also know that it must be bad because no one is talking about it to them; no one is helping them to understand and find language to talk and be comforted. So they learn to comfort themselves, they learn to be afraid of things not spoken; they learn to become hyper-vigilant, super-quiet or super-good. They know. Emotionally, they know. Physiologically, they know. The next question is in what way this might affect not only their adult lives, but also the lives of their children.

Psychological stress (trauma) is a type of damage to the psyche that occurs as a result of a traumatic event or series of events. The heightened arousal of a child’s primary caregiver signals danger to the child. Without knowing what is wrong, they nevertheless begin to physiologically imitate the nervous system responses of their parents.

With increasing levels of stress (or trauma) we begin to see some signs of insecure attachment. Secure attachment is a form of affect regulation. Damage may involve physical changes inside the brain and to brain chemistry, which damage the person’s ability to adequately cope with stress.

With exposure to trauma as a child, a person may re-experience the trauma and try to avoid trauma reminders. Often, the person is completely unaware of what is happening and begins to engage in disruptive or self-destructive coping mechanisms.

The brain uses epinephrine to execute autonomic and neuroendocrine responses, serving as a global alarm system. The autonomic nervous system provides the rapid response to stress known as the fight-or-flight response. The interactions between the mental state, nervous and immune systems can impair developmental growth in children, which later alters their perceptions of, and reactions to, stress.

The trauma associated with addiction in a family is similar to a bomb going off in a room. Everyone is hit, but the family identifies only one member as the problem. Whether that one person recovers or does not recover, the family still has the autonomic trauma responses.
Since the other co-dependent family members believe the only problem is the identified “problem one”, no one seeks help. Each member in the family goes on to create their own families based on unhealed trauma.

“Childhood adversity, stemming from abuse, parental loss, witnessing of domestic violence or household dysfunction is a major cause of poor mental and physical health. One major consequence of early adversity is a markedly increased risk for substance use, abuse, and dependence“ (Chapman, ET. Al. 2004, Dube et al, 2003; Felitti, 2002).

From a Harvard Medical School study, we now have new information about stress on children.
“Under non-addictive states, the nucleus acumbens receives input from a number of brain regions, including the hippocampus and the prefrontal cortex. These inputs serve to modulate the response of the nucleus accumbens in a manner that is controlled, flexible, and contextually relevant. Following stress exposure, this system is less well modulated. Hippocampal gating of cortical inputs is reduced. Moreover, the prefrontal cortex inputs respond more selectively to drug-conditioned cues which is a vital critical factor leading to relapse.” 1

This study goes on to explain that with this loss of flexibility, the ability to experience stress relief easily, access pleasure and the simple joy of the world around us is significantly reduced… until a person with this brain state encounters a drug, such as alcohol, or other drugs (including some medication). At this point, the individual experiences relief, euphoria and relaxation, never before realized. This becomes the euphoric recall that presents itself in times of real or imagined stress. The negative consequences after the drug use are not stored in the same manner.

When we look at family members who have not developed the primary addiction, we frequently see patterns of behavior intended to soothe, relax and give pleasure. These behaviors have a similar impact as drugs to the addict. They work for a short while then need to be repeated….over and over and over. These behaviors include: shopping beyond one’s means daily or several times a week; Internet addiction; gambling; sexual compulsion; control issues; work that excludes balance; serial monogamy – always needing new relationships and the chemistry that goes with them; and food addiction of all kinds, such as compulsive overeating to starving oneself to binging and purging.

A study unrelated to addiction but of major importance was first introduced by Dr. Lars Olov Bygren, a preventive-health specialist who is now at the prestigious Karolinska Institute in Stockholm. He is a pioneer in the study of epigenetics, which is looking at how one’s environment and choices can influence your genetic code and that of your children – not over several generations, but immediately. We have always believed that the choices and circumstances of our lives might negatively impact our brains or bodies, but wouldn’t change our genes, our DNA . Now it appears that “stressors can activate epigenetic marks, modifying histones or adding methyl groups to DNA strands. These changes can turn genes on or off and may affect what gets passed down to your offspring. If you overstimulate genes for, say, obesity or a shortened life span, your kids can inherit these overactivated sequences. That could mean a lifetime of battling unfavorable gene expression”. 2

What can we do to begin to affect a change and not simply treat symptoms? Families need help as intensively as does the family member with the primary disease. Children need to be involved. Children are always involved in the problem; we need to involve them in the solutions.

Open up conversations appropriate to their age level and begin to teach them ways to become healthy, relieve stress, talk about whatever is bothering them, listen to what they are saying carefully and respond. The Betty Ford Center in California has a program, at an extremely reasonable rate, for children and a stand-alone program for co-dependents. Neither of these programs requires that one have a family member in treatment. There may be other similar programs around the country as well.

We need to focus and develop mechanisms to help families over a period of time – not just a week or weekend, but extended therapeutic intervention and training. If more interventionists included intensive family work – education; skills training; directing to treatment when possible; Al-anon and Alateen, over a period of months, we might begin to make some changes to this multi-generational affliction. Some have started doing this work – more is necessary.

