Recovery is exhausting

[simco]

I recently stumbled onto an interesting article (http://journals.sagepub.com/doi/abs/10.1177/1948550616679237):

[h=1]What?s So Great About Self-Control? Examining the Importance of Effortful Self-Control and Temptation in Predicting Real-Life Depletion and Goal Attainment[/h]
[h=2][/h]
Self-control is typically viewed as a key ingredient responsible for effective self-regulation and personal goal attainment. This study used experience sampling, daily diary, and prospective data collection to investigate the immediate and semester-long consequences of effortful self-control and temptations on depletion and goal attainment. Results showed that goal attainment was influenced by experiences of temptations rather than by actively resisting or controlling those temptations. This study also found that simply experiencing temptations led people to feel depleted. Depletion in turn mediated the link between temptations and goal attainment, such that people who experienced increased temptations felt more depleted and thus less likely to achieve their goals. Critically, results of Bayesian analyses strongly indicate that effortful self-control was consistently unrelated to goal attainment throughout all analyses.


[emphasis is mine]

This resonated with me because my therapist recently mentioned her belief that resisting impulses is a particularly exhausting form of activity.

The article is interesting in many ways, but to me, it was really eye opening to read so clearly what I had intuited on my own--resisting cravings and other drug-related impulses is not only difficult in its own right. It's also profoundly depleting, and over time, this exhaustion/depletion of energy can compromise our best intentions at recovery.

One implication of this article is that it's important not only to resist destructive behaviors, but also to invent ways to reduce how often and how intensely we experience cravings. Personally, a lot of this goes back to stuff I learned in NA--avoiding people, places, and things that I associate with using. That is, if I keep myself away from situations that consistently make me want to use, I crave dope less often and less acutely, and in the long run, I feel less exhausted by my efforts to stay away from heroin.

I'd be curious to hear what other SL folks think about this. Is it your experience that resisting the devil on your shoulder leaves you feeling compromised and tired? How do you try to limit your exposure to negative influences?

 

[Grinders Kiefers]

I agree that resisting cravings and urges to use drugs or act out on other unhealthy behavior is extremely exhausting, but each time I get through that sort of experience without giving in, it seems to build character and promote personal growth.

I don't know how I feel about avoiding people, places and things. There are a lot of situations I don't inherently associate with using that make me want to get high and that I tend to avoid if I'm not being mindful. I don't hang out at the dope house or around other people using drugs anymore, but being out there in the "real world" sometimes makes me feel so stressed out and vulnerable that hiding in my apartment under a numb blanket of drugs sounds like a good idea. I guess what I'm getting at is that avoiding the old lifestyle helped me in the beginning but now that I'm a little more removed from that, I'm having to do more than just avoid, and actively look for new, healthy environments to spend my time in. Actually, I think I am doing that instead of avoiding people, places and things - redirecting the focus to something positive instead of spending a bunch of time and energy on avoiding or controlling.

 

[tired of crap]

Hear, here. Or is it here; hear?

Either way I agree.
The first little bit is always the worst for me. As is a few months down the road when a particularly stressful event crops up and Im drained from resisting all this time and I just say "fuck it". And when Im drained from work, fighting the good fight is so much harder.

For me, Ive tried the avoidance method of reducing temptations - I avoided places and situations and people. Ya it worked, Im almost 6 months sober, but it feels so damn isolating. What I am attempting to integrate now is more of a proactive avoidance approach. Instead of avoiding x,y,z put myself in a,b,c. I still avoid what I need to but am now also engaged in beneficial activities. But its a slow learning curve - I feel so stunted by my addiction.

 

[Jabberwocky]

Here is something related to this discussion:

Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders: a randomized clinical trial.

Abstract

IMPORTANCE:
Relapse is highly prevalent following substance abuse treatments, highlighting the need for improved aftercare interventions. Mindfulness-based relapse prevention (MBRP), a group-based psychosocial aftercare, integrates evidence-based practices from mindfulness-based interventions and cognitive-behavioral relapse prevention (RP) approaches.

OBJECTIVE:
To evaluate the long-term efficacy of MBRP in reducing relapse compared with RP and treatment as usual (TAU [12-step programming and psychoeducation]) during a 12-month follow-up period.

