Let’s return to John’s driving metaphor and fit it with what we know of the brain. As per my last post, let’s look at choice as a blip, a flash of intention, that rides on the momentum of underlying habits. Skillful drivers have built up a repertoire of good habits, like alertness, sensitivity, self-monitoring, and flexibility. So, even though they can’t promise to never have an accident, they can minimize the risk.
“Driving responsibly” like “drinking responsibly” sounds like Big Brother claptrap. In fact driving well is very Zen. Today I took the car out on the winding roads at the foot of the French Pyrenees. I thought about John’s metaphor and became more aware of what I actually do when I’m driving. I took the curves gracefully, skillfully, even though the skill wasn’t something I could put my finger on. It wasn’t something I possessed. Rather, it felt like a moment-to-moment balance between assertion and surrender, focus and flexibility. It had to be that way, because I was moving fast through complex terrain, and I was thinking with my head but also with my body, my instincts, and that vast unconscious part that puts it all together, moment by moment.
This view of choice fits well with brain mechanics. Sensory input pours in from the retina to the occipital area at the very back of the brain. That’s the primary visual cortex. Then it gets passed forward toward the centre of the brain, and it becomes more holistic, more comprehensive, along the way. Stage by stage (but very quickly) it joins with other sensory information (e.g., the feeling of the wheel in my hands) as well as memories and feelings. By the time it arrives at the orbitofrontal cortex, it is a gestalt with a familiar meaning.
At the same time, motor output cascades from the centre of the cortex outward toward the periphery, going through stages in the opposite order. It starts in the dACC, or a region just north of the dACC called the supplementary motor area. That’s where plans seem to emerge. From there the output stream gets increasingly articulated, as it passes through the premotor cortex, where plans are translated into global action patterns, and finally to the motor cortex, where the actual muscle movements are orchestrated.
These streams, input and output, flow at the same time – the output stream doesn’t wait for the input stream to finish before it starts up.(If it did, we’d respond to our environment at the pace of a slug.) So a special trick is needed to coordinate these streams. The brain connects the input stream to the output stream at each level, from detail to gist, with multiple connecting links, like rungs on a narrowing ladder. At the bottom rung, concrete sensory details connect with concrete action commands, so the visual details of a sudden curve in the road are coordinated with the movements of my hands on the wheel. The rungs continue to connect the two pathways, as they get closer to the centre of the cortex, where a meaningful visual scene connects with a meaningful motor plan: I’m driving this narrow winding road, which feels good, but a car could come around the corner at any moment so I’ll downshift to second gear and slow down. Which I do.
Intention – where “I” make a voluntary choice – is a difficult thing to locate in the brain. But our best guess is that it happens near the centre of the cortex, where orbitofrontal meaning connects with emerging plans in and around the dACC.
So choice takes up a rather small part of the whole sensory-motor process. Think of it as the top rung of the ladder, with all the other rungs stretched out below it, doing their business of integrating perception and action. Was it a choice to change gears just then? Certainly. But that choice was the cream at the top of a dark, frothing mixture of perception and action at multiple levels. And what about those links below the level of choice? They are automatic, unconscious, and they are shaped and refined through repetition, through learning. Those links are where habits get built, by way of synaptic shaping, and those habits determine a very large part of our behaviour.
Driving is a great metaphor for how we negotiate the attractions and hazards of life, which is also complex and difficult, and which also comes at us around each corner with great speed. Driving relies on something like flow, but flow depends on smoothly running habits. Being a good driver requires good habits, to give choice a chance (paraphrasing John Lennon). Being a good ex-junkie or ex-drunk also requires good habits, if you’re going to stay on track. First we try to build up those habits, then we simply do our best to make good choices, whenever the road takes an unexpected turn.