1 From Neuroscience and Biobehavioral Reviews, a review of “Desperately driven and no brakes: Developmental stress exposure and subsequent risk for substance abuse”. By Susan L. Andersen and Martin H. Teicher, from a study of Developmental Biopsychiatry Research Program, McLean Hospital/Harvard Medical School, Belmont, MA

2 From “Why Your DNA Isn’t Your Destiny”, Time magazine, January 2010, by John Cloud, Vol. 175, No. 2

When we hear this word predisposition, what do we think of first? The answer: genes. That is, talk of genetic predisposition fills the dialogue space around discovering the biological markers for why people develop an addictive disorder. And while there are definitely genetic predispositions, what I am going to shed light on here are fundamental brain predispositions that make one vulnerable to develop irrational behavior around a substance. To clarify, here is what I am not talking about when I allude to brain dispositions:

• Something fixable by cognitive behavioral therapy
• Psychopathology
• Mental/Mind-related constructs

What I am alluding to is a framework of wiring default patterns that structure thinking itself; we all have it in us and it affects our decision making. It turns out this is cutting-edge knowledge. Did you know that 80 percent of the knowledge about the brain discovered before 1995 has now been proven false? That’s how new of a frontier this information is, and with that newness comes the need to reeducate people about the brain from the ground floor up, so we can better discern addiction-based oddities of behavior from the neuro-irrationalities that are inherent in all of us.

Learning some characteristics of the normal irrational brain will better inform us all – addicts and non-addicts alike – about human behavior.

• The brain makes decisions through emotions not through rational thought. The notion that the perfect normal brain is rational is a myth. Sorry, Aristotle. Neuroscientist researcher Antonio Damasio proved this by taking people who lost the ability to have emotions and put them through regular, everyday decision-making tasks. They were not even able to initiate the task. Many people were left staring at a toothbrush with toothpaste on it forever. Emotions matter, and the trick is to harness them for a purposed direction.
• The brain does not multitask. You hear many traumatic brain injury patients get frustrated in their cognitive rehabilitation because they cannot quite “get back to normal.” In my coaching of these individuals, I have always found it hard to re-teach them what are recycled old beliefs that seemingly pull them toward a faulty vision of renewal, and what is the truth. Can’t blame them, for non-brain-injured people are deluded as well when it comes to the notion that we will all get more done in this productivity-centered world if we can figure out how to do more things at the same time. This is a myth. There is a larger hit to consciousness than we think when we attempt to do this; we perceptively miss a lot more than we realize.
• The brain is a pattern-maker, not a truth-maker. The brain seeks what is known and makes variants of that seem like innovative progress to us all. It is why so few of us proceed into some panacea of enlightenment in this world. The brain doesn’t want to take the trip with us, but it wants to tell you its interested and will, as soon as it can, find its airline ticket. But it never does. This is a key point in recovery, for being fully recovered may mean more to reduce one’s level of illusions and mental addictions by being more aware, not by being removed from them completely.

Together these three brain points are essential for addicts and their caregivers to keep in mind, so as to better benchmark reality and progress. It may be a relief to the addict to hear that the true goal is not to eradicate the addiction, but rather the meta-addiction underneath that is driving a purely rational life after recovery. Good luck. Non-addicts haven’t found that place either.

When the National Institute on Drug Abuse (NIDA) recently came out with its report, “NIDA InfoFacts: Treatment Approaches for Drug Addiction,” it provided a helpful synopsis in a meta-analysis sort of way on the key principles of effective treatment. Being the neuroscience-oriented change agent I am, who has seen the practice of psychotherapy enhanced by understanding the secret world of the brain, I thought it would be helpful to view these classic research findings from the lens of your brain; to see if “it” sees things the same way we as outsiders believe behavior change works. Let’s take a look at a sample of these points:

1.    Addiction is a complex but treatable disease that affects brain function and behavior.

Brain’s Response: Neuroscience has shown a less-than-perfect linear, cause-and-effect relationship here; it has also shown that the brain is affecting the addictive response and manifestation. It’s a fine line between a true addictive disorder and the fundamental “wishing that reality was something else than it is” response that colors most of our everyday decision making.

2.    No single treatment approach is appropriate for everyone.

Brain’s Response: Because the brain is wired to “feel right” and not necessarily to be effective, we all have unique ways of reducing the anxiety and dissonance we feel of the “one approach” coming at us. What remains unclear is whether it is another approach being more effective or our defenses being less effective in rationalizing the benefits away.

3.   Treatment needs to be readily available.

Brain’s Response: Research on neuroplasticity and deliberate practice has shown us that it takes a lot more concerted effort and repetition to change behavior than we think. Being “readily available” allows the brain to practice counter behaviors at an exponentially higher level, so as to rewire neural networks.

4.    Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.

Brain’s Response: Research on why the best cognitive rehabilitation strategies work on the brain after a certain traumatic event seems to convey the importance of a cross training effect on boosting rewiring potentials. That is, working all the lobes, not just where the supposed injury occurred. Such is potentially the case with why a multidisciplinary approach works with addiction; from a neuroplasticity angle, you increase the chances of success by enlisting the support on non-injured, healthy and addiction-busting neural networks.

5.    Remaining in treatment for an adequate period of time is critical.

Brain’s Response: Though time is indeed correlated to treatment success, I am curious what the exact correlation coefficient would be. Could it be a cognitive bias of ours that makes us think this is literally true, but in reality the data could be something else? Do we not have examples of people who show insight potential around behavior change across the whole spectrum, from one intervention to 10 times in rehab? The brain is an inadequate distinguisher between things that make sense and things that are literally true. My hunch on this one is that in actuality, the correlation is mediocre at best; that time in treatment is a powerful variable when supported by many moderating variables (family support, level of pain experienced per intervention, accountability factors and so on).

