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How Carecreds may work in restoring Motivation Edit Text

 

 

                                Everyone coming into contact with addiction whether patient, family or therapist knows that motivation to stop is the key to success. Yet they are baffled by why sufferers are so poorly motivated even when experiencing really dreadful consequences of their addiction. It has been a mystery why treatment is so generally useless but at last current research is begining to find an answer.

    At a deep biological level, animal motivation evolved over millions of years out of the need to survive.  It is this system that generates pleasurable and satisfying feelings whenever we have thoughts or actions that promote the benefit and the survival of ourselves or of the group to which we think we belong. It employs the hormone dopamine to produce rewarding feelings such as enjoyment, relief, contentment, pride and happiness. (Interestingly, this is the same hormone that seems necessary for all thinking and that in excess generates psychosis).

o    Unfortunately some genetically predisposed individuals, often in the course of seeking relief from stress, discover substances and behaviors that directly produce this relief and these dopamine rewards for virtually no effort. Thereafter they become trapped by the memory of achieving this and they develop a powerful addictive drive to repeat getting their dopamine by this “route one” method. This perverse motivation can then override their pursuit of health and survival and subvert the whole purpose of their life. Patients who survive severe addiction describe hitting “rock bottom”. The degradation, discomforts, isolation and semi-suicidal risks suddenly become too much to bear and they find an alternative way of life albeit with constant risk of boredom or stress induced relapse.

o    Others continue on in varying degrees of entrapment, indeed it has been estimated that the average career of a Class A addict lasts 9 years. An unfortunate way of coping with stress found in over a third of addicts is the switching off from reality by unconsciously undergoing a personality change. (See below) Their changed personalities are often amoral, criminal or childishly manipulative and generally cause increased stress for other people.  Irrespective of whether they change like this, nearly all severe addicts end up running parallel competitive stories of motivation; on the one hand wanting to care for themselves and their families and on the other wanting to get dopamine directly from their old habits.  

o    Our CareCred scheme is designed to provide a system of social intervention alongside medical substitution therapy that helps patients regain and then retain healthy motivation. Its focus is NOT on reducing the unwanted habits so much as supporting the attractiveness of the wanted ones.  A long-term stress-reductive, non-judgmental clinically supportive relationship is a key to its success.  Because addiction diverts natural love it very often destroys caring family relationships. CareCreds sets up a system of encouragement and earnable rewards that enable patients to be nudged out of their bad habits into good ones. The theory being that these good habits have a more fundamental genetic basis that will re-emerge and take over when given the opportunity.

o    It relies on a team approach with other local services and resources. It is focused on re-socialization rather than exclusion and punishment (which despite popular support have proved completely counterproductive and unsustainably expensive). CareCreds are by no means the perfect solution but they have been shown to be more effective than other measures and much more economic.  Our first target has been to get all patients off the dangerous use of street drugs and on to legal substitutes. Then instead of leaving them  ”parked on Methadone” we aim to get them reducing and detoxing so that they can start moving back into normal society. With CareCreds many  patients with chaotic unstable street addiction have become clean in 3 years. Although it is clear that some may be so badly damaged that that the best we can achieve is secure long-term care. 

What is Personality Disorder and how is it linked to addiction?

            Although having a personality is a very important part of being human, as every pet owner knows, animals also have recognizable personalities. Indeed it seems likely that having a personality has evolved in all higher animals as a way of assisting individuals to join in group collaboration in the common struggle to survive. 

            Although in following our instincts to be attractive and respected etc we create a rich variety of personal styles that are as recognisably different as our faces, underlying this variety are at least three basically similar personality states. These states are popularly described as Parent, Adult and Child. They are appropriate to (and are most easily seen) in three social situations that require 1) Quick (parental) defensive or aggressive "Fighting"  2) Calm (adult) calculation as to what action might be best  3) The (childish) fear reaction to "recruit assistance" and enable a quick "Flight" from danger.

           Personality disorder is when someone repeatedly slips into a personality state that is inappropriate to collaborating with others in dealing with the situation at hand. Typically it results in showing too little or too much emotion in the dialogue with them. This is known as incongruity of affect. Like substance abuse, personality disorder seems often to be caused by a need to escape the distress caused by chronic or severe stress. If switching personality relieves stress it becomes habitual, despite its damaging effect on harmonious collaboration. The commonest personality disorder is inappropriate regression. This means going back to behaving more like a teenager or toddler when sensible or responsible action is required. The style of personality-disordered behavior can be elaborate and even bizarre including criminal and sexual deviancy etc. Doctors often can recognize the age of someone's disordered personality as corresponding to a recorded stressful event in their medical records.