Informed by unparalleled neuroscientific insight and written with his usual flare, Marc Lewis’s The Biology of Desire effectively refutes the medical view of addiction as a brain disease. A bracing and informative corrective to the muddle that now characterizes public and professional discourse on this topic.” —Gabor Maté, M.D., author of In The Realm of Hungry Ghosts: Close Encounters With Addiction
Excellant, spot on but how do we ex’s form those good habits? Replacement? Extinction? This seems to be the key to recovery. George Vaillant beleived alcoholism was both an ingrained habit and a disease. When he followed alcoholics for 60 years* he found substitute dependencies the top factor in recovery. He also cited supervision, poor health, new love interests and AA as important factors. Supervision included things like risk of loss job, loss of marriage etc. Supervision, a new love interest and poor health seem like life style changes that change one’s outlook and allow new habits to be formed. A substitute dependency or joining AA seem to require a conscious choice. All would effect neurobiological systems. Perhaps you could explain how these work?
*(George Vaillant, “The Natural History of Alcoholism” (1983, 1995, 1998 and 2003)
(I hope I have the dates right.))
How do we form new habits? That is the million dollar question. The situations Vaillant describes have one thing in common: and not necessarily a substitute dependency, because a new love isn’t a dependency (yet) and neither is poor health. Rather, each of these situations gets you to take stock, thoughtfully, reflectively, of your day-to-day moment-to-moment habits. Each situation either requires you (in the case of AA or loss of a job) or invites you (in the case of a new love) to CHANGE.
Habits run smoothly, without reflection or thought. And the only way to change habits seems to be through reflection or thought. We have to locate ourselves, so to speak, in that part of the frontal brain where the dACC and the orbitofrontal cortex meet up. There we can make a selection. We can choose one route over another, through the effort required by disaster or by opportunity.
I probably should not have said: first we change habits, then we try to make good choices. Because changing habits is itself a choice.
Becoming conscious is the only antidote to habit that I know of. Otherwise, habit just keeps on keeping on. But becoming conscious, taking stock, does entail some work, so people aren’t likely to go there unless there’s a very compelling reason to do so.
“Becoming conscious is the only antidote to habit that I know of.” ~ Agreed. The work in becoming conscious can be agonizing, and requires steady containment of fear … easier said than done!
About addiction and choice in general … As long as we have the capacity to choose (i.e., cognition and volition are intact), and have the ability to go after what we want, we alone are responsible. When we are lucid enough to see this — to realize that this is a path we have put ourselves on — once we comprehend our own volition in a flow of events, only then can we act rather than addict.
For some people, awareness of responsibility is a terror … and we’ll do whatever we can to run from it. I’ve wrestled with the reality of my own responsibility (response – ability) for decades, being a survivor of trauma in infancy; my volition was all but wiped out of me before I was even conscious that volition existed. My habit is to run, run, run. I don’t run with booze or drugs, but in my most harrowing moments, I tend to obliviate my consciousness in other ways — primarily by sleeping, reading compulsively, and cutting off contact with my loved ones.
The run — the tearing away — from our own ability to respond, our own presence … I think that’s figural in facing addiction. At some point we just have to stand still and affirm that ‘Yes, this is where I am.’ Addiction keeps us far, far away from our own presence …
If we substitute a new habit, doesn’t that diminish the choice aspect? First we choose to make the substitution(s) but eventually it runs like a new habit. Pavlovian and operant conditioning are well understood at least in animals. We could even try to choose substitutes which approximate the addiction like food for alcohol. Methadone maintenence and suboxone seem to work for some addicts. Even AA knows it soothes the craving to eat somthing. Not an expert but food triggers dopamine, endorphins and decreases ghrelin as does alcohol. Indeed alcohol has calories. My point is it would help us to get beyond that no man’s land where reaction takes over and choice becomes non operational. We live reactive lives especially over time. We all hope the neuroscientists will find the key which the chemists can synthesize. But maybe that’s just a dream and we all have to experience that transformation where we decide – never again.
New habits do indeed diminish the role of choice. And, yes, many paths taken by people in recovery substitute new habits for old ones — often habits that give us some of what we miss without the terrible price we paid for our addictions in their previous form.
But I don’t think that’s so bad. It’s just the way it is. I think choice is a flimsy thing, a reed in the wind. It can’t take a lot of weight and it can’t be relied on when other systems are not lined up to support it. So I say YES to building new habits. True, it keeps life somewhat mechanical, not as full of awareness and alertness as it might otherwise be. But it works, and that’s crucial.