DESIGN, SETTING, AND PARTICIPANTS:
Between October 2009 and July 2012, a total of 286 eligible individuals who successfully completed initial treatment for substance use disorders at a private, nonprofit treatment facility were randomized to MBRP, RP, or TAU aftercare and monitored for 12 months. Participants medically cleared for continuing care were aged 18 to 70 years; 71.5% were male and 42.1% were of ethnic/racial minority.

INTERVENTIONS:
Participants were randomly assigned to 8 weekly group sessions of MBRP, cognitive-behavioral RP, or TAU.
MAIN OUTCOMES AND MEASURES:
Primary outcomes included relapse to drug use and heavy drinking as well as frequency of substance use in the past 90 days. Variables were assessed at baseline and at 3-, 6-, and 12-month follow-up points. Measures used included self-report of relapse and urinalysis drug and alcohol screenings.

RESULTS:
Compared with TAU, participants assigned to MBRP and RP reported significantly lower risk of relapse to substance use and heavy drinking and, among those who used substances, significantly fewer days of substance use and heavy drinking at the 6-month follow-up. Cognitive-behavioral RP showed an advantage over MBRP in time to first drug use. At the 12-month follow-up, MBRP participants reported significantly fewer days of substance use and significantly decreased heavy drinking compared with RP and TAU.

CONCLUSIONS AND RELEVANCE:
For individuals in aftercare following initial treatment for substance use disorders, RP and MBRP, compared with TAU, produced significantly reduced relapse risk to drug use and heavy drinking. Relapse prevention delayed time to first drug use at 6-month follow-up, with MBRP and RP participants who used alcohol also reporting significantly fewer heavy drinking days compared with TAU participants. At 12-month follow-up, MBRP offered added benefit over RP and TAU in reducing drug use and heavy drinking. Targeted mindfulness practices may support long-term outcomes by strengthening the ability to monitor and skillfully cope with discomfort associated with craving or negative affect, thus supporting long-term outcomes.

JAMA Psychiatry. 2014 May;71(5):547-56.

https://www.ncbi.nlm.nih.gov/pubmed/24647726

NSFW:

Relative Efficacy of Mindfulness-Based Relapse Prevention, Standard Relapse Prevention, and Treatment as Usual for Substance Use Disorders: A Randomized Clinical Trial (2014;71(5):547-556) was the first study of its kind exploring the relative efficacy of MBRP, RP and TAU. The study followed individuals who received SUD treatment over the course of a 12-month period, measuring rates of substance use and abstinence. Participants were recruited, randomized to control for variables, and assigned to eight weeks of MBSR, RP or TAU aftercare program. The study demonstrates MBRP as the most effective of the three.

The sample size is robust, at n=286. The study sought to contrast MBHR and RP modalities with TAU, consisting of 12-step and psychoeducation groups. RP was the implicit control, matched for MBRP in time, format, size, location, and scope of assigned homework. The TAU group is considered the norm for SUD treatment aftercare. The inclusion of an RP group serves to determine whether it is the particular mindfulness-based foundation of MBRP that enhances treatment outcomes over TAU, as previous studies have demonstrated, or if intervention efficacy might correlate with modalities unrelated to mindfulness.

MBRP is an intervention combining elements of RP with MBSR and MBCT. RP is essentially CBT oriented around maintain abstinence and avoiding triggers. TAU involved 12-step support and abstinence-only psychoeducation groups, the norm for aftercare in the US. The study measured the time until first drug use, drug use days, and heavy drinking days at the completion of primary SUD treatment, +3-month, +6-month and +12-month follow up points.

The study found that RP and MBRP are superior to the typical 12-step based TAU aftercare interventions. MBRP supported long-term abstinence more effectively than RP. Among all 3 groups, the rates of substance use and heavy drinking were significantly lower compared with those of other SUD treatment studies, indicating that the quality of support received by participants was higher than the norm of SUD aftercare.

The RP group had the longest time until first use/lapse. Between group differences were not found at the 3-month follow up. At the 6-month point, among participants who drank heavily, RP and MBRP participants reported 31% fewer days of heavy drinking compared with those assigned to TAU; RP and MBRP participants had a significantly higher probability of abstinence from drug use and significantly higher probability of not engaging in heavy drinking. At the 12-month follow up, MBRP participants, compared with RP participants, reported 31% fewer drug use days and a significant higher probability of not engaging in any heavy drinking.