6.    Treatment does not need to be voluntary to be effective.

Brain’s response: Sure, on one level this is true. Behavioral compliance can come from both an involuntary or voluntary event. However, because the brain makes one-size-fits-all emotional responses, it gets tricky to discern from words used — and even behavioral evidence — the committed from the compliant individual. The brain is masterful on reading the environmental needs around it and assessing the patterns to learn what it needs to do to fit. So arguably, from a brain training side, this statement is correct. The brain can learn from the environment thrown on it or co-created. The problem comes when “what gets you here doesn’t get you there” and the tipping point of life kicks in and more is needed than just compliance.

As you can see, when we look at these common assertions of treatment efficacy with a more discerning light of neuroscience, we can’t help but question our thinking about our thinking. Is this troublesome? I think not. Ironically, perhaps it is this meta-cognitive stance that is most beneficial in building humility-based practitioners who use neuroscience as a knowledge-helper and not a rule-generator.

In this thought-provoking series, I will share the stuff of addiction that is in between the lines — the afterhours thoughts, if you will, the bubbles above our heads. Not that training, education and all sorts of counseling are not helpful. Of course they are. But in the understanding of addiction, we forget that for the fullest level of knowledge around anything, we must know what is and what is not. The latter is especially tricky to arrive at when the brain is involved, for it is a master of disguise, always rewiring itself to feel right, to be ineffective, to reduce dissonance and to avoid the truth. We should be most skeptical of our thinking especially — and ironically — when we choose to move beyond these illusions through conscious awareness or, in other words, when we choose treatment.

So how does one tackle this elusive, slippery slope of neuroscience mechanisms when we want to live a life of freedom and truth, and eradicate the chains of addiction? I would like to share some thinking guidelines that we should keep handy and use wisely while reviewing brain myths — untruths that sadly have been popularized by culture as being gospel. We have become a society intellectually dumbed down, one where correlations are confused for causality, and where things that make sense are called true. This is tricky enough in the absence of addiction. In my addictions’ coaching work, I tell clients who are working through their addictions that they have to step up their critical thinking immune systems even more so than others.

Therefore, in the spirit of Einstein, who said, “No problem can ever be solved from the same level of consciousness that created it,” the following are some guidelines that may help take those living with addiction to this other, higher level of thinking. These overarching natural laws of thinking should be at hand while digesting the brain myths I will bust.

• Pause, then pause again. And when you think you know what “it” is talking about, pause one more time. The brain is quick to fill in gaps of knowing, and without countering this with an extraordinary amount of intention, we are left not knowing really how we know something.
• Beware of spiritual narcissism. This comes from over-identifying incidences that prove that you are doing well or under-identifying incidences that are blind spots for you.
• Know the difference between transactional and transformational goals. The brain loves itself and has a tendency to seek ideals above and beyond reality — no matter how irrational these ideals might be. There are certain things in life that can not be broken down into a to-do list. The brain will tell you, “No way!” and put you on a nice, neat journey in that vein.
• Embrace dialectics. Just a fancy phrase for two opposites coming together to make a more meaningful whole. The ability to do this is key in digesting and working through building an addiction-free life that calls B.S. on the brain. Two examples of dialectics are:

Truths and wrongs that are opposite, yet together make for the only path of higher learning.

Pain gives life more meaning, and in that gives many people joy.

• Think about your thinking. Know your first-draft story about yourself, your life, your partner and your decisions in general. Chances are, it is wrought with half-truths that make sense to some part of your brain, but is like an MC Escher painting — if you look at it long enough, another image emerges, releasing you from what you thought was true.

Still, I try. And whenever I read this research, I never fail to notice two things.

First, how well it speaks to the experience of addiction; how it explains so many of the baffling and frustrating behaviors of pre-recovery addicted people. Why do addicts continue to use despite the threat of prison? There’s a reason for that. Why do addicts put drugs and alcohol above the people they love? There’s an explanation for that one, too. In fact it’s all there for the reading. Yes, there are many mysteries still to be untangled, but as brain disorders go, the pathophysiology of addiction is pretty well fleshed out.

The second thing that strikes me is that even though this research has been steadily accumulating over the last twenty years, there is still no good way to get it to the people who need it. To the people who wake up in detox, wondering how they got there, asking themselves why they act in ways they do not value. Or to the family,  secure in the belief that their child does not use drugs, who gets a call from the school announcing their child has been suspended because marijuana was found in his or her locker. This astounding neuroscience should not pile up on the dusty shelves of medical libraries. It should be delivered swiftly to the people who need it most, and to whom it most belongs, so that families can feel some hope, and patients can feel less ashamed.

Yet there have only been two major media projects in the last ten years on the subject of addiction: the PBS “Close to Home” series with Bill Moyers, and the HBO video and companion book “Addiction,” made in collaboration with the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, and the Robert Wood Johnson foundation.

These are fine, well-made, incalculably beneficial programs. They have given millions of people a better understanding of addiction. But, “Close to Home” was made in 1997, and the HBO project filmed in 2006. Their total length combined is less than ten hours. They reflect certain perspectives about addiction. Neither addresses in detail what I maintain is the most important question about addiction, the one on which the entire credibility of addiction medicine hinges: is it really a disease?

These programs share one other problem: they are not fun to watch. They are grim. They are serious. That makes sense; addiction is a serious matter. But when I read the research on addiction, the message I come away with is that the news is pretty good. Addicts do terrible things, yes: they lie, they cheat, they steal. But this research indicates quite clearly that addicts are not intrinsically liars, cheats, and thieves. There are very good reasons for their behavior. And, people get sober all the time – more now than ever before. More people are entering treatment earlier; they’re keeping their jobs and families. More young people are getting sober and avoiding a host of health problems. There are now some good medications to help them get a foothold in sobriety, and more are on the way. The future looks bright for people seeking recovery.

Where’s that message?

