Monthly Archives: September 2015

09/7/15

Preventing and Stopping Cravings

© Boris Ryaposov | 123rf.com

© Boris Ryaposov | 123rf.com

Not all addicts and alcoholics struggle with cravings in recovery. And not all addicts and alcoholics experience them with the same intensity. But knowing how to recognize the sets ups and triggers for a craving are crucial skills for those in recovery who do experience them. Otherwise, it’s like living through a drug and alcohol-themed version of Groundhog Day.

On his blog, Terence Gorski described a three-stage model to manage cravings without them leading back to active drug or alcohol use. Two previous articles “Ready to Cope with Cravings” and “Getting Set to Cope with Cravings” reviewed the three stages of Gorski’s model to understand cravings. This final article of the three part series describes how to prevent cravings and stop them once they do occur.

Craving is not an inevitable process. They can be prevented if you follow a few simple guidelines. And they can be managed without a return to active drug use. Gorski suggested five preventive measures against craving.

  • First, develop and maintain a structured recovery program that keeps you in regular, continuous, daily contact with other recovering people.
  • Second, know what your triggers are. “Identify the things that activate the craving and learn how to cope with those triggers.”
  • Third, know and avoid your set-up behaviors; learn how to cope with them if you can’t avoid them.
  • Fourth, dismantle euphoric recall—intentionally include where the “fun” of the high will eventually lead you. Remember where it took you in the past.
  • Fifth, stop awfulizing sobriety and put an end to magical thinking.

Despite your best efforts, you may still experience cravings. Remember that they are a normal symptom experienced by most addicts in recovery.  While there are a fortunate few who have minimal or no problems with cravings in early recovery, they are the exception, not the rule. So if you have cravings, stop them from leading you back to active drug use by practicing a few simple steps.

  • First, recognize the craving. This may seem obvious, but sometimes the craving is mild and appears to be something you can “white knuckle” it through until it’s over. “Many addicts fail to identify mild craving as problematic and wait until they are full-blown, severe cravings before taking action.”
  • Second, don’t panic if you have one. Remember that cravings are normally experienced by addicts in recovery. It doesn’t mean you are doomed to resume active drug use or that you aren’t doing enough for your recovery.
  • Third, get away from where you are. A craving might be activated by an environmental trigger. You may have thought a situation wouldn’t be a trigger, only to discover once you are in it, that it triggers you. GET OUT OF THERE and go to “an environment that supports recovery.”
  • A fourth step you can take is to talk the craving cycle through with someone. “If you talk it through, you don’t have to act it out.” Honestly talking the process through from beginning to end can discharge the urge to use because you are mentally removing yourself from it. It’s like you have a video of the process that you are reviewing. You stop, rewind, fast-forward, and go frame by frame with the recording of what happened to discover the timeline and cause-and-effect chain reaction of what led to the craving.
  • Fifth, distract yourself. Divert attention from the craving by engaging in other productive, positive activities that require your full attention.
  • You could do some aerobic exercise, a sixth action step to cope with cravings. Aerobic exercise can stimulate brain chemistry that reduces cravings.
  • Seventh, you can try meditation or relaxation. Cravings are often intensified under high stress. “The more a person can relax, the mower the intensity of the craving.”
  • Eighth, you can eat a healthy meal to nourish your brain.
  • Ninth, remember they are time-limited and will eventually pass. Most cravings won’t last more than two or three hours. If you persist in the steps suggested here to the point of getting fatigued enough to fall asleep, many people wake up with the craving gone.

It is possible to understand drug craving and to learn how to manage craving without returning to use. A model that allows people to identify set-up behaviors, trigger events, and the cycle of craving itself, and intervening upon this process has proven effective in reducing relapse among addicts.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, Terry Gorski’s blog, where he graciously shares much of what he has learned, researched and written over the years. You can access additional articles stemming from Terence Gorski’s material under the Gorski link on Faith Seeking Understanding.