The study did well to contrast MBRP with RP, as opposed to only with TAU, as previous studies have already demonstrated MBRP’s superiority over TAU. One potential issue was that the MBHR and RP utilized homework assignment which did not have an equivalent in TAU, however the main limitation seems related to who led the groups, which was only controlled for MBRP and PR.

MBRP and RP therapists had significantly more professional and academic training than the TAU facilitators. If TAU facilitators had equivalent academic and professional backgrounds, would that group have done better? Is TAU less effective because the group facilitators did not have the same degree of rigorous training?

In terms of group participant-professional ratio, there were two therapists in each MBRP and RP group, while there was only one facilitator leading TAU groups. Would the TAU group have done better if it was led by more than one facilitator? Although the study was vague on this point, it seems to imply the MBHR and RP groups also had lower participant-to-instructor ratios than the TAU groups. If participants in the TAU group had the same degree of individual attention from the facilitator, would the outcome have been more favorable?

When it is incorporated into a post-SUD treatment regiment, the standard 12-step TAU based aftercare is woefully inadequate. One aspect of this is the organization of 12-step groups and how they are run, without the leadership of trained professionals. The 12-step model was never developed as a form of professional treatment, yet that is precisely how it is being used, largely for financial reasons (MBRP and RP programs incur higher overhead).

Due to lack of oversight, standardization and accountability, it is not unusual for involvement with 12-step communities to cause harm to vulnerable newcomers (e.g. “13 Stepping”). Could it be that the group environment created by the more highly trained therapists in MBRP and RP was a primary factor contributing to their increased efficacy? By creating a healthier, more inclusive and respectful group, with leaders attuned and catering to the needs of individual participants, would TAU be more conducive to establishing ongoing psychosocial integration and success in early recovery?

It would be interesting to also see MBSR compared with RP and MBRP. Something that should be noted is that the most effective approaches to SUD treatment and recovery are integrative, strategies involving multiple modality. Non-professional peer support groups are much more effective when one is also receiving individual therapy, medication, and MBSR/MBCT/MBRP. Nothing about this study says that RP or MBRP is mutually exclusive with TAU programs.

As the research above highlights, avoidance based coping skills are important. Personally, I feel the more effective coping long term tends toward integration, which is where the whole mindfulness thing gets really interesting.

But I also am starting to realize that different learning styles work best for different individuals. Another way of saying that, different individuals have different developmental trajectories. One isn't better or worse than the other. Differences are merely a reflection of how each of our lives have distinct causes and conditionings.

Some people are big time bottom up learners. Stuff like mindfulness seem particularly helpful here (speaking only for myself), although some approaches are more effective than others within the mindfulness paradigm.

Other people, perhaps such as people for whom the avoidance based coping strategies are most effective, are perhaps more top down learners. I don't have experience with what works well for top down folks, at least not off the top of my head, but it's definitely a bit different (perhaps more direct) than what works well for someone like me.

The distinction I just made, take it with a grain of salt. It's my working hypothesis based off what I understand about how learning happens differently for different individuals. To each one's own

 

[jdfisse]

I do have to laugh at the explanation of the TAU model that they utilized. Going to meetings alone 1 to 2 times a week facilitated by a licensed chemical dependency counselor. That is a "process" group, not a 12-step model. Why suggest use of a twelve step model without any of the DBT and CBT that comes through the actual step work.

 

[jdfisse]

Additionally, and probably why step work (the actually "program" in a 12-step program) was not included in the study, Mindfulness based practice is an integral part of the step process and has been for more than 80 years. 12 step fellowships understood that about 60 years before John KZ brought it more in to the mainstream. It is unfortunate that the vast majority of people I run in to (including members of this forum) believe that the "fellowship" is "the program". The "fellowship" is one small facet, while the steps and traditions are the majority of "the program" and are based in DBT, CBT, and Acceptance and Commitment therapy principles.

 

[SoCal424]

TOC-
You wrote:

it feels so damn isolating

What kinds of things did you do for fun before drugs entered your life? Do they still interest you enough to go out among people with similar interests? ie: a music class or auto repair classes? If you are close to your family, consider visiting them more often. If you like fixing up stuff around the house like me, there are small one and two hour training classes at Home Depot and it's a good way to meet others with similar interests. Anyone special in your life? Take them to the zoo and/or on dates in places you've never been before. Do you have sober friends that you lost track of due to drug use? Maybe you could track them down and restart your friendships? Please don't stay isolated - waiting to be rediscovered by you.