Instead of programs building on the fine work of PBS and HBO, I see the proliferation of cable television shows about addiction that focus more on the symptoms of addiction than the reality of recovery. They depict the rights of addicts as patients routinely violated in the service of coerced treatment. They use self-serious cinematographic techniques such as high-grain film and slow shutter speeds that convey more bathos than pathos. And they take an almost prurient interest in showing intravenous drug use.

These programs worry me, because they show addicts at their worst, with very little explanation of the brain mechanisms behind these behaviors. Yes, the symptoms of addiction are graphic, but do the viewers really understand what they’re looking at? Do they know that the hyperprioritization of drugs because of their effect on the dopamine system explains why addicts keep on using despite terrible consequences? Is it explained that relapse is a largely unconscious process, or that addiction is a disorder of the brain’s pleasure system that damages its decision-making capacity? I’ll state it plainly: do these programs cash in on the suffering of addicts for entertainment value?

I confess that I don’t know if these programs are exploitive, or whether they increase or decrease stigma, or if they bring more or fewer people to treatment. All I know is that I have always wanted to see a different kind of media project about addiction. Something positive, even upbeat, that portrays recovery as much as it does addiction. I yearn for high-definition, broadcast-quality, beautifully filmed programs that convey the wondrous neuroscience of addiction, that lay out an argument for why it can be rightly considered a disease.  Programs that paint that bright future. I dream of a renaissance of expression – films, music, art, theater, poetry and prose that give voice to the experience of addiction and recovery.

Most of all I would like to see a simple, sixty-minute video that a family can pop in their DVD player, or a patient can watch at his or her treatment center, to get a solid understanding of the research behind addiction, to see that there’s more to addictive behavior than just bad people, making bad choices, behaving badly. It would show no people in gutters. No shots of intravenous drug use, and at the end of that video the dignity of the addict would remain intact.

For these last ten years, as I sit out practicing medicine waiting for my recovery to solidify, I have given lectures on addiction at a number of different treatment centers. I try to bring a positive message when I explain this exciting new picture of addiction as a brain disease to patients and their families. I focus on that bright future. I never fail to mention that the news about addiction is good, and that most people who stick with recovery eventually get it.

Not surprisingly, the lectures have been well received. And I’ve often been asked, “Do you have a DVD of that lecture?” So far the answer has been “no,” for several reasons.

One is that I don’t want to be the next doctor trying to get on T.V.  I’m not sure how that serves the mission of carrying the message of recovery.

Second, although I dream of that perfect, sixty-minute video on addiction, I’m not sure it can be done. Lecturing is easy. Filmmaking is hard – and I know nothing about it. It would be a very tough project to pull off well. It would require a level of creativity, talent and production quality that I’m not sure I have, or have access to. If the project worked, it might help a lot of people. But if it came off badly at best it would look stupid, at worst it would be little more than an exercise in narcissism. The project frightens me.

A film of a lecture would be mind-numbing, and even if it could cover all the neuroscience of addiction it would last hours. This video could be no more than 60 minutes. To counter the tendency toward melodrama, it would have to be visually spectacular – eye-candy even, filmed in high-definition, using animation, beautiful locations and clever visual images to propel the material. It should look good enough to captivate the viewer even with the sound off. Dialogue must be tight. There will be no time to explain complex neuroscientific concepts. The first rule of film is “show, don’t tell.”

But how to do it? How do you convey complex neuroscientific concepts of addiction quickly so they stick in the viewer’s mind?

There is also the problem of funding – I estimated a project like this would cost between seventy-five and one hundred thousand dollars. Any less and the production quality would suffer so much the whole project would fall flat. Currently, good animation costs $1,000 a second. Where would I get that kind of money?

And talent: Do we need a stage? Actors? How about music? Where am I going to find a good cinematographer – a high-definition cinematographer?

For five years, these problems floated around in my head with no solution. It looked like this DVD would never be more than a fantasy.

Then, quite unrelated, I went on a trip to one of my favorite places on Earth. The first time I drove through Utah I immediately fell in love with it, and I knew that someday I would make this state my home.

Nothing is like Utah. It is totally unique. Colorado is nice, but it can look like Idaho. Areas of Oregon resemble California. But nothing looks like Utah, except Utah.

One day I was hiking near Moab and I found myself ruminating on my addiction video problem, as I was apt to do in my quiet moments alone.

Something occurred to me: like Utah, nothing is quite like the brain either.

One of the first things you learn in medical school about the brain is its feature of localization. Different areas of the brain handle different functions. And I realized that I could come up with a different place in Utah that reminded me of each different part of the brain involved in addiction.

When I thought of the frontal cortex, proud and rational, I thought of the majestic white stone monuments of Zion National Park.

When I thought of the midbrain, deep and spooky, I thought of Bryce Canyon, or the slot canyons in the Vermillion Cliffs wilderness.

The fiercely strong neural pathways of addiction reminded me of the Colorado River carving out the Canyonlands.

Hypofrontality – Monument Valley.

Anhedonia – the Bonneville Salt Flats.

This was fun.  And then, suddenly, I knew how to portray addiction: I could take a driving tour around Utah and describe addiction using its different and varied landscapes.

Over the next two years this idea began to take shape. There were huge gaps in the storyline and problems so seemingly insurmountable I had to block them out of my mind to make any progress.

In June 2008, I drove from one end of the state to the other, scouting locations. I stayed in cheap motels in tiny towns with names like Kanab and Loa. Each night, I’d spread a National Geographic map of Utah out on the bed to plot the next day’s exploration.

