Acts Of ServiceStrengthening the neural pathways through acts of

service

Mary Crocker Cook, D.Min., LMFT, LAADC, LPCC, CADCIImary.cook@sjcc.edu

www.marycrockercook.comwww.marycrockercookbooks.com

“If addiction is best considered a chronic condition, then we are not providing appropriate

treatment for many addicted patients.”Thomas McLellan, Ph.D., Director of Treatment Research Institute

We are treating a chronic disease with an evidence-based, acute care model

Neu ro plas tic ity

The catchy phrase behind neu ro plas tic ity is “neu rons that fire together wire together”

The idea is that when two events (neu rons fir ing) occur in the brain at the same time, the events (neu rons) become asso ci ated with one another, and the neu ronal con nec tions (wiring) become stronger.

Neuroplasticity allows the neurons (nerve cells) in the brain to compensate for injury and disease and to adjust their activities in response to new situations or to changes in their environment.

Brain reorganization takes place by mechanisms such as “axonal sprouting” in which undamaged axons grow new nerve endings to reconnect neurons whose links were injured or severed.

Undamaged axons can also sprout nerve endings and connect with other undamaged nerve cells, forming new neural pathways to accomplish a needed function.

As with any path way, the more a par tic u lar path is used, the more ingrained it becomes, and path ways near one another become asso ci ated with each other. If a path is under uti lized, over time it will be co-opted by other path ways that are branch ing out and need more space.

Cognition in Early Recovery

Drug abusers who progress to the second stage of addiction are subject to withdrawal when they initiate abstinence. Many drugs produce cognition-related withdrawal symptoms that may make abstinence more difficult. These include:

• cocaine—deficits in cognitive flexibility amphetamine—deficits in attention and impulse control

• opioids—deficits in cognitive flexibility • alcohol—deficits in working memory and attention • cannabis—deficits in cognitive flexibility and

attention• nicotine—deficits in working memory and

declarative learning

A Timeline for Cognitive Recovery after Abstinence

Two Weeks: The average recovering alcoholic experiences:• Increased confusion • Increased irritability• Distractibility• A decreased ability to attend and concentrate• Slower reaction times• A decreased ability to use verbal abstract reasoning• Decreased verbal short-term memory• Impaired verbal learning abilities• Impaired mental flexibility• Impaired visual-spatial abilities• Decreased non-verbal short-term memory

These thinking problems help to explain high relapse rates during the first period of abstinence and underscore the need for effective compensatory coping strategies (such as those you would learn in an addiction treatment program).

Two Months

• By 60 days into recovery, distractibility, confusion and irritability have disappeared, but:

• memory problems• concentration• learning• mental flexibility• abstract reasoning• and visual-spatial deficits remain.

Never-the-less, in response to an acute-care model of addiction treatment, the majority of the social cognitive neurology research has addressed changing the structure and function of brain circuity through cognitive restructuring or mindfulness-based relapse prevention, meditation, and very little on the neurological benefits of service.

Altruists and Psychopaths

Abigail A. Marsh, Ph.D., Assistant Professor, Department of Psychology, Georgetown University, who recently discovered extreme altruists, altruistic kidney donors, have different brains. Their amygdala is larger.

Consistent with these findings, other research has also found that psychopaths have smaller amygdalas and are therefore less able to empathize with others. Dr. Marsh, et. al. used structural and functional brain imaging to compare extraordinary altruists, specifically altruistic kidney donors, and controls.

Altruists exhibited variations in neural anatomy and functioning that represent the inverse of patterns previously observed in psychopaths, who are unusually callous and antisocial. These findings suggest extraordinary altruism represents one end of a caring continuum and is supported by neural mechanisms that underlie social and emotional responsiveness

While Dr. Marsh had detected increased amygdalas in altruists, I wondered if altruism, particularly service could increase amygdala volume.

The amygdala is the seat of emotions and emotional memory so key to the reward pathway central to addiction. Research results help to clarify the amygdala’s structural and functional differences in recognizing emotion from faces, to social behavior and differences in sociality and social networking building, and to reward learning and instrumental behavior.

The importance of service to the ongoing sobriety of alcoholics

In an investigation involving data from Project MATCH, Pagano and colleagues (20)(2009) demonstrated that 94% of alcoholics who began to help other alcoholics at any point during the 15-month study period continued their helping behaviors. In another study, (21) second pattern that emerged from this study pertains to the course of general versus AA specific helping behaviors.

