Tuesday, April 10, 2007

Understanding the Alcoholic's Mind: The Nature of Craving and How to Control It

By Arnold M. Ludwig, M.D.
ISBN 0195059182

Reviewed by Diane J.

I have a confession to make (no, no, not THAT one)--I bought this book strictly because of the subtitle. And it was definitely a good impulse: Understanding the Alcoholic's Mind is a fascinating and elegant little book on craving and relapse, the cognitive distortions that accompany both, and methods used by successfully sober alcoholics to "avoid or resist temptation." The strength of this book is in its vivid presentation of thinking patterns that support drinking and of thought techniques that can be used against these.

Ludwig, a member of the Department of Psychiatry at the University of Kentucky and a prolific researcher and author, begins his book with the flat acknowledgement: "There is no general agreement about the nature, cause, or treatment of alcoholism"--a truism he drives home with a brief discussion of the "paradoxes and contradictions" in current attitudes. Searching for "a common area of overlap" that will allow a clear description of "what individuals need to do to insure sobriety", Ludwig proposes that the answer is "in the mind," and sets out to describe the ways in which alcoholics can change "their thoughts, attitudes, and motivations."

As you may be aware, the alcoholic's mind is an interesting but not exactly low-maintenance piece of work, and Ludwig does it some justice in the chapters that follow. In "The Lure of the Sirens", he traces the ways in which some alcoholics "covertly maneuver to arrange a slip", complete with some disconcertingly plausible examples, and links this to a persistent unconscious belief that one can SOMEDAY, SOMEHOW learn to drink safely again, that "this time will be different." (In a lengthy footnote essay, Ludwig ties this insight into an interesting critique of Marlatt and Gordon's work on the 'abstinence violation effect'.)

The following chapter details nine "drinking scripts" Ludwig identified in the course of his research, patterns of thoughts and attitudes that tend to accompany and intensify craving. Ludwig notes that this kind of thinking is hardly unique to alcoholics, but that it presents special dangers for them given the possible severe consequences of acting on it. He considers the scripts "private self-statements, a type of nonvocal inner speech" that mediates between the intention to drink and the actual act of drinking.

The scripts, which are vividly described and quite recognizable, include "the escape script" (all I want is a little peace....); "the relaxation script"; "the romance script"; the "to-hell-with-it script" (a personal favorite); "the self-control script" (more popularly known as the "I'll just have one--maybe two" script); and, for good measure, the "NO control script": "Just as believing in one's ability to handle alcohol intake is usually a setup for relapse, the attitude of not being able to control cravings virtually insures it."

Having surveyed the distorted thinking that accompanies craving, Ludwig turns his attention to "the mystery of craving" itself, in a chapter that combines anecdotes about craving with an excellent and balanced survey of cognitive-behavioral studies of craving, including research into environmental cues, conditioned responses to emotional states, and the highly individual nature of each alcoholic's personal "Pavlov's bells". (It should be noted that Ludwig makes little attempt to deal with the biology of craving, except to note that it increases markedly if the craver actually drinks.) His ultimate point is that craving is not a mysterious or uncontrollable event, that an individual can learn to predict the likelihood of craving and to resist it, and that it weakens and disappears if the alcoholic abstains for an extended period.

All well and good, but how exactly is this craving, drinking-thinking, planning-for-relapse alcoholic going to be motivated to abstain for long enough to weaken those cravings? And what techniques can she or he possibly bring to bear against powerful cravings triggered by personal cues and the seductive "logic" of the inner drinker whispering from the favorite "drinking script"? I do not think Ludwig has done a particularly persuasive job of answering the first question, but his answers to the second are intriguing and useful.

Ludwig's discussion of the "devloping the proper frame of mind" (adequate motivation) for sobriety is preceded by his survey of the often dismal recovery statistics and review of practically every available treatment modality. The chapter title, "On and Off the Wagon", gives some indication of his tone. While he is generally approving of AA, he does not shrink from the low success rate, notes the existence of other sobriety organizations, and suggests that "the very process of group affiliation" may support abstinence. He then proceeds to discuss "hitting bottom", in what is probably the weakest section of the book, piling up suitably striking anecdotes about various "bottom experiences" and "spiritual conversions to AA" without much analysis. It is clear that he believes that the "spiritual experiences" he portrays have purely psychological explanations, but he escapes by making reference to William James in the text, burying his scientific explanation in a 7-page footnote, and concludes with "If God doesn't intervene, alcoholics will have to find a way of resisting temptations on their own." (Thank you, and about time, too.)

Back on his own cognitive-behavioral ground, Ludwig spends the rest of the book detailing ways of resisting temptations, and they are good ones. He opens by pointing out that some commonly used thought-control techniques are relatively ineffective. Direct counterpoint thinking, "fighting a craving head-on", can fuel it. Resolving NOT to do something can create more difficulties than it solves, as "The picture of NOT doing triggers an image of doing what the individual is resolved not to do...[but] individuals cannot visualize "NOT", so the image of drinking may grow in intensity if you merely oppose it with the idea of "NOT DRINKING." He suggests that you should instead picture a substitute behavior every time the image of the unwanted behavior occurs to you.

Other "mind-control" techniques covered include "distraction", "substitution", "thought-ignoring" and "thought-stopping," "postponement", "playing the thought through" and "immediate negative conditioning". If some of these sound like methods you are already using, they probably are: the advantage of Ludwig's presentation is that he gives a clearly organized description of each one and notes its strengths and weaknesses. He also discusses their similarity to Buddhist meditation techniques for focusing concentration.
The nine "drinking scripts" from the earlier chapters are matched by five "sobriety scripts" drawn from Ludwig's interviews with recovering alcoholics. These are "the negative consequences script," the "benefits of sobriety script", the "rationality script", the "avoid-the-first-drink script", and the "prayer script". Again, you will probably recognize some or many of these, but they are vividly detailed, often in the words of the interview subjects, and you will probably find ideas and phrases that will work for you.

The final chapter, "The Sober Mind", is a brief and rather pedestrian discussion of "living sober." The most interesting portion of it is an extended footnote essay in which Ludwig offers his "personal sobriety formula".(Since this is the third time I have had to refer the reader to the footnotes, let me just urge you to READ the footnotes: there are several full-length essays in there on subjects ranging from Marlatt's Relapse Prevention theory and Gregory Bateson's "The Cybernetics of Self" to drug-induced religious experiences. Ludwig could have used a more adventurous editor.)

All in all, I found this to be an interesting and very useful book. It can be quite valuable to have a "classification system" for those drink-fighting thoughts, and at least one of those drinking scripts is guaranteed to hit a nerve if you are familiar with alcoholism.

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