"It's not whether you get knocked down, it's whether you get back up and keep moving forward."
Your BL friend,
Dale

 

[MrRoot]

For myself the recovery process was exhausting when it started but after a while it has been much more easier than living a life controlled by drugs.

As I have good connections I didn't have to pay street prices for drugs ever and got them as pure as they can and as I get quite good income the financial aspect of druggie lifestyle wasn't ever a concern but it was exhausting to deal with those guys as well as what the drugs did to me.

After I get over with excessive cravings I have felt like I can function much better than while on drugs and it is a good feeling.

I am lucky to live in a country where every publicly funded rehab must be evidence based.

 

[Jabberwocky]

I really need to make this obvious, so I'm going to use ridiculously large font to explain:

12 step programs ARE NOT based in professional modalities used in the clinical treatment of substance use disorder and process addictions. 12 step programs, even when facilitated by people with comparable professional backgrounds, have extremely little in common with with modalities like DBT, MBSR/MBRP/mindfulness-based interventions. 12 step programs are NOT based in them.

What little 12 step programs share in common with clinical approaches to treatment like ACT/DBT/etc is pretty universal wisdom, hardly something 12 step programs have a monopoly on.

Frankly the biggest difference between 12 step programs and programs like DBT is that DBT type therapists tend to have infinitely more training, education and professional experience than people who facilitate 12 step stuff.

If your everyday 12 step programs requires people to actually have proper training, they'd be more effective. However, then they'd cease to be the average 12 step programs. And even with the best trained 12 step facilitators (and I've certain met some amazing ones by any standards), what they offer still doesn't begin to address the depth that programs like MBRP do.

I do have to laugh at the explanation of the TAU model that they utilized. Going to meetings alone 1 to 2 times a week facilitated by a licensed chemical dependency counselor. That is a "process" group, not a 12-step model. Why suggest use of a twelve step model without any of the DBT and CBT that comes through the actual step work.

Wait, are you trying to suggest 12 step work is in any way comparable to DBT or even CBT provided by a trained professional? That's problematic on soooo many levels.

Additionally, and probably why step work (the actually "program" in a 12-step program) was not included in the study, Mindfulness based practice is an integral part of the step process and has been for more than 80 years. 12 step fellowships understood that about 60 years before John KZ brought it more in to the mainstream. It is unfortunate that the vast majority of people I run in to (including members of this forum) believe that the "fellowship" is "the program". The "fellowship" is one small facet, while the steps and traditions are the majority of "the program" and are based in DBT, CBT, and Acceptance and Commitment therapy principles.

Hah! Again, seriously?!

It's laughable to compare what Kabat-Zin creates with the 12 step program. Theoretically speaking they have some similarities, but the differences are far more extreme.

Do I really need to list them all? Lets start: one is a non-professional peer based program, the other is a program provided by trained (and often licensed medical) professionals.

Your last statement is really incredible. How is 12 step work of their christian traditions based in medicine? That goes against the entire history of the 12 step model and community.

If anything, 12 step work is now becoming greatly enhanced by framing it from the perspective of modern medicine. Please are using modern treatment modalities like CBT (which is probably still the most popular) to enhance 12 step work, but this demonstrates the need for these more modern modalities to fill gaps in the 12 step paradigm/program.

In other words, there is a lot 12 step work does not address for many (if not most) people. These other modalities are effective with 12 step work because they fill the gaps. That means the opposite of what you're suggesting.

TAU in that study isn't the idealized version of someone who commits 100% to a fully functioning 12 step program. TAU in that study is what the name suggests: "treatment as usual," which generally is limited from a clinical perspective to going to a few 12 step meetings and working with a drug and alcohol counselor.

And even that is more than a hell of a lot of abstinence only treatment programs provide in the way of after care. Most simply don't provide it, short of suggesting people to attend meetings or live in a sober living. In a sense, you're right to laugh - as treatment as usual (live in sober living, attend peer support, see a counselor) is a complete joke when it comes to meeting the needs of people in early recovery. Treatment as usual is a joke.