It was during that week that it all came together. Over the next month, I banged out the screenplay – the first version was bound with brass brads just like they do in “the business” with a blue cardstock cover. There would eventually be seven revisions and seven colored covers: blue, yellow, red, green, gray, lime and fuchsia.

Proud though I was, the project was barely off the ground. So many problems loomed, chief among them the problem of finding a cinematographer. This project had to really pop off the screen. So I felt it had to be filmed in HD. I knew nothing about HD. Or SD, or VD, or any kind of D.

Then my coworker, Jim, who eventually became the producer of the DVD, approached me and said, “Hey, there’s this guy who lives a couple doors down from me who does a lot of video work. We should go over and visit him.”

I rolled my eyes. C’mon, I thought, I need a serious cinematographer – not the guy two doors down! We’re going to have to go to LA or someplace to find someone with that kind of talent, not Utah.

But to be polite, I agreed to go see Norm.

Norm, it just so happens, was an HD cinematographer for (guess who?) National Geographic. His basement was a theater with a full editing studio: two quad-core Macintosh computers, stacks of terabyte hard drives, and the latest version of the same timeline editing software they use at Universal and Paramount … and PBS and HBO. He played me some of his work, and there it was on the screen: the breathtaking, eye-popping, sharp-as-a-tack, 1080p eye-candy of high definition video. I found him – the cinematographer from heaven. Or rather Jim did, two doors down. That was the moment that this project went from a pipe dream to a distant but possible reality.

The next piece of the puzzle was, again, solved by Jim: funding.

He drove, he flew, he called, he shook hands and solicited the people he knew were in a position to support our project. They were polite, but most declined. Then a few more companies helped us. Not all of them wanted to be named, but they helped us just the same. We were off the ground.

Norm and I could now focus on the creative end of the project. We still faced huge conceptual hurdles. There are as many as five theories that are currently in use in neuroscience to describe addiction, and they each have a different explanation. Some say it’s dopamine. Others claim it’s genetics. Then there’s stress and memory to keep in mind, too. Don’t forget impaired judgment. To describe them all would never work – the video would be too heavy. At the same time, we couldn’t leave any one of them out.

One night, I was sitting at the sober living house we run in Sandy, watching a movie with the residents. One of them was eating Oreo cookies, addict-style: stacking two on top of each other. And then it hit me: the theories don’t conflict if you stack them on top of each other.

Addiction is a disorder of pleasure, yes, and of genes, and of memory, and stress, and finally, in the frontal cortex, choice. Each theory describes what’s going wrong at each level of brain processing as the brain tries to generate a pleasurable experience … and fails.

So pleasure is a construct – different areas of brain processing woven together into a unified perception. Except in addiction, that process breaks down, and pleasure becomes unwoven.

Okay, how to show that? One Sunday I saw a Russian Nesting Doll in a shop window in Park City and thought, I wonder if I can make a nesting doll of something pleasurable, like … a cookie?

My call to St. Petersburg was a bit strange. “You want picture of cookie? On doll?” the voice said in a thick Russian accent.

“Yes, please.”

It arrived three weeks later – perfect.

Dopamine pathways. Glutamate pathways. How to keep them straight? By throwing green and red garden hoses up to the cortex (Zion National Park) and down to the midbrain (the Paria River slot canyon). Green water flowing out of one hose stood for Dopamine (green for Go!). Red water for Glutamate (red for Stop!).

How to show the Dopamine Hypothesis – that what all addictive drugs and behaviors have in common is their ability to release dopamine, and they can, therefore, easily be substituted to produce cross-addiction? My mother, avid fly-fisherwoman that she is, sent me a Columbian T-shirt for my birthday. On the back was a spoof on the Periodic Table of the Elements from Chemistry class, only instead of the elements there were different flies and bait. Hey, wait a minute, I thought. How about a Periodic Table of the Intoxicants?

Five trips to Southern Utah.

Six thousand miles of driving.

Fourteen hours of tape.

Two weeks of solid, fourteen hour days of editing.

Sixty thousand dollars.

And now, as it reaches its final days of post-production, I can only wonder: Does it work? Is it hopelessly corny? Or worse, narcissistic?

I’ll leave it for you to decide.

The premiere is November 6th in Newport Beach.

With such a complex etiology it is clear that treatment needs to address multiple issues for it to be successful.  In a recent article we have presented the Moonview Model of treatment (http://moonviewsanctuary.com/research/multimodality-alcohol-treatment.pdf).  While not exclusively used for addiction, it is particularly suited to address this complex condition.  The model incorporates a team of practitioners each with a different specialty, working together on a single individual.  By integrating different modalities and perspectives this approach facilitates multiple treatment tracks addressing mind, body and spirit.  In this article I’d like to discuss a very specific integration of a subset of these approaches that I personally utilize that works well with the addict population.

Previously I have described a model for early childhood development that I referred to as “Primitive Gestalts” (PG) (http://moonviewsanctuary.com/research/primitive-gestalts.pdf).  A PG is a hypothetical construct describing how the brain develops in response to its environment.  It is the result of a learning process in which neural networks are formed, or imprinted, based on reinforcement history.  Because of the overwhelming importance of the child’s primary caregiver(s) each person’s PG will be primarily in response to these relationships.  Our self-view or image, and world-view are direct reflections of these primary relationships, and represented in the PG.

As a result of the neurodevelomental process, PG patterns become fixed and self reinforcing.  In fact, I suggest that a parcillation process takes place in which non-reinforced neural networks are eliminated in a “survival of the fittest” process.  The result is a brain that has an ongoing selective perception of itself and the world based on childhood reinforcement patterns.   Thus, one selectively receives or accepts those aspects of one’s environmental interactions that support the PG and reject or explain away conflicting information.  A good example of this is how negative self images are maintained by the person only noticing and dwelling on their mistakes – even the 10 percent wrong with a 90 percent result – while thinking that their success was lucky, coincidence or that anyone could have done it.

