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This won’t be a long blog. I was reading the other day about parents who were prosecuted because they said their faith prevented them from getting their child medical treatment for leukemia. The same day I read an article about an organization getting a government grant to do faith based treatment for the disease of addiction. I don’t understand how the same government can see the faith based treatment of one disease as perfectly normal and worthy of tax payer support but not the other. The only conclusion I can come to is that the government doesn’t actually believe that addiction is an illness as biological as leukemia.

I don’t blame the government for that. I blame us, the people who treat addiction.

In spite of all the knowledge we have about the neurobiology of the illness, we continue to refer to it with the term substance abuse. Until we are clear that substance abuse and addiction are two different things, the lawmakers will continue to be perplexed as to what to do about this chronic, incurable, progressive illness. They will continue to allow educational and social programs, appropriate for people with normal brains who use substances, to be used to “treat” people who have a biological brain illness. And we have no one to blame but ourselves.

This post is a follow up to a previous post about Daniel Kahneman’s book Thinking, Fast and Slow. He makes a point in that book that tells us a lot about relapse in addiction.

Kahneman tells us of other researchers’ work about when we use the parts of our thinking that he calls System One and System Two. As a refresher, System One is intuitive and effortless. When we use System One we don’t even realize we’re thinking. System Two on the other hand requires real work. It takes attention and effort, and there’s not the least bit of doubt in our minds that we are thinking. This work, he says, gives us the Law of Least Effort.

What the Law of Least Effort says is, that, given a choice between effortless System One and effortful System Two, we will always pick the thinking method of least effort to solve the problem before us. This is one reason for the wide prevalence and persistence of cognitive biases that Kahneman is so fascinated with. Here’s an example he gives: “A bat and ball cost $1.10. The bat costs $1 more than the ball. How much is the ball?”

Got your answer?

Most people just subtract $1 from $1.10 and say, “ten cents.” In fact for the bat to be $1 more than the ball, the ball must be $.05 and the bat $1.05.

He also points out that under stress or even non-stressful use of mental resources, we are more likely to default to the simple (and wrong) answer. Rather than engage in effortful use of System Two and go through a calculation, we chose to answer a different question that is easier to answer.

Let’s be clear; by we I mean humans, not people with addiction. All humans will resort to the easiest method, the one we’ve practiced the most, the one that takes the least effort. So what does this have to do with recovery and relapse?

When people are new to recovery, they haven’t practiced the techniques of recovery much at all. They have practiced the techniques of active addiction. The techniques of active addiction, having been learned well and practiced much, reside in System One where they are intuitive and effortless. The new techniques of recovery reside in System Two and take a lot more effort.

So we should expect in early recovery for relapse to old behaviors to be more common until the new recovery techniques have been practiced enough to become second nature. And even then, when under stress or even non-stressful exertion, it will be harder not to default to the older, more deeply learned techniques of active addiction.

So, the important thing for me, and anyone treating addiction, is that our goal is not to teach people to use System Two or to convince them that System One is bad, but rather to help practice the techniques of recovery until they naturally move from System Two to System One. There they can be taken up intuitively and effortlessly. Unless recovery is as easy as using, the human brain will not default to recovery. The goal of treatment is to teach recovery and make it easy enough to keep.

© Howard C Wetsman MD FASAM 2012

I was reading an article online from the New York Times (http://www.nytimes.com/2012/05/18/science/many-rare-mutations-may-underpin-diseases.html?_r=1&ref=health) and it brings up a problem with most genetic views of chronic illness. There was a sort of unspoken doctrine in those looking for genetic precursors of illness; that is, that if the illness is common, the genetic difference will be common. It was a good idea, a hopeful idea, but very naive. Unfortunately most genetic literature I read today still shares this idea.

As full genetic sequencing (still too expensive to use in routine medical practice) has become more and more available, it has become clear that there are many more changes in each of us than we had previously thought. Let me point out a good example of that.

I’ve written before about MTHFR, a gene that produces an enzyme responsible for the production of L-methylfolate, which is, in its turn, required for good dopamine synthesis. Almost everyone who studies MTHFR looks at a single SNP, rs18001133, and occasionally at another, rs18001131. If a physician orders the test from a regular lab, they only get the answer for those two SNPs and bases the decision on whether or not to prescribe L-methylfolate on the answer to those two SNPs alone.