What we do know for certain is that 12 step programs are significantly more effective when they're integrated with professional modern clinical modalities. However, nothing about this should be taken to suggest modern clinical modalities like mindfulness-based interventions, motivational interviewing or DBT (which all involve an approach that couldn't be more different from standard abstinence only fair) are a product of the 12 step paradigm, grew out of 12 step programs, or anything of the like.

My hope is that people running 12 step program, people who have benefited from 12 step program, they will continue to wake up to the reality that people have a diversity of needs in recovery. Just because something worked for one person doesn't mean it should be the only option afforded everyone else, or that it's even the best way for everyone to do their recovery.

Especially with the opioid use crisis, 12 step community leaders are waking up to the limits (and life or death dangers) of narrow ideological abstinence only approaches to recovery - or that an abstinence based program doesn't necessarily require providers working with a black and white abstinence only mentality when deciding what treatments are most important for which people in their programs.

What this all does suggests is that 12 step programs don't work as simply as "it works if you work it," that they're are missing stuff people need, and that these other modalities help to fill gaps to better support more people more effective in recovery.

12 step programs can be amazing, and they do a lot of good for a lot of people. But nothing about that needs to mean that they're the only viable approach to recovery. As fucked as the current situation with treatment is in the US, it would be so, so much worse off if all we had was 12 step programs.

It's hard to imagine how we could be even more fucked than we already are though.

 

[aihfl]

I'm stil not over the soul crushing insomnia I'm out of Ativans so I resorted to 45 mg remeron and 1.8g gabapentin and a glass of wine on top of that when my mother woke me up this morning I was grogggy as fuck. Thank god I get more Ativans tomorrow so I can not use so much ganapentin or remeron and do back onto something "smoother"

 

[jdfisse]

I really need to make this obvious, so I'm going to use ridiculously large font to explain:

12 step programs ARE NOT based in professional modalities used in the clinical treatment of substance use disorder and process addictions. 12 step programs, even when facilitated by people with comparable professional backgrounds, have extremely little in common with with modalities like DBT, MBSR/MBRP/mindfulness-based interventions. 12 step programs are NOT based in them.

What little 12 step programs share in common with clinical approaches to treatment like ACT/DBT/etc is pretty universal wisdom, hardly something 12 step programs have a monopoly on.

Frankly the biggest difference between 12 step programs and programs like DBT is that DBT type therapists tend to have infinitely more training, education and professional experience than people who facilitate 12 step stuff.

If your everyday 12 step programs requires people to actually have proper training, they'd be more effective. However, then they'd cease to be the average 12 step programs. And even with the best trained 12 step facilitators (and I've certain met some amazing ones by any standards), what they offer still doesn't begin to address the depth that programs like MBRP do.



Wait, are you trying to suggest 12 step work is in any way comparable to DBT or even CBT provided by a trained professional? That's problematic on soooo many levels.



Hah! Again, seriously?!

It's laughable to compare what Kabat-Zin creates with the 12 step program. Theoretically speaking they have some similarities, but the differences are far more extreme.

Do I really need to list them all? Lets start: one is a non-professional peer based program, the other is a program provided by trained (and often licensed medical) professionals.

Your last statement is really incredible. How is 12 step work of their christian traditions based in medicine? That goes against the entire history of the 12 step model and community.

If anything, 12 step work is now becoming greatly enhanced by framing it from the perspective of modern medicine. Please are using modern treatment modalities like CBT (which is probably still the most popular) to enhance 12 step work, but this demonstrates the need for these more modern modalities to fill gaps in the 12 step paradigm/program.

In other words, there is a lot 12 step work does not address for many (if not most) people. These other modalities are effective with 12 step work because they fill the gaps. That means the opposite of what you're suggesting.

TAU in that study isn't the idealized version of someone who commits 100% to a fully functioning 12 step program. TAU in that study is what the name suggests: "treatment as usual," which generally is limited from a clinical perspective to going to a few 12 step meetings and working with a drug and alcohol counselor.

And even that is more than a hell of a lot of abstinence only treatment programs provide in the way of after care. Most simply don't provide it, short of suggesting people to attend meetings or live in a sober living. In a sense, you're right to laugh - as treatment as usual (live in sober living, attend peer support, see a counselor) is a complete joke when it comes to meeting the needs of people in early recovery. Treatment as usual is a joke.