Lower levels of general helping while drinking increased to moderate levels at 1 year and 20 years sober. This finding parallels the pattern found in a similar study of 17 alcoholics with 20.7 years sobriety and long histories of AA participation. Kurtz and Fischer (2003) noted a gradual progression of community activities that followed involvement in 12-step organizations.

In a ten year study, Pagano, White, Kelly, Stout,& Tonigan, (2013), Controls for pretreatment levels of OOI, (One item from the Beck Depression Inventory (BDI) (64) were used as an index of AA’s espoused behavior towards others (i.e., “. . . trying each day to be a little more thoughtful and considerate to those with whom we came in contact” (65, p. 356).

With regard to interest in others in the past week, participants rated the OOI item from 0 (no loss of interest) to 3 (lost all interest). those engaged in AAH (AA-related Helping) were significantly more likely to report higher interest in others. These findings suggest the importance of meeting attendance to abstinence as a newcomer and in long-term recovery, and support AA’s suggestion to help others as way to stave off an urge to drink and increase interest in others

Is something happening at the neurological level that creates an evidenced-based reason to purposefully integrate service to other into individualized treatment plans?

Sharon Begley in her book, Train Your Mind, Change Your Brain, speaks to how attention to what we are paying attention to changes your brain. This is an excerpt from an article that she wrote for the Wall Street Journal (24);

Through attention, UCSF's Michael Merzenich and a colleague wrote, "We choose and sculpt how our ever-changing minds will work, we choose who we will be the next moment in a very real sense, and these choices are left embossed in physical form on our material selves."

The discovery that neuroplasticity cannot occur without attention has important implications. If a skill becomes so routine you can do it on autopilot, practicing it will no longer change the brain. And if you take up mental exercises to keep your brain young, they will not be as effective if you become able to do them without paying much attention."

The implications for neural circuity changes as a result of acts of service, to the extent that service and prosocial acts become “autopilot” behaviors are profound for long term recovery.

The focus on service in recovery is particularly crucial, given the research finding at the Case Western Reserve/Case Medical Center University Hospitals on Recovering addicts and service (25) which found lower monetary giving and volunteerism lending empirical support to the often observed lack of other oriented regard among addicts/alcoholics.

Summary

Although research has clearly demonstrated the physical and mental health benefits derived from helping others, its impact on substance dependent (SD) individuals is not yet fully understood.

Emerging research suggests that SD adolescents participate less frequently in prosocial behaviors and thus may receive fewer benefits (Pagano, Carter, Johnson, and Exline, 2010). This study aims to replicate prior findings that substance dependency is associated with reduced levels of prosocial behavior involvement with SD adults.

Using a matched pair design, 43 adults admitted into an intensive outpatient treatment for SD were compared to 43 normative adults from the annual General Social Survey. Prosocial behaviors were assessed with the six-item General Social Survey (GSS) altruism module: (i) donating blood, (ii) giving food or money to a homeless person, (iii) volunteering, (iv) giving money to a charity, (v) looking after a neighbor’s home, and (vi) carrying a stranger’s belongings. With reference to the past year, items were rated from 1 = ‘‘more than once a week’’ to 6 ‘‘not at all in the past year.’’

Approximately half (51.2%) of the clinical sample were female (n = 22), 43 years of age (M=42.77) on average, 68.29% were alcohol dependent, and 70.73% were substance dependent at the time of treatment admission.

Across samples, most participants rarely or never donated blood in the past year (94.19%), approximately half had not cared for a neighbor’s property (58.14%) or volunteered (59.30%), and one out of three rarely or never gave money to the homeless (30.23%) or charity (29.07%).

When matched by age and gender to a normative adult sample, SD adults had significantly lower prosocial behaviors in three domains: (i) giving money to the homeless (ii) (ii) giving money to charity (iii) (iii) volunteering

The results of this study are consistent with prior research with prior research with SD adolescents. SD adults, like SD youth, appear to give less money to the homeless and charity. SD adults also volunteered less than normative adults. These findings of lower monetary giving and volunteerism lend empirical support to the often observed lack of other oriented regard among addicts/alcoholics.

The bottom line is that people in early recovery enter the recovery process LESS inclined toward

service, or even altruism than the average person.

Why might this be?

Developmental Issues

Modern theories on narcissistic pathology and ego psychology propose that the use of substances is linked directly to narcissistic disturbances (Acker, 2002) (26).