09/4/15

Hardened, Unbelieving Hearts

© joannawnuk | stockfresh

© joannawnuk | stockfresh

Ryan Bell received a Master of Divinity degree from Andrews University and a Doctor of Ministry from Fuller Theological Seminary. He was a pastor for 19 years, most recently the senior pastor of the Hollywood Seventh-day Adventist Church until March of 2013 when he resigned his position. Beginning in January of 2014, he formally began to live for one year without God. He started a blog on this journey, “A Year Without God.” There is a documentary of this time in the works. And at the end of that year, Bell decided to keep on living without God. During an interview with NPR at the end of 2014, he said: “I think before, I wanted a closer relationship to God, and today I just want a closer relationship with reality.”

As he began his “journey” into atheism, Bell said: “For the next 12 months I will live as if there is no God. I will not pray, read the Bible for inspiration, refer to God as the cause of things or hope that God might intervene and change my own or someone else’s circumstances.” In effect, he would do whatever he could to enter into the world of atheism for a year. At the time, he felt it was important to clarify that he was not an atheist; at least not yet.

In an NPR interview at the end of 2014, Bell said he looked at the majority of the arguments for the existence of God and didn’t find a convincing case. “I don’t think that God exists. I think that makes the most sense of the evidence that I have and my experience.” As I write this, Bell continues on without God and hasn’t shown any signs of turning around. This last quote seems to indicate the central factor in his journey away from God: evaluating the evidence for God from the starting point of his own reason and experience.

Frankly, I think that any attempt to reason your way to a belief in the existence of God or to self-consciously live apart from God will end in a similar place. It doesn’t matter if you do so in the midst of taking a break from God or not. Christianity sees human reason as tainted—fundamentally searching for autonomy from God. That’s the story told by The Fall in Genesis 3: wanting to be wise like God. Wanting knowledge of good and evil independent of God’s counsel. Wanting your reason and experience to be the final arbiter of all things.

Bell had determined to live as if there was no God, and in the process he drifted away from God. Personally, I think his drifting began a long time before he began his year away from God. The desire for independence from God meant that when he cast off his anchors (praying, reading the Bible, etc.), the drifting just accelerated. I say this with no rancor towards the man; I don’t know him, but I do know myself. And I know that if I tried to live my life independent of God—to cast off my own anchors—I would drift too.

The writer of Hebrews knew of this danger and cautioned his readers to be careful: “Therefore we must pay much closer attention to what we have heard, lest we drift away from it”  (Hebrews 2:1). Again in verse 3:12, he warns that an evil, unbelieving heart will lead you away from God. In Hebrews 3:12 and 13 the warning is twofold: to not lose your faith and to encourage one another so that your heart is not hardened by the deceitfulness of sin.

Take care, brothers, lest there be in any of you an evil, unbelieving heart, leading you to fall away from the living God. But exhort one another every day, as long as it is called “today,” that none of you may be hardened by the deceitfulness of sin. (Hebrews 3:12-13)

The author of Hebrews had just quoted Psalm 95 in verses 3:7-11 and now applies the situation of the wilderness generation of Israel described there to the circumstances of his readers. Verses 3:15-19 directly connected this section of Hebrews to the warning given in Psalm 95. Verse 3:15 repeated the caution of verse 3:7 and Psalm 95, if “you hear God’s voice, don’t harden your hearts” as you did on the day of testing at Meribah.

The Israelites had accused God of abandoning them, of bringing them into the desert to die of thirst. Even though they experienced what God did for them in the past, their reason failed to see how He would provide water for them and their cattle. “Is the Lord among us or not?” So at the command of the Lord, Moses struck the rock at Horeb and water came out (Exodus 17:1-7).

The progression in Hebrews 3:12-13 is from a heart that is evil (sinful) and unbelieving, to one that turns away from God and is ultimately hardened by the deceitfulness of sin. David Allen noted in his commentary on Hebrews that this is not a passive turning away. Rather it was deliberate disobedience. “This is the antithesis of the spirit of those who draw near to God” (Hebrews 10:22). In Instruments in the Redeemer’s Hands, Paul Tripp said this progression was the result of indwelling sin.

