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Harvard Commentaries
35320
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Minding Your Mind Minding Your Mind
 

Treating Addictions -- Act Sober


November 16, 2013

By Michael Craig Miller M.D.

Harvard Medical School


Addictions to any substance, including alcohol or tobacco, are common and difficult to break. Addiction is not a moral problem. Rather, it's a brain problem: Drugs change the brain's self-regulating mechanisms, which means a persistent loss of self-control.

Maybe that's why the Alcoholics Anonymous (AA) advice to new members — to "fake it till you make it" or "act as if" — is so well-established. The idea is, follow AA's 12-steps — even if you are initially skeptical — and the program will help you avoid addictive behaviors. In other words, if you want to be successful in your sobriety, you must develop new habits to replace the old ones

Although thoughts and attitudes are an important part of developing the motivation to change, research supports this idea that may seem to be an example of backwards logic: You're more likely to stop abusing a substance and maintain abstinence by focusing at first on changing your behavior rather than changing your thinking and attitudes.

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Why Behavior Before Thought?

One way of explaining this phenomenon is the aptly named "reverse causation theory" of behavior change. According to this theory, behavior comes first and thoughts later — the reverse of what we imagine. Some people who are forced by the courts or pressured by family members to attend 12-step meetings stop using drugs. These individuals think their behavior change is a result of their participation in the group rather than as a response to legal or family pressure. In the end, they feel more committed to the 12-step approach, and that in turn helps to reinforce the new behaviors.

The second explanation is that addiction exerts such a powerful hold on people, physically and mentally, that an intensive focus on behavior is necessary to give the person a chance to successfully resist using. In contrast, if a person has a disorder that involves distorted thinking — such as depression or panic — he or she may be more likely to benefit from cognitive interventions.

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Alternatives to 12-Step Meetings

What about people who don't want to attend 12-step meetings? Some research has showed that people who sit in a meeting without participating do not have successful outcomes. For those people, it may be better to read materials about alcoholism or call a sponsor for support, particularly if that is what they are willing to do.

This implies that people who are reluctant to attend 12-step support groups might still benefit if they add an active component to their treatment, such as reading literature or getting involved with online meetings. However, more research is needed to find out if this approach would actually work.

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The Bottom Line

Behavior change may need to come before changing thoughts and attitudes if you're trying to overcome an addiction. It seems you don't have to understand why or how changing your behaviors works. But you probably do need to be actively engaged in dealing with the problem. This could be either counseling, encouragement from a sponsor and/or support from family and friends to take a leap and change that behavior. This may seem like too much pretending, but — in the case of addiction — there is at least some evidence now that acting "as if" has merit.

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Michael Craig Miller, M.D. is editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 25 years.

 

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