However, I’ve had the chance to look at over 100 SNPs in MTHFR for quite a few people who have responded to L-methylfolate as part of a treatment for addiction. There are other polymorphisms that can increase a person’s likelihood to respond to L-methylfolate and some that seem to make it unnecessary. This calls into question the conclusions of almost all modern genetic research in common illnesses.

Taking addiction for example, so many people look at one SNP and then report that they have found a significant difference in the prevalence of that SNP in a population with addiction using a certain substance. It’s easy to get these papers published. The problem is that they will not impact effective treatment much at all.

First we will require a good definition of addiction, which ASAM has provided us with just recently. ( http://www.asam.org/for-the-public/definition-of-addiction ). Then we will require whole genome sequencing of large numbers of people. The work of 23andme and other GWAS providers is just a beginning. I know that the public has a great amount of hope for genetic testing in disease, and it has already proven valuable to some with addiction, but this is still in its infancy and much, much more is yet to come.

© Howard C Wetsman MD FASAM 2012

I’ve often heard the old saying that everyone has enough intelligence to be able to follow the 12-step program of recovery, but some have too much. It’s a great joke and a old saw that reminds us to keep things simple, but is it true?

Johah Lehrer, blogging on Frontal Cortex at the New Yorker website (http://www.newyorker.com/online/blogs/frontal-cortex/2012/06/daniel-kahneman-bias-studies.html) had a recent post titled “Why Smart People Are Stupid.” Lehrer writes about the work of Dr Daniel Kahnerman and others on our mental biases. These biases are based on mental shortcuts that seem to be our natural way of thinking. Psychologists look for these shortcuts by asking simple logic problems and noting the answers. Here’s an example. “Billy buys a bat and a ball for $1.10. The bat costs $1.00 more than the ball. How much does the ball cost?” The short cut answer, and the wrong one, is 10 cents. The ball costs 5 cents and the bat costs one dollar more, $1.05.

Lehrer wrote the blog to report on a new study by Richard West and Keith Stanovich in the Journal of personality and Social Psychology. West and Stanovich looked at a number of these classic bias questions but also looked at measures of intelligence in the same sample. Here’s two paragraphs from Lehrer summing up the findings.

“Perhaps our most dangerous bias is that we naturally assume that everyone else is more susceptible to thinking errors, a tendency known as the “bias blind spot.” This “meta-bias” is rooted in our ability to spot systematic mistakes in the decisions of others—we excel at noticing the flaws of friends—and inability to spot those same mistakes in ourselves. Although the bias blind spot itself isn’t a new concept, West’s latest paper demonstrates that it applies to every single bias under consideration, from anchoring to so-called “framing effects.” In each instance, we readily forgive our own minds but look harshly upon the minds of other people.

And here’s the upsetting punch line: intelligence seems to make things worse. The scientists gave the students four measures of “cognitive sophistication.” As they report in the paper, all four of the measures showed positive correlations, “indicating that more cognitively sophisticated participants showed larger bias blind spots.” This trend held for many of the specific biases, indicating that smarter people (at least as measured by S.A.T. scores) and those more likely to engage in deliberation were slightly more vulnerable to common mental mistakes. Education also isn’t a savior; as Kahneman and Shane Frederick first noted many years ago, more than fifty per cent of students at Harvard, Princeton, and M.I.T. gave the incorrect answer to the bat-and-ball question.”

So what does this have to do with addiction and recovery? Imagine if you’re faced with a problem that you can’t think your way out of, like addiction. If you trust your thinking more than you should, you’ll try harder and longer to think your own way out before you ask for help. And help can come in a number of ways. It could be asking another person. It could be in using simple tools given to us by others in recovery. I remember telling a very intelligent patient once that he should do a written 4th step inventory and read it to his sponsor. He told me he didn’t need to write these things down because he had them all straight in his mind. Unfortunately, he trusted his own brain.

What the work of these psychologists shows is that it’s a normal human trait to over-trust your own brain and that people with higher SAT scores over-trust their brains more than most. It’s not just people with addiction that can’t trust their own thinking, it’s all of us. However when you have an illness like addiction, which requires surrender rather than thinking to treat, this normal human trait can be a handicap to wellness. And perhaps smarter people have a greater handicap. So maybe it’s true that everyone has enough brains to be able to work a 12-step program, but some have too much.

© Howard C Wetsman MD FASAM 2012