This model suggests that PGs exert a “gravitational pull” such that even after a series of psychological successes a person can easily be pulled back into the orbit of the PG.  Said in the language of complexity theory, the PG is like an attractor state, making it very difficult for permanent change to occur.  Now, I’m suggesting that this is true for everyone trying to make changes, but that for people dealing with substance abuse the task is even more formidable due to the neurological impairment, cognitive and emotional deficits resulting from the addiction.

In my own work I utilize three primary modalities in treating substance abuse as well as other issues:  Neurofeedback, Gestalt Therapy and Shamanic practices.  While these appear to be very different, and they are, they allow me to work closer to a person’s core, offering a greater opportunity for creating a shift in their PG.

NEUROFEEDBACK

As noted in my concept of Primitive Gestalts, just as our behavior settles into fixed patterns, this can also be said of the functioning of our brains.  The electroencephalogram (EEG) is a primary way of referencing the functioning of the brain.  Neurofeedback is the process of monitoring the EEG at a specific scalp location, and then filtering the EEG, which is a complex mix of different brain wave frequencies primarily from one cycle per second to approximately 40 cps, and presenting to the client feedback or information about their frequency patterns that allows the brain to self regulate or to shift into a particular attentional state.

What do I mean by “self-regulate”?  There are many ways that the brain may not be functioning optimally.  If it is producing too much slow wave activity – in other words, brain waves that are lower than 8 or even 10 cps –we can say that the brain, at that location, is under activated.  This is typically found, for example, with people with Attention Deficit Disorder (ADD) and the result is a brain that has difficulty staying focused.  It appears that over a third of substance abusers also experience ADD.   If the brain is producing too much very fast brain wave activity, say above 22 cps, the result might be anxiety, obsessive behavior, worry and tension.  In other words the brain is over activated.  We know, in fact, that alcoholics have more activity between 22 and 28 cps than non alcoholic subjects.

Thus, neurofeedback is a method for feeding back information to a client about their EEG by letting them know when a change in the right direction occurs, so their brain can learn to more readily go into this optimal pattern.  On one level this process can help the brain normalize, or adjust into more normal patterns.  On another level, this process, by giving a person a way of shifting their EEG, tends to make the brain more flexible and more capable of change.

In a previous publication I have described additional ways that Neurofeedback can facilitate healing in addicts.  These include an enhanced ability to turn down the activation of the nervous system and go to a place of calmness, and even deeper, where traumas can be healed.  Related to this is becoming more comfortable in one’s own body, something that is very difficult for many addicts.  This research demonstrating the effectiveness of Neurofeedback was published in the American Journal of Drug and Alcohol Abuse and can be found on the Moonview website (http://moonviewsanctuary.com/research/eeg-biofeedback-effects-on-substance-abusing-population.pdf).

GESTALT THERAPY

If we were to analyze our process before any action, or if we were to tape this process and then play it back in slow motion, we would notice that somewhere inside ourselves a voice speaks up telling us what to do.  Or after a behavior, that voice tells us what we did right or wrong and how we should feel.  I would suggest that this is the voice of our PG.  Some may refer to this voice as one’s internal parent.  In Gestalt Therapy it’s sometimes referred to as the “Top dog”.

This voice is very powerful and dominant and in most addicts typically presents continuous negative messages, either about themselves or about aspects of the environment.  Again, we can see that this loud voice serves to maintain the PG, or existing beliefs.  When undergoing a process of healing, change or healthy development, it’s important to find a way to hear a second voice.  This voice typically starts out very meekly, and will get drowned out or overwhelmed by the voice of the PG.

The Gestalt therapeutic technique of separating these two voices and engaging them in a dialogue, for the first time gives the voice of change, the voice wanting things to be different, the light of day.  The dialogue encourages the new voice to be heard, and to begin speaking up.  It also serves as a rehearsal process giving this new found voice an opportunity to practice responding to the arguments of the PG.

Little by little, the new voice gains strength in standing up to the PG, in recognizing the toxicity of the PG and of its false arguments and dead-end reasoning.  As the therapist, I aid in this process by coaching the new voice; disputing the inappropriate cognitive map of the PG, addressing the emotional needs and feelings of the new voice and finding self-acceptance.  The goal is for this new voice to ultimately become more dominant than the PG.  This is the process of shifting from a brain dominated by its PG, to the development of a new and Healthy Gestalt (HG).  Thus, there is a shifting of the center of gravity to the new pattern: a new attractor state.

SHAMANIC APPROACHES

Most addicts feel a sense of disconnection as well as the loss of a spiritual foundation.  Some refer to the process of “soul loss” to describe how deeply this disconnection goes.  It doesn’t matter whether we say that one’s soul, or part of one’s soul is lost during a trauma, or we refer to the psychological process of dissociation, disconnecting or numbing in order to escape emotional pain.  Whether we consider “soul loss” metaphorically or in actuality, the result is the same.  It results in a loss of personal power or self-efficacy leaving an addict helpless to participate in their own healing.

The Gestalt approach through the emphasis on the “I-thou” relationship begins to address this disconnect.  Shamanic beliefs and practices more fully engage the person with the notion of the interconnectedness of everything.  In addition, its belief in a state of non ordinary reality, a spiritual realm and the powerful healing potential of both, helps reintroduce the client to their spiritual self.