As I tried to show in the post, most of what the brain does is unconscious and sort of mechanical. Best to ride on top of all that rather than try to carry the whole burden with our wobbly will.
Dear Marc (or Dr Lewis, whichever suits you)
I am a new contributor so please forgive my somewhat off-topic catch-up.
First a brief history. I was diagnosed with endogenous depression (now Chronic Endogenous Double Depression) at the age of 23. I am now 65 . I suffered in silence for many years because of the fear of being branded as crazy, lazy or just morally deficient. When I told my sister,30 years ago, what I had her answer/solution was “snap out of it”…never discussed it with her again.
Now that I am a semi retired American businessman with a fairly successful career behind me I don’t G.A.S. who knows. I am also a recovering alcoholic (a disorder I believe) with 9 years in AA.
My problem is this: I spent lo these many years becoming and being an “Adreneline Junkie” in order to measure up to a very successful family (ex: my Uncle was head of the Oregon Health Sciences Med School). It was my way of overcoming the ennui associated with my condition.
I also learned a few years ago that my disorder was cause by a bout with Mersa Staph combined with Peritonoitis after an appendectomy when I was 11, and not a moral failing (big relief).
Now that I have read your book 3 times (that speaks volumes on my respect for your work)I am coming to grips with the Limbic system as the center of this activity, most likely the interactive loop between the dACC and Amygdalae. Hence “Ego Fatigue”
Question is, since it was not caused by addiction (I really didn’t drink that much, just steadily) and so many years elapsed, what are the chances of permanence?
I now take a “basket” of meds beause SSRI’s no longer “do it” for me as I have so many fritzy receptors.
Wish I would have read your May post calling for volunteers beause I would “kill” to be able to discuss all this with you. But just writing and maybe a “yes or “no” answer would be enough.
Thanks you so much for your brilliant book. It was a real game changer for me.
Best Regards
John L Krier
PS: If you like, you can read more about me by googling my first and last name with middle initial. Don’t want to bore you too much though.
Interesting! I’ll reply in a few days, but meanwhile I’d love to hear what others think.
Hi John. I’m home with more time to reply now. Ego fatigue is present in so many aspects of our lives, but it always involves some sort of ongoing resistance or inhibition (or avoidance or denial) pitched against an urge or impulse. We get it at the end of the work day, when, after being polite to people we don’t necessarily like, etc, we come home and yell at our kids…or speak grumpily to colleagues on our way out the door. Or stop on the way home and have a drink. The role of ego fatigue in addiction is clear: we try to say No to ourselves repeatedly until the dACC runs out of fuel. And then the amygdalae (as you say) or the ventral striatum (involved in attraction/approach) is let loose, without restraint, much to our eventual disadvantage.
But I’m not sure what it is you’re trying to inhibit or overcome. Is it the urge to drink…which you say isn’t a huge problem? Is it the chase after adrenaline? (many would die to feel that kind of excitement and eagerness in their lives). Or has it to do with the depression? I’m just not sure.
Being an adrenaline junkie is indeed a sleight of hand, substituting one addictive goal for another. But is that so bad? It’s more or less what psychoanalysts call the “manic defense” — we get involved in “doing” so that we don’t have to sink into the anxiety of “being”. It’s what Freud called sublimation. Sublimation accounts for how good (productive, useful) actions arise from the rerouting of fundamental drives, which cannot be expressed in their pure form without dire consequences.
If that’s what you’re trying to overcome, then I hope you have something else to fill in the space. Your depression, wherever it comes from, is likely to be maintained by all sorts of self-deprecating ruminations and anxious concerns. If you want to face these, more power to you. I think meditation is one of the best ways to do this, but finding a good therapist can be just as helpful.
Thanks for your comments about my book. Really makes me happy that I wrote it and that it reached sensitive, inquisitive people like yourself. And no, I don’t think these circuits are beyond repair. Not at all. The trick is to stay focused on ANOTHER way of processing information, of living, of thinking, long enough to build up alternative synaptic architectures — i.e., habits of thinking and feeling. These can reduce the power of impulses — impulses either to indulge or to run away — so that the ACC doesn’t have to work so hard to control them.