On the cross and in the resurrection, Christ broke the POWER of sin over us (Rom. 6:1-14), but the PRESENCE of sin remains. Sin is being eradicated within us, and this will continue until we are sin-free. But while sin remains, we must remember that sin is deceitful. Sin blinds—and guess who gets blinded first? . . . Since each of us still has sin remaining in us, we will have pockets of spiritual blindness.

To illustrate the importance of the community of believers in dealing with our pockets of spiritual blindness, imagine a circle of people sitting in a room with several posters on each wall. Then one person is asked to describe the poster hanging directly behind them without turning to look at it. They can’t—because the poster is in their blind spot. But any of the other individuals can help them, because the poster is not in their blind spot. That is why the writer of Hebrews encourages us to watch out for and encourage one another. We all have spiritual blind spots that we can’t see into. And sin is likely to approach us within our blind spot. Remember it is deceptive.

Along with David Allen, I agree that it would be reading too much into the words “evil, unbelieving heart, leading you away from the living God” to see this as having the sense of apostasy. Once I taught a course on biblical counseling at a small Christian institute. Theologically, both myself and several other staff members were theologically Reformed. At the annual board meeting for the institute, the board voted to not renew the contracts for all Reformed-leaning faculty. Reportedly, one board member said: “We have purged the evil from among us.” Christians are sometimes too quick to see individuals with theological beliefs at variance from theirs as “unbiblical” or “apostate.” As David Allen commented on the passage:

The context does not define what the author intended here. “Taking the Greek term apostēnai as it is used here and burdening it with the theological baggage of apostasy is premature. . . . It is better to interpret it broadly as distrust, disobedience, or disloyalty, and not attempt to define the exact scope of the warning.

So instead of entering into an Arminian (he lost his salvation), Calvinist (he never really was converted) debate over Ryan Bell and his current state of professed atheism, I think I’d rather pray to the God he doesn’t believe in to make Himself known. For those who do believe in God, there is still hope for Bell and others who demonstrate distrust for God in their life. The author of Hebrews declares:

For the word of God is living and active, sharper than any two-edged sword, piercing to the division of soul and of spirit, of joints and of marrow, and discerning the thoughts and intentions of the heart. And no creature is hidden from his sight, but all are naked and exposed to the eyes of him to whom we must give account. (Hebrews 4:12-13)

09/2/15

Do No Harm with Antidepressants

© Jrabelo | Dreamstime.com

© Jrabelo | Dreamstime.com

In April of 2006, I first read Irving Kirsch’s 2002 article, “The Emperor’s New Drugs.” In that article, Kirsch described how 80% of the response to antidepressant medications was duplicated in placebo control groups. Kirsch’s analysis was of the very same clinical data submitted to the FDA between 1987 and 1999 for the approval of 6 widely prescribed antidepressants. The allusion to Hans Christian Andersen’s tale, “The Emperor’s New Clothes” was fitting. Kirsch played the role of the little boy in Andersen’s tale to my understanding of how antidepressants work. He pointed to antidepressants and said: “But they have little or no therapeutic effect at all!”

Since 2006 I’ve become familiar with the work of several individuals questioning the received wisdom of psychotropic medications, including Joanna Moncrieff. Her book, The Myth of the Chemical Cure, had its own “aha!” moment in the development of my thinking on the clinical use of psychiatric medications. A search of  “Faith Seeking Understanding” by their names will pull up other articles where I have referenced them.

Not too long ago, I saw a link to a new article by Joanna Moncrieff and Irving Kirsch, “Empirically derived criteria cast doubt on the clinical significance of antidepressant-placebo differences.” I’ve read previous articles written by Moncrieff and Kirsch, “Efficacy of antidepressants in adults” and “Clinical trials and the response rate illusion.” But still looked forward to reading their latest. It seems to have hammered home the final nail in the coffin of the ineffectiveness of antidepressants for me.

