...but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience...To be 'cured' against one's will and cured of states which we may not regard as disease is to be put on a level with those who have not yet reached the age of reason or those who never will.
- C.S. Lewis
Disease Model Vs Bio-Psycho-Social Model
In North America, the vast majority of treatment programs for addictive disorders are based on the 12-Steps of Alcoholics Anonymous. According to this view, incentive use disorders are diseases. Treatment emphasizes admitting powerlessness over the illness, complying with a plan developed by treatment providers, and adopting the norms and values of a new social group—the support or self-help group—in order to achieve total abstinence, which is the only acceptable outcome goal. The victim of the disease is responsible for neither the cause nor the resolution of the problem.
An alternative view, The bio-psycho-social model: You are not responsible for falling into your addictive trap—you had no control of your genes, early conditioning, and social history. However, now that you are an adult you are responsible to develop the skills and faculties that enable you to act in accord with your interests and principles. Rather than encourage you to accept powerlessness over a disease, this approach encourages you to develop the power of your will so that you can act as intended despite the influence of local stressors and temptations.
The treatment approach should be matched with the attributes of the person receiving treatment.
- Individuals who are cognitively impaired due to chronic substance abuse, head injury, or psychiatric disorder required substantial external supervision and are best matched with a treatment program based on the disease model.
- Some cognitively intact individuals, especially those who are religiously oriented and outer-directed, are best matched with a 12-Step treatment program
- Some cognitively intact individuals are best served by a treatment approach such as the one presented here, which focuses on strengthening the skills and faculties required to act as intended during times of great stress and temptation.
Total Abstinence vs. Moderation
Treatment programs based on the disease model assume that the individual is powerless to control incentive use, and so do not permit moderation as a treatment goal. The bio-psycho-social model does permit such a goal, which for many individuals is a weakness of this approach. Experience suggests that going for moderation rather than complete abstinence is probably a bad bet; everyone thinks they can do it, but it is a much greater challenge than they realize. Be aware that there are only 3 possible outcomes: 1) abstinence, 2) controlled use, or 3) uncontrolled use. If you cannot control your incentive use, then you must choose between the two remaining options. At some point you must make the call and accept responsibility for it.
If you want to pursue moderation rather than abstinence as a goal, I request that you take the PIG’s wager: If you win, you get to be a controlled user; if you lose you must admit that the PIG is stronger than you had imagined (or are capable of imagining), and your only choice is between abstinence and uncontrolled use.
The PIG’s Bet
- Establish whatever rules you think are appropriate regarding incentive use.
- Whatever these rules are, the PIG bets that you can’t follow them.
- Take the PIG’s bet—that is, you wager that you will adhere impeccably to your rules.
- If you win the bet, you get to continue to use the incentive under the terms of your rules – that is, the rules that define controlled use.
- But if you lose the bet you must admit that you cannot be a controlled user. There are no “do overs.” Any violation of the rules means you lose, so bear this in mind when you make your rules.
Controlled use means that you are following your own rules, so there must always be rules pertaining to this aspect of your life. You may modify your rules according to some predefined schedule—never on the spur of the moment.
Disinhibition Resulting from Alcohol and Other Substance Use
Intoxicants in general, and alcohol in particular, disinhibit impulsive behavior. So even though alcohol abuse may not generally be a problem for you, you are much more likely to relapse when you are intoxicated than when you are clear thinking and sober. The more intoxicated you are, the greater the impairment of impulse control. Many people taking this course will dramatically increase their chances of success by explicitly controlling their alcohol intake, and hence their blood alcohol level (BAL). The recommended method to intentionally control BAL is to self-monitor—that is, note the time you start drinking and count the number of drinks you consume. With this knowledge and your body weight you will be able to calculate your BAL by consulting a BAL chart, or using a BAL calculator online.
If this is a consideration for you, or if you are not sure, please consider the recommendations below:
- Specify maximum number of standard drinks per day and week.
- Recommendation: No more than 3 per day and 14 per week for men; no more than 2 per day and 7 per week for women.
- Specify maximum number per special occasion.
- Specify maximum drinking rate.
- Recommendation: No more than 1 per hour, no shots, and no doubles.
Idiosyncratic rules, examples:
- No drinking during identified High-Risk Situations
- No drinking when angry
- No drinking with certain individuals
- No drinking when driving
- Decrease sip rate
- Decrease sip amount
- Substitute non-alcoholic beverages in certain situations
- Alternate alcohol and non-alcoholic drinks
Rigid Vs Flexible Strategies
You cannot be reasonable when battling corruption (corruption loves it when you are reasonable). However, being rigid creates its own set of problems. The fundamental strategic question regarding the exercise of will: Should you be rigid or flexible during high-risk situations?