Hello Dr. Lewis,
I was interested in the language that you use when describing the act of consciously “raking the reins” of intention, choice, or whatever we want to call it. You seem to favor a meditative mode of awareness, and believe this would be useful in making wiser choices. Some examples:
“… take stock, thoughtfully, reflectively, of your day-to-day moment-to-moment habits”
“Becoming conscious is the only antidote to habit that I know of”
While reading your book, I was struck by its lopsided structure – you seem to devote many more pages to your lived history of active addiction, as opposed to your recovery. At one point, I recall noticing that you seemed to discount meditative practice as a possible path to recovery. In fact, you seemed to be at a loss for what exactly triggered your eventual climb out of the depths.
I have spent some time reading about Alan Marlatt’s work on relapse prevention, specifically the mindfulness-oriented RP program he developed just before his passing. This converges very nicely with your own ideas about reflective moment-to-moment awareness . It also links up with Daniel Siegel’s descriptions of “response flexibility” or the capacity of the middle prefrontal brain regions in governing choice.
I guess what I’m curious about is whether you feel these concepts have any value in treating addictions, whether in your own circumstances or others’.
Yes, I think they have a lot of value! The “lopsided” nature of the book has been pointed out by others. What can I say? I don’t think I truly understood how I stopped, so I didn’t make it a big part of the story (the book is more about addiction than recovery) although I understand it better now, and I’m also trying to understand how to stay stopped, how it works. I don’t have time for a longer response right now, but I’ll get back to you soon. Thanks for raising these points.
I Just perused Marlatt’s approach, and yes it seems vey simpatico with my own views. Of course, he’s the expert on meditation and recovery. All I know is that meditation helped me in the weeks and months following quitting, and it has continued to be a good friend since then, especially in dealing with depression.
Which leads me to another reason why my book appeared lopsided in not dealing in more depth with recovery. It’s because I just didn’t know much about it. I guess i already said that. In a nutshell, I was an expert when it came to addiction, but a beginner when it came to recovery.
Sorry, let me try again. In rereading your comment, I now understand the discrepancy you note. At one point I seem to be saying that one must become conscious and live in the moment, then at another I seem to say let’s develop better habits so that we won’t have so much riding on momentary awareness. You’re right, it seems contradictory. But I don’t think it really is.
Getting into the moment is a momentary thing. We can’t expect to be there hour by hour, day by day. Getting into the moment also alerts us to the demanding voices that want what they want, and also perhaps the other punitive voices that end up making things worse. Even in meditative states, we can be aware of habits of thought and we can adjust them. We can make friends with a “protective” self that seems to look after things when we’re not so present. That may be the fulcrum between momentary awareness and the laying down of new habits that make it easier to stay on course.
Does that help?
Hi Dr. Lewis,
Thanks for your thoughtful responses!
I’m actually not sure I had noticed the discrepancy between forming positive habits and cultivating moment-by-moment awareness. I actually feel that they can go hand in hand, as rehearsal of short term neural “states” can eventually lead to long term “traits” (i.e. mental/behavioural habits). I guess that when I read your book, I sensed that you might have more to say about recovery and specifically meditation, although these topics weren’t the focal point. I really appreciate your ability to describe your own experiences and I guess I just wanted to hear more on this.
On a related note: Norman Doidge pointed out that simply paying attention in a deliberate, mindful manner activates the nucleus basalis and stimulates release of BDNF (brain derived neurotrophic factor). According to Doidge, this increases neuroplastic potential, and I can imagine it would be a powerful tool in restructuring the brain’s synaptic architecture. Is my understanding of this too simple, or does it make sense that mindful awareness promotes neural revamping?
Habit is the most effective teacher of all things.
—Pliny
We are what we repeatedly do. Excellence, then, is
not an act, but a habit.
—Aristotle
Habit is second nature, or rather, ten times nature.
—William James
For in truth habit is a violent and treacherous
schoolmistress. She establishes in us, little by little,
stealthily, the foothold of her authority; but having
by this mild and humble beginning settled and
planted it with the help of time, she soon uncovers
to us a furious and tyrannical face against which
we no longer have the liberty of even raising our
eyes.