Using Shamanic techniques I honor and “invite in” the ancestral spirits and invoke their concerns, love and healing powers to impact the participants within a ritual gathering.  Rituals typically incorporate some form of ceremony that evokes a sense of anticipation and a different or altered emotional or attentional state.  I facilitate this typically with the use of drumming and music.  From psychological research we know that the more intense and energized you can make an experience, the greater the likelihood of its long term impact through enhanced focus and learning.  By creating an environment in which a person is fully immersed in an otherworldly, or altered state experience, the more it’s able to impact and shift the PGs described above and the greater the ability for creating a sense of connection – with the other participants and with something beyond what is concrete and located within the space.

Another part of the Shamanic approach is the telling of stories.  Most ancient traditions highly value their stories.  We can think of our PGs as our original story.  It’s this primitive story that we hold so dear, that we have such loyalty to and that we keep telling ourselves that maintains the old maladaptive patterns.  Shamanic practices allow for the presentation of stories that, through metaphor, begin to establish new patterns.  Sometimes it is a story that will resonate with the client.  At other times it is a story that I know will trigger other reactions, such as disgust.  Shamanic practice after all, is frequently about shaking up the client’s belief system.

However you conceptualize what happens during a Shamanic ritual, the energy and the power of the experience is palpable.  The creation of this “cauldron” peels away layers of defense and serves as a catalyst for the healing process.  It is also the ultimate “holistic” healing as it takes into account all aspects of an individual.  When this is integrated with the Neurofeedback to disrupt old patterns and encourage new neuronal networks, and Gestalt therapeutic approaches to help identify, develop and strengthen the voice of a new pattern, the result is powerful.

For the purpose of the online CE Course, the article objectives are:

• Understand how neurofeedback works.
• How Gestalt techniques are used with an addict.
• Identify two approaches used within the Shamanic session.

The focus of this article is to explore and introduce recent work in the field of addiction recovery as it relates to the neuro-cognitive dimension. This article is the first of a series of articles focused on identifying and then developing a treatment program for addiction based disorders. Part of the intent of this article is to help those new to the field of substance abuse to understand that individuals suffering from Substance Abuse Disorder (SUD) must be both viewed and treated from a Biopsychosocial model of healing. This requires us to consider not only the personality traits and behaviors of the individual, but also to treat many of the underlying physical causes, which are driving the addictive cycle.

The author’s experience, within the Crossroads Institute Centers, has shown that by including traditional based treatment programs in combination with body health recovery and a valid brain-retraining program using the latest neuro-imaging studies, can help overcome measurable losses of cognitive functional ability, due to substance use disorder. (Gunkelman, Cripe, 2008) We’ve further found this approach gives these individuals the ability to not only abstain, but also to reintegrate back into their society in a manner of their choosing.

Today, substance use disorder (SUD) still remains one of the major social issues which plague our culture.  It affects all walks of life (Mathias R., 2008).  There are many programs that attempt to address this issue; most focus on abstaining from the substance of choice. Some more modern programs attempt to teach both interpersonal and vocational skills in the hope of preventing substance abusers from relapsing. The final goal is reintegration back into normal life.

Recent findings in brain research indicate that there is a neuro-cognitive component, with an underlying brain mechanism associated with SUD (Mathias, 2008; Fahrion, 1992). These findings also indicate that a measurable loss in cognitive function (or abilities to think) occurs as a result of SUD (Mathias, 2008; Fahrion, 1992). These findings make SUD both biologically based and behaviorally based, which requires us to rethink our treatment programs.

Addiction starts in the brain not the behavior. Most people who enter addiction treatment programs started their addictions as adolescents. Current research on brain development, in typically developing humans, indicates that the full adult maturation process is not complete until after 25 years of age.  When drugs and alcohol are introduced during this maturation process, this will have an effect on the brain’s development and may explain why many individuals suffering from SUD have common issues in their cognitive function.

The interference in developmental changes offers a physiological explanation for why addicts act so impulsively, and have difficulty in recognizing that actions have consequences.  For many, this impacts their level of social maturation. Recent neuro-imaging techniques using both fMRI and fqEEG indicate a specific area of the brain, called the nucleus accumbens, processes pleasure/rewards signals. This area is supposed to mature before the brain’s prefrontal cortex, which is located behind the forehead. This maturing process isn’t complete until somewhere in the late twenties. The prefrontal cortex is involved in executive function, memory, planning, and making decisions.

Through recent neuro-imaging studies, it appears this is one of the areas that is adversely affected by SUD. It seems to be one of the areas in which the addicted brain is not able to process information effectively, and which is necessary to make responsible decisions in life. By using a neuro-imaging technique called fqEEG, a clinician is able to gain deeper insight into the addicted brain. Of equal importance, if proper biological treatment, based on identified brain dysfunction, is included in the treatment, these dysfunctions are able to be retrained and help reduce if not eliminate some of the addictive drives that are brain-based (Gunkelman & Cripe, 2008).

