Making good decisions

Decisions, decisions! We all have to make them. Some are trivial and some are life-altering. Sometimes we’re pleased with the results, other times we regret them. Here are some thoughts on the kinds of decisions we have to make, and things we can do to help us make decisions we can live with.

But first I’d like to explain the drive-reduction model of behavior, something I learned about when I was studying gestalt psychology. It has to do with motivational priorities. According to this model, we constantly have an emerging drive that needs to be satisfied: thirst, hunger, elimination of body waste, attention, pain reduction/avoidance, sexual gratification, etc. If the emerging need is extreme (i.e. you’re dying of thirst or hunger), your exclusive focus is on meeting that need, and you may  engage in extreme or uncharacteristic behaviors to get what you need. Once a need is met, another drive comes to the fore. As Gilda Radner put it, in her SNL role of Rosanna Rosanadana, “It’s always something!”

Either/or conflicts can be approach/approach or avoidance/avoidance. An example of an approach/approach conflict is when Tom is attracted to both Susan and Joan, who are friends. He can’t court both of them, so he has to decide which one of them he’s most attracted to. He might make a decision and make a move, or might get stuck in ambivalence and not act at all. In an avoidance/avoidance conflict, one has to choose which of two undesirable alternatives is the “lesser of two evils.” If a person’s only available opportunity to make money is a job that is repugnant to her, she has to choose between taking that job or living day-to-day in dire poverty, hoping that another opportunity will eventually become available.

A third kind of conflict involves a single prospect that has both positive and negative aspects. This is called an approach/avoidance conflict. It may be that a prospect seems relatively attractive from a distance, but the closer one approaches it, the less attractive (or more frightening) it becomes. This can be a recipe for protracted ambivalence – going back and forth.

Consider an alcoholic’s conflict regarding sobriety. He may want to stop drinking and may see the benefits of sobriety clearly, but the longer he goes without a drink, the less attractive – or more frightening – the prospect of lifelong sobriety becomes, relative to having a drink right now. Recognizing that sobriety is the best option in the long term, but craving a buzz, he may decide “I’ll quit tomorrow.”  This is an example of a profound, and often persistent, state of ambivalence.

One method I’ve taught as a therapist, to assist clients in resolving ambivalence regarding a major decision, is listing positives and negatives. Let’s say Rhonda is being courted by Jim. She thinks he’s handsome, enjoys his company, and  especially enjoys all the attention he lavishes on her. But when she senses that he’s about to propose, she’s unsure about what to do. So she draws a line down the middle of a sheet of paper, puts a “+” at the top of the left-hand column and a “-” at the top of the right-hand column. Then she “shotguns” her thoughts, jotting down everything (positive or negative) that pops into her mind about her prospects for happiness with Jim as a husband.

On the positive side, Jim (1) has a great job and makes enough that she won’t have to work outside the home if she doesn’t want to, (2)  is sexually attractive and (3) good in bed, (4) is generous, (5) has a great personality and (6) sense of humor, (7) is popular and well-respected, and (8) treats her like a queen, always telling her how much he loves her. Now, in the case of some +/- lists, there may be a nearly-equal number of positives and negatives, giving you a numerical basis for comparison. But in Rhonda’s case, she can only think of two negatives. She doesn’t like Jim’s father – but she could live with that. However, number two outweighs all of the positive qualities she’s listed: she isn’t in love with Jim.

So it’s not always a numerical comparison of positives and negatives. The final step in this method is to assign a weight to each quality listed in each column. One quality in one column might outweigh all of the qualities in the other. Using this method to decide between two attractive job offers, the weighing of qualities might be helpful because a quantitative comparison reveals one job to be slightly more attractive than the other.

The shotgunning of ideas can be very helpful when a group has to arrive at a decision. Any group member in the room can call out a factor or idea relevant to the decision, and someone records it (i.e. on a whiteboard or a large piece of paper taped to the wall) for all to see. Once all relevant factors the group has come up with are on display, the group doesn’t assign weights as with the +/- method, but rather discusses the relative merits of each. In this manner the group can arrive at a well-considered decision that everyone (or almost everyone) can live with, because it was based on group consensus.