—Montaigne
Excellent!! Quite a bit more gracefully said, but I think the message is the same. Habits are the foundation on which the flimsy structures of choice rise and fall. And once they’re established, says Montaigne, they completely dominate us.
But keep in mind that habit formation is just a consolidating pattern of synaptic connection, and as we know now, from principles of development and neuroplasticity, habits can be reformed and transformed through practice.
Hi Marc
Sorry for the late reply. I have been in your home country for the last week on business.
I tried to keep my first note short so I guess I left out some important points.
First and foremost of my problems with the “Ego Fatigue” relates to my inability to QUIT SMOKING. Since the dACC is a will power center it is crucial for it to be fresh and functioning.
I quit in 1986 for 15 years then started again at a time of peak alcoholism, divorce, building a new (quite large) company, and commuting to Europe where all my colleagues drank and smoked up a storm back in those days. Thought I was “bullet proof” from a recurrence knowing little or nothing about the nature of addiction.
What you are describing as a solution is something I have tried many times in the past. I used the Buddhist Virpassna (Mindfulness) meditation methods (I even had a Guru) for two years to help successfully quit alcohol. But alcohol is much simpler in it’s action affecting 2 or 3 receptors as opposed to 14 identified (so far) in cigarrettes containing nicotine combined with other nasty “secret ingredient” chemicals to keep them burning evenly etc. Consequently I am having one hell of a time even starting.
Your suggestion (even though much more erudite than I hear down here) is directly related to what we called Cognitive Behavioral Therapy, the latest buzzword. I have been using it on my own for years as it is composed of common sense exercises. It has merit but I shrink from ANYTHING Freudian (bad previous experiences with idiot shrinks).
My personal Dr is strictly a brain chemistry specialist….brilliant guy but does almost no counseling except for common sense stuff. He allows me to do most of my own treatment based on ideas gleaned from voracious reading that he puts the thumbs up or down on….I did forward your reply to him for discussion today.
Which brings us to the connection to the book and the urgency to quit smoking. I have an inherited tendency (my sisters both have it) to high LDL Cholesterol. I can’t tolerate statins of any kind so I use diet and magnesium which I can tolerate. Even though I have a much lower count than my sisters I have had 2 surgery/procedures in as many years for blocked arteries. They have had no problems. The difference? Smoking.
Fairly important arteries as well. I have a stent in the L2 and a scar outside the right carotid.
The latest was the carotid surgery and that is where the connection begins. After I found out (a plaque particle was found on the back of my retina by an Optometrist for God’s sake) I went to a recommended Vascular Surgeon. Previous to my visit I happened to be looking at the last brain cross-section in the book and made the connection between lack of blood flow and the location of the emotional neuromodulators. I was having, in the run-up to surgery, the worst mood swings of a 50 year career in (attempted) mood control. Totally out of control major depressive episodes culminating in a suicde attempt that my wife caught just in time. I was so crazy at the time I didn’t even think much about what I was doing. When I gave him (the 1st surgeon) my theories, he basically laughed at me (his notes are a sight in ignorance of brain function to behold) and told me I didn’t need surgery. (Typical specialty egotistical God complex, a..hole surgeon) Yes , I know….”how do you really feel about the guy, John”. But the bastard almost killed me.
Fortunately my architect has a close friend who is one of the best in town,,,,nice guy and took my theory seriously. After the surgery my mood improved to the best it’s been in years. Unfortunately my will power has turned to flab and I blame it on the horrendous psychic pain I endured during the months of blockage. Now the Med school (Oregon Health Sciences..my Uncle was head medico there for 30 years and my surgeon is head of his department there) is considering a study on my theories.
Finally, I can see that some of your readers/correspondents have a lot of tech knowledge but very little “up close and personal” experience with real addiction. When they complain about your lack of coverage of your recovery phase in the book, they don’t understand that addiction and recovery are like Venus and Jupiter. Two totally different subjects and dynamics.
A second book should be written about that, although your short description of your ability to recover (rare indeed the way you describe it as something like a bolt from the blue) makes it seem somewhat of a mystery even to you. Personally I am glad you stuck to addiction as you segue’ from personal experience to easy-to-understand medical explanations of the dynamic in question, are absolutely seamless.