Specifically, those with narcissistic personalities may use alcohol or drug intake as a primary mechanism to ‘‘refuel’’ the pathological grandiose self, ensure its omnipotence, and provide protection against a potentially frustrating and hostile environment in which gratification and admiration are not forthcoming. More recently, psychologists have hypothesized that the narcissism/addiction link results from a pattern of yielding to inner urges in a way that proves costly and self-destructive (27) (Baumeister & Vohs, 2001).

ego-centrism and ego development

• Youniss (1990) (29) proposed that heightened sensitivity, self-absorption, and a preoccupation with self-characterizes the normative ego-developmental period of adolescence. In contrast, the defining characteristics of ego-centrism include a grandiose sense of self importance, a tendency to exaggerate accomplishments and talents, and an expectation to be noticed as ‘‘special’’ without appropriate achievement (Kohut, 1971; Millon, 1990 (30)

• According to Miller & Eisenberg (1986) (31), in the course of healthy development of a sense of self, adolescents gradually increase their interest outside themselves and learn to use other people, things, and activities as means to regulate self-esteem and modulate mood.

• These outward-directed interests are known as prosocial behaviors, or altruism, which according to Macaulay and Berkowitz’s (1970) (32) conceptual definition, are ‘‘behavior[s] carried out to benefit another without anticipation of rewards from external sources.’’

In dramatic contrast, it is theorized that an adolescent with substance dependency fails to complete such normal development with any degree of success. As a result, such an individual does not transition to a stage of healthy ego development and increased interest outside the self and toward others. Instead, the adolescent becomes developmentally arrested, and addiction becomes the determinant of his or her models and values (Kohut, 1971; Ulman & Paul, 2006) (33).

To explain further, illicit substances become a surrogate ideal or a substitute value that normally would be supplied by an internal sense of meaning, goal directedness, and value orientation. Instead, the adolescent’s goals become external; the relief and pleasure sought with help of illicit substances lead to a predominantly self-serving lifestyle of drug-seeking behaviors Wurmser, 1974) (34).

My experience as an addiction recovery provider has taught me that the majority of early

recovering people are not characterologically narcissistic but more likely have under developed neurological connections,

connections pruned over the course of addiction.

The answer to addiction involves the nucleus accumbens, a cluster of nerve cells that lies beneath the cerebral hemispheres. When a human being or other animal performs an action that satisfies a need or fulfills a desire, the neurotransmitter dopamine is released into the nucleus accumbens and produces pleasure. It serves as a signal that the action promotes survival or reproduction, directly or indirectly. The system is called the reward pathway. When we do something that provides this reward, the brain records the experience and we are likely to do it again. Damage to the nucleus accumbens and drugs that block dopamine release in the region make everything less rewarding.

In the last few years, research has suggested that addiction involves many of the same brain pathways that govern learning and memory. Addiction alters the strength of connections at the synapses (junctions) of nerve cells, especially those that use the excitatory neurotransmitter glutamate.

• Resilient people realize that they are “connected”—through compassion (to self and others) and through community (reaching out and receiving help).

• Neurologically, the research suggests that at least two connections are relevant: (1) the right-brain with the left-brain through the corpus callosum and (2) the frontal cortex with the emotional brain through specific limbic-cortical pathways.

Timing, planning, having SOCIAL resources, and self-monitoring all appear to be important. Again, prosocial behaviors seem to work here—helping others, being altruistic, paying it forward, showing appreciation, allowing others to help us

This leads me to ask, again, how can we stimulate these changes through behaviors, such as service to others. A key question replete with both theoretical and practical significance is whether explicit interventions or training designed to foster prosocial behavior and well-being, or more naturally-occurring forms of positive social interaction and social support, can induce neuroplastic changes in the brain.

Protocol

New Outpatient Program participants will be given the Prosocial Personality Battery (PSB) and asked to complete it anonymously and as honestly as possible. Each test will ask for the last 4 digits of the participant’s social security number to be recorded on the test for retest purposes.

Half of these participants will be asked to complete, and record, at least three acts of intentional service each week, and submit their logs to their counselor. Half of the participants will complete the program as it is currently offered.

At the end of 90 days, they will again be given the Prosocial Personality Battery (PSB), with their initials recorded on the survey, so the survey can be matched to the original. Changes, if any, will be recorded. Three months later, these same participants will take the Prosocial Personality Battery (PSB) one more time, and changes will be recorded.

Prosocial Personality Battery Review

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