Relapse Prevention, Part 2

In my last post I wrote about triggers for relapse and the importance of having a relapse prevention plan, if you’re trying to establish and maintain a clean-and-sober lifestyle. The relapse prevention curriculum I developed in at the University Hospital of the West Indies in Jamaica included modules on stress  management, anger management, and rational thinking – all topics I’ve covered in previous posts. In this post I’ll be writing about other aspects of recovery from addiction.

I’ve met people with serious substance abuse problems who were too  proud to admit that they needed help in their recovery. (“I’m man enough to do it on my own!”) I’ve also known drug abusers who couldn’t imagine talking to other people – especially strangers – about addiction-related things they’d done and were ashamed of. But I’ve never met a recovering addict who got and stayed clean-and-sober without help from others, either in the form of professional help, or peer support groups such as AA. The road to recovery isn’t a road to walk alone.

Although I never saw him staggering drunk, my own father was an alcoholic. A military man who prided himself on his self-control, he once went for a year without drinking, to “prove” his ability to control his drinking. He went for exactly 365 days without a drink, but he hated every day of his self-imposed sobriety. It’s a condition known in the recovery community as “dry drunk.” As planned, on Day 366 he resumed drinking, moderately at first. But within weeks he was back to hiding bottles and drinking at the level he’d been drinking before his year of “white knuckle” sobriety.

There are individuals, I’m told, who’ve regained control of their excessive drinking and become moderate “social drinkers” – but I’ve never met one. “Someday I’ll be able to drink again” is a dangerous thought for people in recovery. Addicts are notorious for irrational thinking and self-deception. Many a relapse starts with thoughts like “I’ll allow myself one beer on my birthday” or “I can still shoot pool with my drinking buddies at the bar, and just drink sodas.” One of the arguments for attending Twelve Step meetings is that in time you’ll come to recognize your own rationalizations, by listening to other addicts who’ve come to recognize their own bullshit. Twelve Step meetings are all about getting real with other addicts who they know won’t judge them, because they’ve been there, done that, themselves.

Some friends and family of addicts don’t want to support their recovery, for a variety of reasons. Other well-meaning people who care about an addicted friend of family member become enablers. With the best of intentions, they try to shield their friends or  loved ones from the natural consequences of their addictions. They think they’re being helpful, but they’re simply enabling the person to continue drinking or using. In order to truly help, enablers need to learn to practice tough love – to stop attempting to rescue the person, and to let them suffer the natural consequences of their substance abuse. A mother practicing tough love won’t bail her son out of jail, because she knows from experience that if she does, he’ll be shooting up again within hours of his release.

Most recovering addicts come to the realization at some point in their recovery that they not only have to stop their drug-of-choice, but all intoxicating substances. I’ve known a number of crack and opioid addicts who initially believed that they could substitute alcohol and/or cannabis for their drug-of-choice, only to find that it was just a bridge back to their preferred drug. Cravings are one of the most common triggers for relapse, and getting high or intoxicated doesn’t improve anyone’s judgment or ability to resist cravings.

In my last post I mentioned euphoric recall (addicts dwelling on memories of the good times they’d had drinking and drugging, before getting addicted) as a trigger. This is one form of rumination, but addicts can also ruminate about how much they’d like to get high right now. This kind of thinking activates cravings that lead to relapses.

I’ve had some personal experience with this, as a recovering nicotine addict. What I found was that when I ruminated on how good it would feel to light up a cigarette, I relapsed time and again. Eventually I was able to identify my ruminations as a predictable relapse trigger, and to stop dwelling on thoughts about how I’d like to have a smoke. I still have occasional situation-specific cravings for tobacco, but I no longer feed the initial thought with more thoughts, and the cravings only last for a few seconds. After years of being  nicotine-free, the long-term rewards of being a non-smoker outweigh any momentary cravings I might have to light up again.

