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.

Who is an addict?

Who is an addict? It depends on who you ask.  To some people it’s an ugly word with negative connotations relative to, say, substance abuser. To others it’s a term with an important meaning, and recovering addict is a badge of honor, one day at a time. Addict is just a word for something real; it’s not a specific thing like a tiger or the Pope. It has no absolute meaning, but is associated with the medical model, in that it classifies addiction as a disease – specifically a chronic, progressive, relapsing disease.  Some add “fatal” to the list of adjectives, believing that if you can’t maintain recovery, your addiction will eventually kill you. To admit you’re an addict is to admit that you’ve lost control.

I’ve attended open Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings, and believe that regular attendance of 12 Step meetings is the only path to recovery for some addicts. I’ve recommended checking out 12 Step programs to many substance abusers during my career, but I disagree with anyone who claims there’s only one way – whether 12 Step programs, or Rational Recovery, or the Bible – to stay clean and sober.

My prescription for long-term recovery from substance abuse is “whatever works for you.” If believing you have a treatable life-long disease works to keep you in recovery, or believing you have an addictive personality, or believing that you have to “get right with God” to stay clean and sober, go with it. Your path to recovery is yours, but might not be what others need. It takes most people with substance abuse problems many relapses to learn what does and doesn’t work for them, as was the case with my recovery from nicotine addiction.

Not everyone has to “hit rock bottom” before getting it right. I’ve known a few people with many years in recovery who didn’t relapse once after resolving to quit. I’ve also known people in long-term recovery who initially needed to attend 12 Step meetings, but said that at some point they internalized the principals of the program and no longer had to attend meetings. Nobody has the authority to tell you that you’ll have to go to meetings for the rest of your life, in order to stay in recovery. But if you do, that’s not  a sign of weakness. It’s just part of your personal recovery plan.

Substance abuse occurs along a spectrum, and people’s definitions of abuse may differ; but being addicted generally means not being able to control your drug use once you start using mind altering chemicals. Within the recovery community it’s generally believed that if you’re addicted to whatever “drug of choice,” you also have to abstain from all other chemical highs in order to keep from relapsing on your favorite drug. I’ve known a number of chronic substance abusers who believed that substituting alcohol and/or marijuana would help them to keep from relapsing on “hard drugs” like meth or heroin or crack. (Alcohol is a hard drug, but it’s legal.) I’ve never seen it work and have concluded that you can’t solve a chemical dependency problem with chemicals.

The concept of addiction has broadened, and now a lot of people believe that sex and gambling and other non-drug-related behaviors can be addictive. The “old school” definition of addiction was characterized by three clinical phenomena: tolerance, withdrawal and physiological cravings. Tolerance means that you have to increase your dose over time to get the high you used to get from a lower dose. Withdrawal means that when you abruptly stop using an addictive drug, your body goes through distinct physiological changes – ranging from unpleasant or painful to potentially fatal – for a period of time. Physiological cravings are like hunger. Your body is telling you it needs something, and a strung-out heroin addict craves a fix the same way a starving man craves food.

Chronic marijuana use can lead to psychological dependence, but cannabis doesn’t meet the old school definition of addictive. Similarly, sex and gambling aren’t characterized by tolerance, withdrawal and physiological cravings. However, in many respects compulsive sexual activity and compulsive gambling resemble addiction, because they involve loss of control over certain activities, and some of the same neurotransmitters are involved. Like drugs, sex and gambling can predictably stimulate the brain’s “pleasure centers.” Psychological learning theory provides a good framework for understanding such compulsive activities, and I’ll elaborate in a future post.

Denial has killed millions of addicts. If drug abuse or compulsive behavior is hurting you or others, or you’re losing control of some important aspect of your life, find someone reliable and get real with them. Explore options and work on developing your personal recovery plan. Even if your plan doesn’t include active participation in a 12 Step program, it may borrow from the 12 Steps or Rational Recovery or other models. And you can’t stay in recovery without help from supportive people who understand you and don’t judge you. You need someone to share your thoughts and feelings with in recovery. We come to know ourselves better by letting others know us better, warts and all.