           The relationship between mood and thought is also a key feature of personality. Moods and emotions are the consequence of brain hormonal secretions and they are evolutionarily much older ways of controlling our lives. The inherited and acquired mood disorders such as psychosis and depression are important factors in how personalities develop, as indeed are thoughts and memories about the events in life. Thought is mainly an electrical process but hormonal secretions are also involved at the synapses where our nerves connect with each other. In this way thoughts can prompt feelings and vice versa. 

          Personalities themselves can be thought of as "roles" in the drama of social life. They develop their own life stories and recurrent patterns of behavior and appear in dream states as well as consciousness. We most easily recognize we have more than one personality state when we silently converse with ourselves at night. 

          Bereavement, losing love etc, indeed anything that breaks our expected or hoped for future, generate stress. The best way of surviving this is to be brave and to be always prepared to plan and implement alternative ways of leading a life story. This solves our problems and reduces stresses while addictions and personality disordered behavior just temporarily avoids anguish but in the long run generates more problems. Fortunately it seems that switching to inappropriate personality states, like relapsing into substance abuse, can be significantly reduced by problem solving stress reduction, which is why a CareCred approach to this is of value.

         Thus in essence our current personality states and their attendant repertoire of individualities are actively engaged in telling the story about who we are and what our life is all about. Through them we have internal and external dialogues that are crucial to our feelings of meaningfulness and worth. How negative or positive these dialogues are can alter both our happiness and hopefulness - both of which are key to either avoiding or recovering from addiction. Understanding this and acting upon it, is the way everyone, in particular the sufferers themselves, can be helped to develop alternative and more enjoyable life stories to solve their problems. 

        People suffering from chaotic addiction are often trying to escape from failing personal relationships and their attendant blame and anguish. Typically whenever they meet up with their former partner they both tend to act like aggressive-defensive children generating a stressful conflict that encourages the persistence of addiction and often steals the love and attention that is needed by their real children to develop into happy stable adults.  A breakthrough comes with the realization that they are both in the unnecessary grip of just one of many possible life stories. They can observe themselves and their partners switch personalities and behave in perfectly sensible ways with other people but somehow cannot see how they can change towards each other. The key is to refuse to converse with the regressed or inappropriate personality but instead to talk to the appropriate person hidden behind it. This conversation must be made in an adult and constructive way and never given up on because of initial failure.Just as "it takes two to tango" allowing a regressed personality in another to bring out the regressed personality in oneself is worse than useless. There is however always a danger that inappropriate personality performances appear to change when in fact they are pretending to be adult. This can lead to exhausting and potentially explosive repression of feelings that are more healthily expressed. The attendant stress of keeping up social pretences may further trigger addictive craving. Our Carecred approach is to encourage chaotically addicted people to rediscover their sensible positive personality state to solve interpersonal conflicts, so that they can then achieve permanent freedom from addiction.

ADDRESSING PROBLEMS WITH THE CARECRED APPROACH

Despite its record of success there are some problems with our CareCred approach. Many mildly addicted patients are living quite successful lives despite their habits and do not need this approach at all. Also giving vouchers to relatively wealthy patients e.g. many alcoholics and Cocaine abusers, can never produce as much of an incentive as it does with patients who are being impoverished by their habit. Furthermore despite our emphasis that credit has to be earned by valid action, clinical enablement is required to prevent even these poverty-stressed patients from viewing the whole system as yet another handout for them to manipulate. This becomes counterproductive to their ever recovering from their regressed personality problems and raises problems as to how long the CareCred service should be offered. To overcome these risks we have developed this service to be effectively "a course" of Carecred earning run via mobile phones. We award "graduation" when nine months of class A cleanliness has been achieved. Furthermore if any individual fails to make any progress after being nine months on the scheme, we withdraw them from it.

We recognise that becoming motivated solely by the childish greed to gain financial credit is nearly as undesirable as only reacting to the primitive fear of avoiding punishment.  This is why we use CareCreds to reignite those self-sustaining rewards that may only be obtained from mutually supportive collaboration.    

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