Relapse prevention, Part 1

I’ve written about my two years (1991-93) as a ward psychologist on the fledgling Detox/Rehab Ward of the University Hospital of the West Indies (UHWI), in Kingston Jamaica. When I started my Peace Corps tour of service, the ward had no treatment model other than the medical model, supported by Twelve Step meetings (Alcoholics Anonymous, Narcotics Anonymous). I introduced a relapse prevention curriculum that was adopted by the ward staff. When I recently checked out the UHWI Detox/Rehab Ward (now called the Addiction Treatment Services Unit) online, I was delighted to see that it’s still using a relapse prevention model. My Peace Corps legacy was a relapse prevention manual that I wrote for use on the ward. A Returned Peace Corps Volunteer who’d served at UHWI years after my departure told me that the manual had still been in use  when he was there.

A relapse prevention approach to recovery works well within the medical model, which – like Twelve Step programs – regards addiction as a disease. I introduced the patients on the ward to the relapse prevention model in my psycho-educational groups. Addiction, I said, is a chronic, progressive, relapsing disease that is ultimately fatal, if the disease progression isn’t arrested. Chronic means it doesn’t just go away at some point. Progressive means it gets worse over time. Relapsing means that most addicts will relapse multiple times before establishing long-term sobriety – if they ever succeed in doing that.

One of the advantages of the medical (or disease) model of addiction is that it helps some alcoholics/addicts to understand why they can’t control their drinking and/or drugging: they have a disease. Guilt and self-blame don’t generally help people to come to terms with their addiction. The medical model tells addicts that while they can never be “cured” of their chronic disease, they can halt its progression and stay in long-term recovery. This is why alcoholics in AA programs still refer to themselves as alcoholics, even if they haven’t had a drink in many years. They’re not ex-alcoholics, they’re in recovery. They may have stopped the disease progression, but they remain at risk of relapse. As any recovering addict will tell you, recovery happens one day at a time.

If you’re an addict, relapse prevention means learning what puts you at risk of relapsing. There are myriad ways that people who are struggling to stay in recovery unconsciously set themselves up for relapse. The first step in creating a personalized relapse prevention plan is to identify your triggers for relapse. Triggers can be people, places, things, activities, attitudes, emotions or thoughts. Different people have different triggers.

Recovering alcoholics may have to sever relationships with their old drinking buddies and stay away from bars and parties where alcohol is served, at least in early recovery, possibly permanently. If a lover is still drinking/using, a person in recovery may have to end the relationship. A recovering crack cocaine addict may need to stay away from the places he used to score and use, and might be triggered by the sight of a crack pipe or the smell of cocaine being smoked. Stress, anger, anxiety and depression might trigger a relapse. Thoughts like, “I’ll never drink again unless ________” can be a set-up for relapse, as can euphoric recall – dwelling on thoughts about the good times you used to have getting high, before you became addicted.

The second step in creating a relapse prevention plan is knowing in advance what you’re going to do instead of using, once you’ve been triggered. That might be going to a Twelve Step meeting, calling your sponsor, or checking yourself into Rehab. If you don’t have a plan for what you’ll do when you’re triggered, you’re probably going to relapse. A slip – defined as a single episode using your drug of choice or a bridge drug – need not become a relapse, if you have a plan and act on it. All too often, when an alcoholic gives in to temptation and drinks a six-pack after an extended period of sobriety, she thinks “I blew my recovery! I may as well go to the liquor store.” If, instead, she goes to an AA meeting or calls her sponsor, and admits what she’s done, she may prevent the slip from becoming a full-blown relapse. I used to quote an African proverb I’d heard somewhere: “If you want to avoid falling where you have fallen before, don’t examine where you fell, but where you slipped.”

I don’t mean to suggest that everyone with an addiction problem has to join a Twelve Step program and go to meetings for the rest of their lives, although for  some that may be exactly what they need to do. I’m convinced that there’s more than one road to recovery. I’ll write more about relapse prevention in another post.