I would also say that even though you were a massive drug user that your history of poly-drug abuse has a lot to do with it. “Drug of choice” seems to play into severe addictive disorder cases although bingeing as you indulged in, is one of the tougher ones to treat.
.
You got a lotta writing talent Doctor. If you see my articles (I am an Econ analyst specializing in Macro housing markets among other things) and witness the struggles I had to just make them mediocre creates a slight jealousy reaction even though jealousy is not an emotion I indulge in often.
Best Regards and Thks So Much for Your Reply
JLK
Thanks, John. A bit too much to respond to here, but I’m glad you’re still alive an kicking. The mood swings and accompanying trauma sound terrible.
Hi Marc,
I absolutely love the blogs you have going here and I have really been impressed by the responses and input from your followers. I am a family practice doc that has worked in a level 1 ER for the last 10 years and I’m an addict. I am about 2 years sober and have found that in recovery I have been given the opportunity to live two lives in one lifetime.
I enjoy the mental masturbation with regards to discussion over the choice vs disease vs self-medication arguments. What I have struggled with, as I progress in my recovery, is the reflection back to the worst times in my addiction. How could I have made the choices that I did? How could I have put myself, my family and my patients at such risk? I truely believe now that my ability to choose was hi jacked by my drug of choice. I feel that the “powers to be” have done a good thing in proposing that the “craving state” be considered in the next DSM. That craving state is true suffering in my mind-no pun intended. The functional MRIs have shown that just being shown your DOC will “light up” your midbrain and “shutoff” your frontal cortex.
My ability to choose was overcome by my DOC.
I know that this sounds like a “cop out” to alot of people but I take full responsibility for my decisions and continue to reap the “benefits” of my prior choices(drug tested regularly, professionally monitored for the next five years).
I have been so fortunate in my recovery to have a supportive family, a job that want to employ me and give me a second chance, and most importantly a group of sober men to surround me and serve as my frontal cortex. The biggest need for that was in the first year. I feel like a toddler now but I know that it takes alot of hard work.
I love the conversation of choice vs disease vs selfmedication because it gives me some ammunition to help communicate with the addicts that I see in practice but so much of recovery is the support system we surround ourselves with and so many people dont have that. There are so many factors that lead to and support addiction-genetics, stress, coping mechanisms, craving etc that no matter how we define the cause I feel that the focus has to be on recovery.
Since being in recovery I have lost 5 close friends to this disease. They all returned to the people, places and things that fueled their addiction. How do we affect those choices? How do we measure true surrender? I dont know?
Thanks,
Paul
Hi Paul,
Thanks for such a frank and intimate look at what’s been going on in your life, and of course, congratulations. I remember very well that feeling of being a toddler — it often felt like the terrain was so new and strange and it would be easy to fall because it was all so uneven…and yet it was wonderful. The air felt clear and fresh and full of life for the first time in ages.
Thanks for your compliment about the blog — and I’m glad it is helping you develop a conceptual framework/language for dealing with other addicts, in your case as a physician. I am also delighted by readers’ responses and am learning a lot through this ongoing and hugely creative dialogue.
I also agree that the focus has to be on recovery…. that is the denouement of the drama, isn’t it, and that’s where readers and correspondents are leading me in trying to formulate my next book.
I disagree, though, that the state of craving should be a category in the next DSM!! Craving has been defined as a fundamental state, indeed one of utter misery, I guess at least going back to the Buddha. It is all about attachment…which is so profoundly natural…which is why I am hesitant about the “disease” label. To me it would be like listing “suffering” or even “life” as a DSM category. It seems that dealing with craving, whether for a substance, for a romantic partner, for innocence, or even for enlightenment, is a natural watershed in life, in growing up, though it can turn into its own hell, and it often becomes a pitiful dead-end.
I agree that this definitional debate can be pretty interesting, though it sometimes does seem too abstract (mental masturbation as you say). But I think its main value is that it really does get you to think deeply about the fundamental nature of addiction. What is it? And how is it different from other pathways in life? ….most of which seem to include a hefty dose of suffering, in whatever form it may take.
Best wishes,
Marc