What we do know for certain is that 12 step programs are significantly more effective when they're integrated with professional modern clinical modalities. However, nothing about this should be taken to suggest modern clinical modalities like mindfulness-based interventions, motivational interviewing or DBT (which all involve an approach that couldn't be more different from standard abstinence only fair) are a product of the 12 step paradigm, grew out of 12 step programs, or anything of the like.

My hope is that people running 12 step program, people who have benefited from 12 step program, they will continue to wake up to the reality that people have a diversity of needs in recovery. Just because something worked for one person doesn't mean it should be the only option afforded everyone else, or that it's even the best way for everyone to do their recovery.

Especially with the opioid use crisis, 12 step community leaders are waking up to the limits (and life or death dangers) of narrow ideological abstinence only approaches to recovery - or that an abstinence based program doesn't necessarily require providers working with a black and white abstinence only mentality when deciding what treatments are most important for which people in their programs.

What this all does suggests is that 12 step programs don't work as simply as "it works if you work it," that they're are missing stuff people need, and that these other modalities help to fill gaps to better support more people more effective in recovery.

12 step programs can be amazing, and they do a lot of good for a lot of people. But nothing about that needs to mean that they're the only viable approach to recovery. As fucked as the current situation with treatment is in the US, it would be so, so much worse off if all we had was 12 step programs.

It's hard to imagine how we could be even more fucked than we already are though.

If you aren't there yet you aren't there yet...

 

[Jabberwocky]

^that implies it is the individual at fault. That kind of fatalistic, victim shaming attitude literally kills, the whole “rock bottom” mentality. Good intentions and the road to hell and all that...

That kind of “thinking” (e.g. belief; dogma; ideology) is mutually exclusive with harm reduction. Granted, dogma and ideology can be powerful motivating forces propelling people into recovery. But it also does a lot of harm.

I love the rainbow of harm reduction because it focuses on harm, not belief, and attempts to meets each individual where they’re at, regardless of where they’re at or whether they’re “there yet...”

The whole they weren’t ready sort of thing is an easy cop out when someone isn’t able to get the help they need, an attempt for people who feel like they let the individual down to deal with their experience of guilt, grief, etc.

Grief can be just as tough to deal with as recovery. In many respects they’re much the same process, with similar challenges and pitfalls.

But I digress... way way way digress...

Anyways, of addiction is a disease it is first and foremost a social one. Actually this is where we reach the limit of the disease model. Much respect to Hari to promoting recovery from addiction as an inherently social process.

Even the most die-hard NIDA drugs-hijacking-the-Brain types would agree with that statement.

 

[Stargazer]

I didn't read the entire thread yet- but will.

I most definitely find cravings and being tempted does deeply affect me. Positive Fellowship (of any kind) that doesn't include drug use of course; seems to be very helpful for my mind and soul.

Sim your therapist made a great point. This is a great thread , I will finish reading later.

 

[Jabberwocky]

Damn right recovery is exhausting but waking up in the morning knowing you didn't use yesterday is just a great way to start the day.

Recovery for me has been so blurry, even now 46 days in am still drained however being addicted to booze / coke / gambling felt like a game of stacks on and eventually it led me to want to kill myself again.

I have begun to recognise some positives though in recovery such as being less anxious in my speech, a reduced desire to use something negative as a way to cope and a clearer path to name a few.

Unfortunately I've replaced substance abuse with over eating and kleptomania. Mainly stealing food for no fucken reason, i.e. not scanning all the items at the self serve counter. It fucken baffles me I went like 3 years with barely ever touching chocolate and being against it as I thought drinking and smoking was bad enough but then I go back to it I have a plan to get fit again but just trying to regain some more energy first.

Hope everyone is getting better

 

[lucifersam666]

I am like 15 or 20 days off opiates, and feel like I am kind of waking up. Finally got the motivation to switch out my laptop hard drive. and yes, yes very exhausting. When you're 27 going on 72 haha. What it feels like.

 

[simco]

I am like 15 or 20 days off opiates, and feel like I am kind of waking up. Finally got the motivation to switch out my laptop hard drive. and yes, yes very exhausting. When you're 27 going on 72 haha. What it feels like.

27 going on 72...heh. yep, that describes it pretty well.