In “The Emperor’s New Drugs,” Kirsch found that the drug/placebo difference was less than 2 points on the Hamilton-D (HAM-D) scale, a scale often used in studies for assessing the effects of antidepressants. Even then, Kirsch et al. were saying that: “the clinical significance of these differences is questionable.” The spin put on his conclusions was that this was only to hold true only for individuals with mild cases of depression. Moderate to severe depression should still have antidepressants as a first-line treatment.

However, in “Efficacy of antidepressants in adults,” Moncrieff and Kirsch pointed out that the studies included in “The Emperor’s New Drugs,” were mainly with patients suffering with severe to very severe depression. They cited additional studies questioning the efficacy of antidepressants and concluded: “Recent meta-analyses show selective serotonin reuptake inhibitors have no clinically meaningful advantage over placebo;” and that “Claims that antidepressants are more effective in more severe conditions have little evidence to support them.”

In their most recent article, Moncrieff and Kirsch tackled the issue of how antidepressants have been shown to be statistically superior to placebo. This statistical significance has been true from the time of Kirsch’s work on “The Emperor’s New Drugs, ” where the authors said that: “Although mean differences were small, most of them favored the active drug, and overall, the difference was statistically significant.” Moncrieff and Kirsch commented that a three-point difference on the HAM-D scale could not be detected by clinicians. Clinically relevant drug-placebo differences would have to be 7 points or greater on the HAM-D scale. “Currently, drug effects associated with antidepressants fall far short of these criteria.”

These conclusions were built upon the work of German psychiatrist Stefan Leucht and his colleagues. You can read a less technical discussion of the importance of this research in Dr. Moncrieff’s blog, here. She said that a reduction of 2 points on the 52 point HAM-D scale, while statistically significant, seemed to be an insignificant amount. “Leucht et al. provide some empirical evidence to support that hunch.”

Given that there was little if any difference in clinically relevant effects between one treatment and another, Moncrieff and Kirsch suggested that patients and healthcare providers should be aware that all treatments, including placebo, produce some positive effect on symptom scales, “while none outperforms a pill placebo to a meaningful degree.”

The small differences detected between antidepressants and placebo may represent drug-induced mental alterations (such as sedation or emotional blunting) or amplified placebo effects rather than specific ‘antidepressant’ effects. At a minimum, therefore, it is important to ascertain whether differences correlate with clinically detectable and meaningful levels of improvement.

So where does this discussion lead us? Treating depressive symptoms with antidepressants should not be a first option. “Given the choice, most depressed patients prefer psychotherapy over medication.” Moncrieff and Kirsch suggest that decisions about treatment should include patient preference, safety and cost. With regard to safety, antidepressants should be a last choice for treatment alternatives.

Their article referenced a study by Andrews et al., “Primum non nocere” (first, do no harm), which noted a series of harmful effects from SSRIs. Serotonin has wide reaching effects on adaptive processes throughout the body and could have many adverse health effects. They described how antidepressants effect the proper functioning of homeostatic mechanisms in the body.  Long-term use is associated with a loss of symptom reducing effectiveness with SSRIs. This suggests that the brain is pushing back against the effects of SSRIs and trying to regain the homeostasis present before the use of antidepressants began. “Because of the complex role that serotonin plays in shaping the brain, antidepressants could have complex effects on neuronal functioning.”

Additional negative side effects included attention problems, driving performance, falling and bone fractures in the elderly, gastrointestinal problems such as diarrhea, constipation and irritable bowel syndrome. SSRIs may increase the risk of abnormal bleeding. They can related to an increase risk of cardiovascular events. There is concern that SSRIs can effect neonatal development. One study suggested SSRI use during pregnancy, especially the first trimester, led to an increased risk of Autism Spectrum Disorders. Andrews et al. summarized their findings here:

We have reviewed a great deal of evidence of the effects of antidepressants on serotonergic processes throughout the body. Some of the effects are widely known, but they have been largely ignored in debates about the utility of antidepressants. Indeed, it is widely believed that antidepressant medications are both safe and effective; however, this belief was formed in the absence of adequate scientific verification. The weight of current evidence suggests that, in general, antidepressants are neither safe nor effective; they appear to do more harm than good.