Brain recovery programs for addiction have a long history. Most programs stem from two therapeutic traditions: Self-help groups (mutual aid), first established in the 1840s and professional medical specialties with roots going back to the postbellum “inebriate” asylums. (Hertzberg, D., b2002) Even though individuals attending treatment centers report short term success for SUD, long term success rates for these individuals is poor (Mark, 2005; Fahrion, 1992) if the treatment is focused mainly on a psychosocial model of recovery. These programs generally focus on changing a person’s lifestyle and habits to eliminate the SUD lifestyle (Fahrion, 1992; Fagan, 1994). Even with this effort there has been little improvement in the relapse success rate. Studied relapse rates remain high, typically over 70% (Fahrion, 1992; Mark, 2005; Fagan, 1994). Gossop, Stewart, Browne and Marsden (Gossop, 2002) reported 60% of heroin addicts relapsed one year following addiction treatment. Studies which have focused on the individuals who are successful with these programs have isolated a common variable. That variable seems to be a person’s sense of self efficacy or the belief that they can overcome and break the addiction cycle. (Mark, 2005)

To help address this added component, there have been several major studies ranging from cognitive behavioral therapies (CBT) to EEG biofeedback, which have shown some improvement over the traditional treatment center approach. Programs, which include a form of EEG biofeedback, are beginning to report a significant improvement; from the traditional 70% relapse rate down to that of only 40%.  These classic forms of biofeedback focus on creating a hypnogogic state (a hypnotic state), using a protocol now labeled the alpha-theta Peniston protocol, named after Eugene Peniston. Peniston demonstrated significantly higher abstinence rates with alcoholics when EEG biofeedback was incorporated into the treatment protocol (Gossop, 2002; Peniston, 1989; Peniston, 1990). The Peniston protocol and its variations focus on placing a person in a highly suggestive hypnotic state. Then,  during this hyper-suggestive state, affirming suggestions are employed, which support the individual’s sense of self-efficacy as being capable of abstaining, as well as helping their ability to focus. These studies showed that eighty percent of subjects in these experiments were reported to be abstinent one-year post treatment, but not necessarily able to successfully reintegrate back into their society.

Upon interview, many abstinent SUD subjects still indicated poor cognitive performance abilities and a feeling of something ‘lacking or missing’ in their life (Gossip, 2002; Peniston, 1989; Peniston, 1990; Mathias, 2008).  Based on the clinical experience at Crossroads, and utilizing objective measures for SUD, fqEEG brain maps often indicate many areas of imbalances in brain wave patterns as they address both cognitive function and personality maturation.

When looking at the fqEEG, two specific EEG patterns called EEG phenotypes, have been identified as common patterns (Johnstone, 2005) within the SUD population. Additionally, EEG phenotypes, which affect a person’s ability to function cognitively, have also been identified in learning disabled individuals. These cognitive impairments include attention and impulse issues (Johnstone, 2005).  Cognitive function which includes cognitive abilities of learning, memory, executive function, abilitiy to inhibit impulses, proper choices and decision making are significant factors when integrating back into societal communities effectively (Mathias, 2008).

In a study published by the authors (Gunkelman, Cripe, 2008) from preliminary neuro-imaging work, based upon the fqEEG, it appears that two different neural “factors” underlie the preponderance of cases studied. This most likely represents separate pathophysiologic drives for addictive behaviors:  1)   CNS Over-arousal 2) Cingulate issues (Obsessive-Compulsive) Fig 1.

Further, the study indicated that not only can the brain based drives be identified, but also more importantly, when a full biopsychosocial-healing model is applied, results from the study indicated that these issues responded effectively to treatment. The pilot study, using clinical outcomes data, represents a non-controlled study. The study addressed observed efficacy on a large clinical case series, comprising the first 30 clients who completed therapy at Crossroads Institute in their BrainRecovery Program™ for substance abuse disorder.

The program uses a biopsychosocial model and includes:

• Phenotype-based neuro-cognitive target
• EEG-assisted cognitive rehabilitation program
• Nutrition
• Counseling

The case series illustrates characterization of the pathophysiology associated with addiction, and generally shows the impact of this approach on various outcome measures as it relates to neuro-cognitive functional performance on pilot data acquired on subjects as it related to fqEEG measurements. Fig 2. Illustrates the changes that resulted from the treatment program.

Our outcomes are not merely abstinence/sobriety from the client’s drug of choice, but reflect a more fundamental improvement in neuro-cognitive function, as seen in our routine pre-post testing.  Some quantification of the “neuropsych” changes associated with our phenotype based neurotherapy approach are seen in measures which were taken both before and after treatment.  Measurements are expressed as standard scores, with 100 being a normal performance.  The following table lists the change in the addiction client’s group mean values comparing the various measurements from before to after treatment.

The first measure is taken from the Woodcock-Johnson III as a “general intellectual ability” measure, is considered a measure of the Fluid Intelligence of the individual and is crudely equivalent to an “IQ” score.   The Thinking Ability metric measures thinking processes used when short term memory information cannot be processed automatically.  Cognitive Efficiency measures the ability to process information automatically, with tasks requiring that information be held in working memory, and also visual perceptual speed. Audio-Visual-Learning Ability measures learning in situations where information is presented both orally and visually.  Delayed Recall is a measure of both auditory and visual recall after a 30 min delay.  Working Memory measures the ability to hold information in immediate awareness while performing mental operations on the information. The following table represents the groups’ pre- and post average scores.

Abstained time group average over 18 months

GIA SCORES -  General Intellectual Abilities – IQ score as measured by Woodcock Johnson III

Thinking Ability Scores – Is a measure of different thinking processes that can be used when information in short-term memory cannot be processed automatically.

Cognitive Efficiency – Is an index on the patient’s ability to process information automatically. This is a measure of two types of tasks 1) Task requiring one to attend to information held in immediate awareness while working on it; and 2) Tasks that require visual perceptual speed.

Audio-Visual-Learning Ability – Is a measure of how one learns in situations where information is present both orally and visually.

Audio-Visual-Learning Delayed Recall Ability – Is a measure of how one recalls oral and visual learned information that is recalled after a 30 min delay

Working Memory – is a measure of the ability to hold information in immediate awareness while performing mental operations on the information.

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